Virtual Orthodontic Visits

LAURANCE JERROLD, DDS, JD*

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In the past few days, I have received a flood of e-mails, texts, and phone calls regarding Virtual Orthodontic Visits (VOVs). Questions have ranged from what types of visits are appropriately conducted in this way to how should they be done, what are the limitations, do I need a separate consent form, and so on. I have been asked as someone who, for the past 40-plus years, has been actively engaged in private practice, organized dentistry, academics, legal practice, and bioethics to offer some commentary on this matter.

The following comments do not represent the position of JCO, any institutions I am affiliated with, or organized dentistry, nor do they constitute legal advice on my part. Working closely with Gerry Samson, along with input we solicited from a number of our colleagues around the country, I have developed this brief article. Feel free to use it as you see best.

Why Should I Be Offering VOVs?

Patients need to know that you are concerned about them. Every practitioner should inform his or her patient base in clear and concise language that as a result of the office being shuttered, you and your staff have addressed their orthodontic needs by performing:

• An in-depth review of every patient’s treatment.
• A determination that most patients require some type of periodic monitoring of their treatment, and that you are prioritizing the appointment needs for every one of your patients based on their original orthodontic problem, their specific treatment plan, the types of appliances chosen to treat their particular problem, and their point in treatment.
• A virtual triage based on these determinations, the result of which is knowing which patients need to be seen in the office immediately, which patients can have an office visit deferred for a given period of time, and which patients can be safely monitored through virtual orthodontic visits.

Can Everyone Offer a VOV?

Each state may have laws that either prevent practitioners from offering VOVs or dictate in some fashion limitations or provisions on how they must be conducted. You are well advised to contact legal counsel who is familiar with the laws of the state you practice in. Many doctors practice in multiple states, which may make this concern more problematic.

What Types of Procedures Are Amenable to a VOV?

Many active treatment visits are not amenable to a VOV and do require an in-office visit. Non-exclusive examples of these types of visits are:

• An emergency that requires an actual adjustment to an appliance (e.g., one side of a bilateral fixed appliance has become loose, impeding a patient’s ability to chew)
• Converting a patient who is in active therapy, where if the specific force applications were not removed, the unsupervised continued mechanics could potentially injure the patient

Nevertheless, there are certain types of visits that can be performed with relative effectiveness utilizing a VOV. The following are non-exclusive examples of VOVs that can be performed to maximize patient benefit and minimize practitioner risk:

• Catching treatment mechanics that pose a potential risk of harm/injury to the patient
• Prescreening potential patients to determine if they are candidates for future in-office orthodontic records acquisition visits
• Most retention visits
• Certain recall visits to monitor dentofacial/dentoalveolar growth and development
• Most clear aligner visits
• Monitoring self-limiting active appliances (e.g., leveling and alignment)
• Checks on elastic wear
• Checks on oral hygiene
• Patient motivation visits
• Visits to help patients deal with certain minor orthodontic emergencies (loose brackets, long wires, etc.)
• Responding to patients’ concerns regarding their treatment
• Enhancing the doctor/patient relationship via communication

How Should VOVs Be Performed?

VOVs should be scheduled for specific times during the day, just as you would schedule routine in-office visits. You want to mimic conducting your practice in as efficient and orderly manner as possible. You must leave adequate time to bring up each patient’s chart, appropriately review it, conduct the VOV, communicate with the patient, and document what treatment or advice you rendered.

There should be a protocol you follow for visualizing the patient’s soft-tissue drape and oral cavity. Every “examination” should be conducted in the same manner, with documentation being conducted in accordance with your office protocol for record keeping. Your patient’s chart should be open during the visit. Clinical notes of your findings and recommendations should be comprehensive and should indicate who was present (staff, parents, etc.) during the VOV. The images you view (video or stills) should be memorialized in some fashion so that they become a permanent part of the patient’s record.

Adequate retraction can be obtained via the “tablespoon method” or some other means. Adequate lighting should be obtained by having someone with the patient use a flashlight, cellphone light, gooseneck lamp, etc. The standard five intraoral images should be “acquired,” along with a visualization of any overjet (positive or reverse) via an upward, downward, or lateral projection.

Occlusal photos will be the most difficult; the patient will require instruction as to what to do with the tongue. The doctor or assistant should be guiding the patient through the photo acquisition process. Rescheduling should be done on a prioritized basis, considering your findings at the patient’s first VOV.

Moving Forward

Your mindset should be that the next month or two will not be the last time you will have to do something like this. VOVs will become a part of every orthodontist’s practice to a greater or lesser extent, based on the character of your practice. There will be a “second wave” of the virus, and there may be another pandemic or public health emergency in decades to come. This is an opportunity to develop the skill set necessary to provide our patients with the best we can offer, given the circumstances we find ourselves having to operate under. For this reason, a patient’s consent to a VOV should become a part of every patient’s initial paperwork.

Do I Need a Special Type of Consent Form?

If you are going to offer VOVs, you must recognize that the very nature of a virtual visit carries with it the facts that: 1) you will not see everything you could see at an in-person visit; 2) you will not be able to provide every aspect of treatment you would normally provide; and 3) mistakes will be made due to the limitations inherent in a VOV. Therefore, it is prudent to inform your patients who will undergo VOVs of these limitations. At the bottom of the PDF is a sample of an informed-consent document for a VOV. Please feel free to tweak it as desired.

*Program Director, Orthodontic Residency Program, NYU Langone Hospital Brooklyn, NY; drlarryjerrold@gmail.com.