GUEST EDITORIAL
Taking control of our workflow and data
Christopher Riolo and James Vaden
Seattle, Wash, and Cookeville, Tenn
T
hrough experience teaching and interacting with
orthodontic residents, we have noticed that atti-
tudes toward organized dentistry in general and
the American Association of Orthodontics (AAO) in
particular have changed over time. Many younger ortho-
dontists do not perceive a positive cost-benefit analysis
with respect to AAO membership. Some perceive greater
value in an orthodontic Facebook group than member-
ship in the AAO. Although we do not like this paradigm,
we must acknowledge it exists. Part of the problem is
almost certainly a lack of effective communication
with these orthodontists about the value of AAO mem-
bership. In addition, the AAO needs to urgently develop
ways to add value to the membership for this next gen-
eration of orthodontists.
Digital orthodontics and computer-aided design
technology, in combination with subtractive and addi-
tive manufacturing technology, have the potential to
be a transformational force for good in the care of our
patients. Unfortunately, until now, these disruptive
technologies have benefited only corporations that
focus on market share and profits, not patient care.
One of the consequences of these technologies is the
rise of corporate providers (ie, Invisalign, Smile Direct
Club, Byte [now Dentsply Sirona], and Candid Co,
among dozens of others). The effect these corporate en-
tities have had on the orthodontic marketplace and
thousands of patients are only the early and most
obvious consequence of ignoring these changes to the
orthodontic landscape. Today, dental corporations are
commanding a higher and higher percentage of practice
revenue as they insert themselves into the doctor–
patient relationship. They use a myriad of tactics to in-
crease their influence on our practices and the relation-
ship we have with our patients:
1. Direct to consumer marketing: in some patients,
treatment is provided without the supervision of a
dentist, let alone an educationally qualified ortho-
dontist. Frequently, important safeguards,
including initial radiographs or documented pre-
Am J Orthod Dentofacial Orthop 2021;160:331-4
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treatment periodontal and caries clearance, are
notably absent. Instead, the responsibility for treat-
ment readiness is placed on the patient.
2. Direct corporate referrals: corporations now
frequently refer patients directly to select providers
through their online portals or storefronts. As the
percentage of patients received and started by a
particular provider increases, the relationship be-
tween the orthodontic provider and the corporation
begins to blur. When the referrer's objective is to sell
a particular product or appliance, who really dictates
the treatment plan? The provider or corporation?
This, in effect, makes all of us their unpaid sales
force.
3. Tiered pricing: corporations commonly employ
tiered pricing to subtly and not so subtly influence
orthodontists to treat patients with a particular
appliance system, whether or not it is the best treat-
ment solution for the patient. These pricing tiers are
now the rule rather than the exception. The ortho-
dontist is encouraged to start a certain number of
patients every quarter. If the orthodontist makes
the next tier, he/she can save hundreds of dollars
for every patient started the next quarter. When
the orthodontist is just a few starts away from the
next level, the implicit pressure is to push a few
more patients into aligner treatment regardless of
the optimal treatment modality. The cost to the or-
thodontic practice of ignoring this tiered pricing
scheme can be many thousands of dollars each
month. At least 1 company has taken tiered pricing
to a new level by offering unpublished pricing dis-
counts to select high volume practices that open
their books to guarantee a percentage of the pa-
tients in the practice will be started with the com-
pany's product! In addition, these corporations are
merging/consolidating and are beginning to bundle
products. For example, the cost of your practice's
next scanner may well depend on the number of pa-
tients that you commit to starting with the com-
pany's product. The AAO has been concerned with
these practices and is monitoring an ongoing
class-action lawsuit against Align Technology (San
Jose, Calif). Corporations such as Align Technology
have very deep pockets; therefore, we have to
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acknowledge that the only chance we have to stem
this tide is to stand together through our respective
professional organizations.
4. Corporate education: corporations are holding their
own educational meetings; they have faculty, and
why not? After all, these corporations are gathering
all the data and doing most of the research on these
new appliance systems. Of course, these data are not
shared with the public; the evidence is presented
back through their key opinion leaders (orthodon-
tists paid to endorse/influence) at their educational
events and large corporate dental meetings. The
American Dental Association and AAO are con-
cerned by this trend; beginning July 1, 2023, the
American Dental Association will enact new
continuing education recognition program regula-
tions that are aimed at curtailing or eliminating
corporate/key opinion leader continuing education.
5. Proprietary data: private insurance companies
have been collecting data for years. Because of
the advent of digital orthodontics, the amount
of data available for collection has exploded,
and the data is far more granular in detail. It
is not a coincidence that almost every major
company collects data; to a greater and greater
extent, in this new economy, data is power,
data is money. These corporations initially use
orthodontists to train their artificial intelligence
(AI) programs through the collection of massive
amounts of treatment data. These AI programs
are then used to power the company's software.
This AI-powered software can then be used to
provide either direct-to-patient care or plan and
stage orthodontic care for general practitioners.
The encroachment of corporate dentistry into
our specialty and the relationship we have with
our patients is most evident in North America
and the United States in particular. These corpo-
rations are multinational, and so are these trends.
This all sounds very grim for the orthodontic
specialty, but disruptive technologies cut both
ways. Digital design paired with 3-dimensional
printing of resin and metal has the potential to
disrupt centralized manufacturing. Custom ortho-
dontic appliances such as Incognito and Invisalign
can now be fabricated locally in our own offices
rather than in multibuilding manufacturing facil-
ities located globally. The future of our specialty
lies in taking control of our data and our work-
flow rather than relying on multinational corpora-
tions for all our custom appliances while at the
same time ceding all our data.
September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Guest editorial
FIRST STEPS TOWARD A REIMAGINED FUTURE
It is clear that we have a problem; what is the solu-
tion? We believe the solution is for educationally quali-
fied orthodontists to stand together for the benefit of
our patients and our specialty. As orthodontists, we
need to reconsider the role the AAO plays in supporting
our members and our specialty. The power we as ortho-
dontists have lies in our participation in organized
dentistry through organizations like the AAO, European
Orthodontic Society (EOS), and World Federation of Or-
thodontists (WFO). There are signs that the AAO is look-
ing for opportunities to enhance member benefits and
generate nondues revenue with the establishment of
the Innovation and Transformation Fund in 2019. The
AAO needs to become urgent in its efforts to develop so-
lutions that specifically allow the orthodontist to control
their workflow and their data. Control of our workflow
means giving orthodontists the means to deliver ortho-
dontic care without having to rely on the for-profit orga-
nizations whose mission is to maximize profits, not to
care about patients or our specialty. These same corpo-
rations are the source of the problems I have outlined
above. The need to control our data should be self-
evident today. Data is the key to evidence-based care,
treatment efficiency, self-evaluation of treatment
outcomes and may be critical in 1 possible future in
which reimbursement is wholly or partially based on
treatment outcome. One thing is becoming clear,
“Data is King;” there are several medical specialties
and dental specialties that have already formed or are
in the process of forming registries to collect their data.
Although there is a myriad of possible strategies that
will begin to move us as a specialty toward a future in
which we as orthodontists control our workflow and
our data, we will outline 1 possible solution below.
Companies like Invisalign, Smile Direct Club, Byte,
and Candid spend hundreds of millions of dollars brand-
ing themselves. They do this to develop the kind of mar-
ket share that a large professional organization such as
the AAO, EOS, and WFO could command on day 1 if
they owned and controlled their own aligner staging
software. If a large professional organization acquired
or developed aligner staging software, it could change
the whole trajectory of our specialty. All orthodontists
will soon own and operate 3-dimensional printers daily;
all orthodontists have the ability to create a thermoform
aligner in-house using a Biostar, Drufomat, or equiva-
lent. Therefore, all we lack is cloud-based staging soft-
ware to provide our patients affordable aligner
treatment.
We want to be clear; we are not proposing an aligner
company or an aligner laboratory. We are simply
Guest editorial
proposing that the AAO provide access to cloud-based
aligner staging software that allows users to download
individual staged STL models that are ready for printing
and aligner thermoforming, either in-house or at your
preferred laboratory. We are also not proposing that or-
thodontists exclusively provide in-house appliances to
our patients. We are proposing that we should have
the choice to provide affordable and flexible treatment
when it benefits our patients to do so. When we deem
it is better to employ a commercial system, we will
have that option. However, these corporations will
have to compete honestly for the privilege to participate
in the care of our patients.
Let us consider the consequences of the AAO owning
and controlling their own aligner staging software:
1. A new player: orthodontists themselves would over-
night become a major player in the multibillion-
dollar aligner market. These commercial companies
spend fortunes on branding and advertising for pa-
tients. Orthodontists, as a community, are the mar-
ket that they are trying to tap. We already have what
these corporations are spending hundreds of mil-
lions of dollars to develop; it is sitting in our waiting
rooms. The professional association that develops
staging software that is 100% owned and controlled
by its membership will become a major player in the
aligner marketplace overnight.
2. Reverse declining membership in organized
dentistry: the strength of any professional organi-
zation is membership; to maintain and grow mem-
bership, an organization must provide value. Our
power is in the numbers; it is imperative that no
matter which professional organization develops
cloud-based staging software, it should be made
available to any educationally qualified orthodon-
tist in the world, provided they are a member of
their national or international specialty organiza-
tion. By allowing the use of the software to an
orthodontist who is a member of their local or in-
ternational professional organization, we add value
to all professional organizations, not just the orga-
nization that developed the software. Consider the
consequence of providing unlimited use of aligner
staging software for only $100 per month to any
educationally qualified orthodontist who is a mem-
ber of organized dentistry in his or her country.
Just 10,000 member users would generate $12
million per year for continued development and
improvement of the software. We could easily see
far more than double that number of member users
worldwide; the numbers are staggering. Consider
the impact we would have on patients worldwide.
American Journal of Orthodontics and Dentofacial Orthopedics
333
In Nepal, the average orthodontic fee ranges
from $350 to $1150 depending on the type of
appliance system employed; access to unlimited
aligner staging for $100 per month would be a
game-changer. Access to this staging software
through an orthodontist's local organization would
add tremendous value to the membership not just
for the member of the AAO but for orthodontists
worldwide who are members of their respective or-
ganizations. The AAO's orthodontist customer base
would then be worldwide; thereby, increasing non-
dues revenue for the AAO. Access to affordable
staging software is likely to reverse the recent trend
toward declining participation in organized ortho-
dontic associations in North America. The more
membership increases, the greater our power in
the orthodontic marketplace.
3. Funding the future: nondues revenue should get the
attention of any orthodontic organization. The pro-
fessional organizations with the foresight to provide
this staging service will also have access to the
excess revenue generated. This type of staging soft-
ware could be used not only to offset member dues
but also for important projects such as an orthodon-
tic registry. We generate huge amounts of digital
data in our offices through the process of treating
our patients. These data have to potential to be sys-
tematically collected and collated into an orthodon-
tic registry that could be invaluable in making our
specialty leaders in evidence-based care. Developing
the means to collect, store, and interact with these
data is the first step in controlling our data for the
good of our patients and the specialty; implement-
ing cloud-based staging software does exactly that.
TWO IMPORTANT GUIDING PRINCIPLES
For organization-based staging software to be suc-
cessful and have the intended effect on our specialty,
it is crucial that we adhere to and emphasize 2 important
guiding principles: First, the software has to be cloud-
based and 100% owned and controlled by the profes-
sional organization's membership, and second, any
educationally qualified member of a legitimate ortho-
dontic professional organization worldwide should be
able to participate.
The first principle addresses the need for orthodon-
tists to control our data and workflow; corporate part-
nerships need to be avoided at all costs. These types of
partnerships are a 1-way street to promote a specific cor-
poration and give away our most valuable asset, market
share. The second principle acknowledges that we need
to stand together as a specialty. Many of these
September 2021  Vol 160  Issue 3
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corporations are international, and we cannot afford to
be fragmented. We are all orthodontists facing similar
challenges, and if we stand together as I have described
above, when an orthodontist anywhere in the world par-
ticipates in organized orthodontics, we all benefit.
Nobody is better positioned than professional ortho-
dontic organizations such as the AAO, EOS, or WFO to
disrupt the orthodontic marketplace. We do not have to
be victims of the changes we are now seeing. We can
be the disruptors! We must act; the first step will be
the hardest, to convince our leadership to think outside
the box and to act to preserve our specialty. Orthodon-
tists value a marketplace that allows the flexibility to treat
patients affordably with the tools that will address
patient needs and desires. In our digital world, it is not
factories and distribution systems alone that command
power in this new marketplace; it is software and data.
Software and data are power, and organized orthodon-
tics is in a unique position to leverage this power for
the benefit of our patients and our specialty.
We need to act now; what can you do? Talk to your
colleagues and contact your representative in your
respective professional organizations. Emphasize the
value that staging aligner software would bring to you,
your practice, and your patients. Discuss the vast bene-
fits that the collection and analysis of data would have
on the orthodontic specialty and its ability to deliver
September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Guest editorial
independent and evidence-based care. Tell them that
without adding value to membership in our professional
organizations, it will be very difficult to convince the
next generation of orthodontists that membership in
their professional organization has any more value
than the orthodontic Facebook group that they access
for free. Organized dentistry and organizations such as
the AAO are the best hope to preserve our specialty.
Continuing education regulation changes for CE certifi-
cation and recent changes to the Commission on Dental
Accreditation standards setting minimum faculty to resi-
dent ratios with graduate programs are good examples
of the value these organizations can provide. If the
AAO does not want to become less relevant for the
next generation of orthodontists, it needs to continue
current efforts on behalf of all orthodontists while at
the same time begin to think and act outside the box
and add greater value to membership. We need to recon-
sider the role of our professional organizations in the
marketplace moving forward. We want to acknowledge
that there are many possible actions that can be taken,
and many need to be taken to begin to change the
role of the AAO within our specialty to facilitate ortho-
dontists’ control of our workflow and our data. We
believe the development of AAO staging software is
one of the most powerful actions we can take as a spe-
cialty at this time.