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Virtual Insanity

In 2016, I wrote an article for JCO about tele­dentistry’s role in orthodontics.1 At the time, Dental Monitoring had just been introduced and mail-order aligner companies were emerging with aggressive direct-to-consumer marketing campaigns. Orthodontists were only beginning to consider the possibility of incorporating virtual consultations and remote monitoring into their practices.

The COVID-19 pandemic brought tele­dentistry to the forefront. By March 2020, the ADA had recommended postponing nearly all orthodontic procedures. Since offices were closed for months, orthodontists resorted to virtual consultations to fill their schedules. This behavior only blurred the lines between orthodontists and mail-order aligner companies, which were already operating as if in-person visits were optional.

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Thanks to the efforts of the AAO Advocacy team and the Nevada State Orthodontic Society, a legislative triumph over mail-order-­aligner companies was recently tallied with the enactment of Nevada Assembly Bill No. 147. AB147 makes Nevada the first state to mandate “an in-­person visit before the patient begins using [an] orthodontic appliance.” Further, the bill offers a template for other states to follow in developing similar policies.

During the 2023 annual session, the AAO House of Delegates approved several revisions to the Clinical Practice Guidelines (CPG), including a section on teledentistry. Specifically, on page 6, the CPG now stipulates that “a comprehensive, in-­person examination must be performed by the dentist prior to the initiation of treatment.” In essence, a virtual consultation is no longer considered an adequate replacement for a face-to-face consultation and is now considered a “virtual screening.”

What do these changes mean as we move forward? If a virtual screening is conducted in the absence of a comprehensive in-person consultation, followed by a technician scanning the patient’s teeth and aligners being delivered, it represents a breach of the CPG and could thus violate state regulations. Above all, we must avoid adopting practices that resemble those of mail-order aligner companies. I also recommend revising your practice’s website to eliminate any references to “virtual consultations.”

Before crying foul, we should note that many patients do not favor virtual treatment. In a 2023 study evaluating orthodontic patients’ perspectives on teledentistry, a significant majority still preferred face-to-face interactions.2 These patients did not consider their treatment inconvenient, nor were they comfortable in replacing their consultations, emergency visits, or retainer checks with virtual alternatives. The study’s conclusion: Teledentistry should be employed primarily to augment doctor-patient communication, not to replace in-person visits.

Even if we discount our patients’ preferences, we still need in-person visits for progress radiographs. For example, a panoramic radiograph should be taken within the first six months of treatment to check for root resorption. Moreover, many oral pathologies manifest during the second decade of life, when children are usually under treatment. Here’s a tip from a seasoned orthodontist who has made many clinical mistakes: Create systems in your office that slow you down and help you focus. Teledentistry does just the opposite.

The underlying goal of our 2016 article was to distinguish teledentistry from mail-order orthodontics. Sadly, some offices are now misusing virtual consultations and remote monitoring to circumvent their responsibilities in what amounts to doctorless treatment. Teledentistry can be a useful adjunct to patient care when applied judiciously, but it remains a poor substitute for routine in-­person visits. You might disagree—but when you miss a critical diagnosis because of virtual treatment, watch how quickly reality sets in.





  • 1.   Kravitz, N.D.; Burris, B.; Butler, D.; and Dabney, C.W.: Teledentistry, do-it-yourself orthodontics, and remote treatment monitoring, J. Clin. Orthod. 50:718-726, 2016.
  • 2.   Griffeth, J.K.; Shroff, B.; Carrico, C.; Cook, P.; and Lindauer, S.J.: Patient perspectives on teledentistry and face-to-face doctor interaction during orthodontic treatment, Am. J. Orthod. 163:328-337, 2023.



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