Is teledentistry effective to monitor the evolution of orthodontic treatment? A systematic review and meta-analysis

ABSTRACT Introduction: With the advent of COVID-19, teledentistry and remote monitoring have become an imminent reality that allows orthodontists to monitor orthodontic treatment through virtual checkups, which complement in-office appointments. Objective: To evaluate the effectiveness of using teledentistry in monitoring the evolution of orthodontic treatment. Material and Methods: Searches were performed in on-line databases. PECO strategy focused on comparing orthodontic patients exposed and not exposed to teledentistry. Searches and data extraction followed PRISMA guidelines. The assessment of the risk of bias and the certainty of the evidence was performed using the ROBINS-I and GRADE tools, respectively. A meta-analysis was also performed. Results: Out of 1,178 records found, 4 met the criteria and were included in the qualitative analysis. The risk of bias for follow-up assesment in aligner treatment was low to moderate; while for interceptive treatment, it was high. Studies are favorable to the use of teledentistry. The meta-analysis was performed with aligners studies only, due to heterogeneity. The certainty of the evidence was considered very low. Conclusion: With very low certainty of evidence, teledentistry using Dental Monitoring® software is effective as an aid in monitoring the evolution of interceptive orthodontic treatment (high risk of bias) and, especially, treatment performed with aligners (low to moderate risk of bias). The meta-analysis evidenced a reduction in the number of face-to-face appointments (mean difference = −2.75[−3.95, -1.55]; I2=41%; p<0.00001) and the time for starting refinement (mean difference = −1.21[−2.35, -0.08]; I2=49%; p=0.04). Additional randomized studies evaluating corrective orthodontic treatment with brackets and wires are welcome.


INTRODUCTION
Digital technologies have been used in all branches of Dentistry. 1 In Orthodontics, teledentistry has become an imminent reality.
Orthodontic treatment complemented by virtual checkups has been strengthened with the emergence of orthodontic aligners, due to remote monitoring technology being applicable for assessing the advance in treatment without the need for faceto-face appointments. 2mote monitoring systems are part of Artificial Intelligence-Driven Remote Monitoring (AIRM).3 At its forefront, is the Dental Monitoring ® software (DM, Montreal, France), a software used on smartphones that allows the patient to accurately capture their teeth, in photos and videos, with the aid of a patented cheek retractor.4 However, studies demonstrate that, depending on the purpose of use, teledentistry can also be performed using photos and videos without the aid of a special retractor.4,8,9 The training of other professionals and remote assistance to a colleague are also situations in which this tool can also be incorporated.The challenges and limitations imposed by the COVID-19 pandemic have further stimulated the use of teledentistry.7,[11][12] Remote checking, when possible, allows zero aerosol emission, reduced personal contact and zero risk of contagion.7,12 A recent study reported that 60% of American orthodontists have started using teledentistry, and 45% plan to keep it as part of their treatment routine.13 This opens perspectives for post-pandemic orthodontics with reduced number of face-toface appointments, without impacting the quality of treatment.14 Systematic reviews 15 prove that the use of teledentistry is effective, and can be comparable to in-person screening, especially in school programs, rural areas, and areas with limited access to health care.However, to date, no systematic reviews have been identified on the use of teledentistry focusing on the evolution of orthodontic treatment.
Therefore, the aim of the present systematic review is to evaluate, through controlled clinical studies (randomized or not) the effectiveness of teledentistry to monitor the evolution of orthodontic treatment.

MATERIAL AND METHODS
This systematic review was reported in accordance with the PRISMA 2020 guidelines (Preferred Reporting Items for Systematic Review and Meta-Analysis, available at www.prisma-statement.org). 16

ELIGIBILITY CRITERIA
The eligibility criteria followed the format of the PECO strategy.
Studies that met the following selection criteria were included: 1. Participants: patients undergoing orthodontic treatment, with brackets, orthopedic appliance or orthodontic aligners, and without restriction of sex, age, race and malocclusion.Syndromic patients were excluded.
2. Exposure: remote monitoring of the evolution of orthodontic treatment, using photos, videos or smartphone apps.
3. Comparison: group with treatment monitoring performed exclusively face-to-face or dentofacial measurements performed in a conventional way.4. Outcome: effectiveness of teledentistry (via photos, videos or applications) to monitor the evolution of orthodontic treatment performed with brackets, orthopedic appliance or orthodontic aligners.Studies in which teledentistry was used for diagnosis and orthodontic treatment planning, or as a patient motivation tool, were excluded.5. Study types: randomized clinical trials and controlled clinical trials.Case series, case reports, expert opinions and reviews were excluded.

INFORMATION SOURCES, SEARCH STRATEGY AND STUDY SELECTION
Electronic searches were performed according to the PECO strategy, from September to November 2021 and checked again in July 2022.Five databases were searched: PubMed (Medline),

RISK OF BIAS ASSESSMENT
Randomized studies were not found, only controlled clinical trials.Therefore, the articles included were evaluated for risk of bias using the Cochrane ROBINS-I tool for non-randomized intervention studies. 17The evaluation was performed independently by two authors (DT and MS).By means of consensus meeting, a third author (DN) intervened for the final decision, in case of disagreements.
The Cochrane ROBINS-I tool has three main assessment domains: pre-intervention, during the intervention and post-intervention.After individualizing the main criteria, the risk of bias was assessed for each level of each domain, and classified as "low", "moderate", "serious", "critical" or "no information".
Finally, an overall judgment of the risk of bias for each study was generated.

METHODS OF SYNTHESIS AND ASSESSMENT OF CERTAINTY OF EVIDENCE
Data from the included studies were analyzed using the Review Manager software (Review Manager v. 5.3, The Cochrane Collaboration; Copenhagen, Denmark) to evaluate the common outcomes tested among the studies and related to exposure and non-exposure to teledentistry.The mean and standard deviation of the score of each test, and the total number of individuals in the control and DM groups were used.The mean difference (MD) was applied, with 95% confidence interval (95% CI).If some of the information needed for the meta-analysis was absent from the selected studies, the authors were contacted to provide the missing data.Heterogeneity was tested using the I 2 index.The random effect model was used in all meta-analyses because the studies were not functionally equivalent, in this, objective to generalize the findings from the meta-analysis.
To assess the level of certainty of the evidence, the Grading of Recommendations, Assessment, Development and Evaluation Pro software (GRADEpro Guideline Development Tool, available online at https://gradepro.org/) was used. 18It classifies the quality of evidence into four levels: very low, low, moderate, and high."High quality" suggests that the actual effect is close to the estimate of the effect; "Very low quality" suggests that there is very little confidence in the effect estimate, and the reported estimate may differ materially from that measure.This tool considers four aspects to classify the quality of evidence: "Certainty Assessment", "Impact", "Certainty" and "Importance".

SELECTION OF STUDIES
A total of 1,178 records were retrieved after the searches in the databases.After duplicate removal, 889 records were screened by reading the titles and abstracts.Eleven articles were assessed for eligibility, and seven were excluded (Table 1): one had the same sample of another included study (information obtained via contact with the corresponding author), 2 one compared orthodontic students with general practitioners, 10 one tested Dental Monitoring ® on typodonts, 19 and four did not have a control group. 11,12,20,21An additional 990 documents were identified via other methods, but none were eligible after reading the titles and abstracts.Finally, four articles 14,[22][23][24] were selected, all from databases.The study selection process is presented in Figure 1.The summaries of the characteristics and results of the articles are presented in Table 2.

Reason for exclusion
Hansa et al. 2 , 2018 According to the corresponding authors, this study presents the same sample of a more recent study included in this systematic review.
Berndt et al. 10 , 2008 Although teledentistry has been used with video-conferences, the main objective was to compare the treatment performed by orthodontic students and by general practitioners.
Morris et al. 19 , 2019 The study did not evaluate telemonitoring in orthodontic patients.The sample was with typodonts.

CHARACTERISTICS OF THE STUDIES
All studies were non-randomized controlled clinical trials 14,[22][23][24] and used the same telemonitoring method: measurements performed with the aid of Dental Monitoring ® software.Two studies were prospective, in which the samples comprised patients in mixed or permanent dentition who were treated with maxillary expansion. 22,23There was divergence in the method of comparison: one study used measurements by intraoral exams and digital models, 22 while the other used plaster models. 23e analysis was performed by intermolar 22,23 and intercanine measurements in the maxillary dental arch. 23e other two studies included 14,24 were from the same research group, being retrospective, and the samples comprised patients in permanent dentition treated with Invisalign orthodontic aligners.The corresponding author confirmed, by email in August 2021, that such studies had different samples.
In the 2020 14 study, the correction was extended to first molars; and in the 2021 24 study, it also incorporated second molars.
Treatment duration (months), number of refinements, number of aligners for refinement, time to first refinement, number of face-to-face visits and differences between predicted and achieved tooth positions were evaluated -this last item was evaluated only in the 2021 study.

RISK OF BIAS IN INDIVIDUAL STUDIES
Table 3 describes the risk of bias (Rob) analysis of the four studies included in this systematic review, performed using the ROBINS-I tool.One study was classified as low risk, 24 as it presented "low Rob" in all evaluated categories.One presented moderate risk, 14 due to not specifying the proposed time of exchange between aligners and the time between face-toface visits, presenting "moderate Rob" in only one category.
The other two studies were classified as serious risk of bias, 22,23 for presenting "moderate Rob" in at least three categories or at least one "serious Rob".This classification was due to the sample size not being representative of the population, 22,23 as well as the report of many losses, 22 non-specification of the rapid maxillary expansion (RME) protocol, 22,23 in addition to reports of a varied prescription of RME and the association of other types of treatment, 22 no description of previous calibration by the examiner, 22 and results without indication of p-values and significance level. 22,23ble 3: Quality assessment of the ROBINS-I tool for all non-randomized studies.

INDIVIDUAL RESULTS OF STUDIES AND SYNTHESIS
Studies with maxillary expansion 22,23 found that monitoring software seems to provide an accurate assessment of linear tooth movements, 23 and that Dental Monitoring ® can remotely identify posterior crossbite correction. 22Regarding the two studies in which orthodontic treatment was performed with aligners, it was reported that, in both studies, 14,24 the telemonitored group had fewer face-to-face consultations, compared to the control group.The 2020 14 study reported a 1.26 (23%) reduction in visits, compared to the control (7.56 vs 9.82; p<0.001); and the 2021 24 study reported a reduction in the number of visits by 3.5 (33.1%) in the DM group, compared to the control group (p=0.001).There were no differences between the DM and control groups, respectively, regarding treatment duration (14.58 vs 13.91), refinements (1.00 vs 0.79) and number of refinement aligners (19.91 vs 19.85). 14Both studies evaluated the time of first refinement, with divergent results.The first study 14 did not notice significant differences between the groups (9.46 vs 9.97; p>0.05), and the second one 24 reported a significant reduction     The certainty of the evidence was rated as low (Table 4).The risk of bias seriously affected the evidence, due to methodological limitations present in the studies, mainly those related to interceptive treatment.The consistency was seriously affected due to the heterogeneity regarding the type of orthodontic treatment performed, methodology and data analysis performed.

Imprecision
Other considerations Controlled clinical studies serious a serious b not serious not serious none The smartphone software Dental Monitoring ® can be used for measuring and monitoring maxillary expansion.(Kuriakose et al. 22 , 2019 and Moylan et al. 23

, 2019).
There were no significant differences in treatment time between patients who received or did not receive telemonitoring, but the number of face-to-face consultations was considerably reduced (Hansa et al. 14 , 2020 and Hansa et al. 24 , 2021).

Very low IMPORTANT
Table 4: Result of the GRADE assessment of certainty of evidence.
a Two studies have a high risk of bias, one a moderate risk, and only one study was classified as a low risk of bias.The tool used was "ROBINS-I".
b Heterogeneity in the type of orthodontic treatment performed, methodology and data analysis.

DISCUSSION
Technologies are becoming common in the orthodontic profes- studies were carried out to evaluate the topic, and demonstrated that teledentistry is a viable solution in emergency situations, and can also be considered for normal times. 7,11,12scoping review 26 noted that teledentistry (with the aid of smartphones) in orthodontics was being used through cephalometric diagnostic apps (six studies: 35%), apps used as reminders (seven studies: 41%), and remote monitoring via apps (four studies: 24%).These last four studies reviewed Dental Monitoring ® : one 19 is part of our list of excluded studies, for not meeting the eligibility criteria; and three studies 14,22,23 were included in the present systematic review.
This systematic review aimed to analyze only randomized clinical studies or those with the presence of a comparison group related to Orthodontics, more specifically to the monitoring of treatment evolution.The included studies concluded that teledentistry is effective in monitoring orthodontic treatment.
However, in all the situations found, it is possible to perceive a requirement for some type of previous training, either by the orthodontist or mainly by the patient.When records are made without experience, even with help of someone at home, reliability and accuracy can be questionable. 27e four studies 14,[22][23][24] used Dental Monitoring ® as a telemonitoring method.Although the models generated by photos and videos are accurate enough for clinical applications, 19 the use of this tool should be taught to patients or guardians with certain training, so that, alone or with the help of family members, they can obtain adequate images and videos.It is essential that the orthodontist also be able to motivate patients, parents or guardians throughout the treatment, in order to avoid non-cooperation.
Among the studies included in this systematic review, only one study 22 reported the reasons for refusing to participate in the research, such as: parents or guardians find it difficult to use the app or did not have a smartphone or did not feel confident with remote monitoring.This study also found dropouts due to inability to properly use the software or follow the proposed scanning protocol (33.3% of an initial sample of 30 participants).
Orthodontists who intend to use teledentistry may face similar situations.However, research directly related to patient satisfaction in the use of teledentistry in times of COVID-19 demonstrated that most patients express positive opinions and ease of use. 28,29th the orthodontist and the patient must be able to effectively use the chosen telemonitoring tool.
Regarding the types of orthodontic treatment evaluated in the studies, these were limited to interceptive 22,23 or the use of orthodontic aligners. 14,24No studies were found with conventional corrective or compensatory mechanics (brackets and wires), except for the 4x2 alignment, which was of low complexity and was characterized as a type of interceptive treatment.Some articles showed 22,23 that not only the most modern treatments, such as those performed with orthodontic aligners, are subject to the use of technology to monitor patients.Teledentistry can provide fewer visits to the clinical environment, which often generates fear, apprehension and discomfort, especially for children patients.
Remote monitoring of rapid maxillary expansion proved to be effective 22,23 not only for checking posterior crossbite correction, but also for evaluating linear measurements, compared to traditional methods, which may be important to quantify the gains achieved.Differences between methods appear not to be clinically important.One of these studies 22 showed that 43% of patients preferred remote follow-up for the assessment of expansion than face-to-face, and 18% reported not having a preference between the two options.
It was also possible to notice that the constant remote monitoring can improve the cooperation of the patient who uses the orthodontic aligner.One of the studies 24 observed that the group that used Dental Monitoring ® achieved greater precision in movements than the group monitored in person.
Based on this, it is understood that the remote monitoring of the patient can bring more commitment and better use of aligners.This greater precision of movement was restricted to the region of maxillary and mandibular incisors, and this may have caused a reduction in the time for the beginning of refinement in the telemonitored group -a possible effect of a more intense monitoring and early detection of problems such as loss of tracking movement or lack of proper alignment of the aligner. 24The patient monitored at distance seems to be more committed to the treatment than the patient monitored only in person.[32] The lower number of visits among the groups remotely monitored also seems to be an interesting finding, as this can be an excellent option for patients who live in other cities or to assist those who cannot attend the monthly visit for some reason.
This practice can bring benefits to the progress of treatment, especially knowing that orthodontic patients were satisfied with virtual consultations through videos and that they would prefer to have more consultations carried out remotely, being more convenient for them. 28ntal Monitoring ® was the telemonitoring method of choice for all studies included in the present review.The incorporation of this tool seems to have increased with the advent of aligners.In conventional orthodontics, it seems to be an excellent option for controlling side effects, detecting passive arches, monitoring tooth eruption and identifying bracket fractures 2,11 .
Torres DKB, Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment?A systematic review and meta-analysis

24
Dental Press J Orthod.2023;28(4):e2322195 The use of artificial intelligence for remote monitoring gained notoriety, especially during the COVID-19 pandemic. 33,34The use of these technologies can incur additional costs for the orthodontist, but simple options, such as the patient sending photos and videos through e-mails 5 or applications such as Whatsapp, 35,36 can be a simple and low-cost solution.It is expected that technologies and apps that are normally part of our daily lives, due to their ease of use, can be used as an aid in monitoring any type of orthodontic treatment.

LIMITATIONS
The restricted number of studies found, the methodological heterogeneity and the very low certainty of the evidence, limit the ability to generalize the present results, reducing the possibility of associating clinical significance regarding the effectiveness of teledentistry to monitor the evolution of orthodontic treatment in all the modalities.

DIRECTIONS FOR FUTURE RESEARCH
Controlled or randomized studies with smartphone apps commonly used during fixed orthodontic treatment are welcome.As a suggestion for future studies, it would be interesting to evaluate the effectiveness of sagittal elastics with and without remote monitoring; also, the monitoring of tooth mobility during orthodontic forces application in patients with a history of periodontal disease.
With the increasing demand for teleorthodontics, it is expected that new technologies associated with artificial intelligence will emerge and be part of future research.

Figure 1 :
Figure 1: Flow diagram for the study selection procedure.

Figure 2 :
Figure 2: Forest plot of the difference in treatment time in months for the use of teledentistry between the "Dental Monitoring" and "Control" groups.95% confidence interval and 95% prediction interval.

Figure 3 :
Figure 3: Forest plot of the difference in the number of refinements for the use of teledentistry between the "Dental Monitoring" and "Control" groups.95% confidence interval and 95% prediction interval.

Figure 4 :
Figure 4: Forest plot of the difference in the number of refinement aligners for the use of teledentistry between the "Dental Monitoring" and "Control" groups.95% confidence interval and 95% prediction interval.

Figure 5 :
Figure 5: Forest plot of the difference in time for the first refinement regarding the use of teledentistry between the "Dental Monitoring" and "Control" groups.95% confidence interval and 95% prediction interval.

Figure 6 :
Figure 6: Forest plot of the difference in the number of face-to-face consultations regarding the use of teledentistry between the "Dental Monitoring" and "Control" groups.95% confidence interval and 95% prediction interval.

20 Dental
sion.Intraoral scanning, diagnosis with the aid of tomographic imaging, 3D-printing and aligner manufacturing are some examples -most of them requiring exclusive skill from the professional.25Teledentistry, on the other hand, is able to welcome the patient, in partnership with the professional, as the protagonist of their own orthodontic treatment.The impossibility of face-to-face care during the beginning of the COVID-19 pandemic led orthodontists to offer virtual control of treatment to patients.During this period, some cross-sectional descriptive Torres DKB, Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment?A systematic review and meta-analysis

Torres DKB, 23 Dental
Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment?A systematic review and meta-analysis

Torres DKB, 25 DentalCONCLUSIONS
Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment?A systematic review and meta-analysisThe studies included in the present review were controlled clinical trials with low to high risk of bias, and very low certainty of evidence.Teledentistry using the Dental Monitoring ® software is effective in helping to monitor the evolution of interceptive orthodontic treatment (high risk of bias), and especially in the treatment performed with orthodontic aligners (low to moderate risk of bias).The meta-analysis showed that teledentistry during orthodontic treatment with aligners reduces the time to start refinement and also the number of face-to-face visits, not being able to affect the total treatment duration, the number of refinements and the number of refinement aligners.Randomized studies evaluating usual technological alternatives among patients and orthodontists are welcome, especially in orthodontic treatment with fixed appliances, due to the lack of studies with conventional corrective or compensatory mechanics composed of brackets and wires.

Table 1 :
Studies excluded after reading the articles in full, as they did not meet the eligibility criteria.

Table 2 :
Data extraction from the studies included in this systematic review.

, year and type of study. Sample (n) / age ± SD Orthodontic treatment Telemonitoring method Comparison method Evaluated variables / statistics Results Conclusion Funding source Conflict of interest report
SD = standard deviation; DM = dental monitoring; NR = not reported.

Torres DKB, Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment? A systematic review and meta-analysis Dental
Press J Orthod.2023;28(4):e2322195

Torres DKB, Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment? A systematic review and meta-analysis Dental
Press J Orthod.2023;28(4):e2322195

Table 1 :
Terms selected to be used during searches, according to the P (participants) and E (exposure) of PECO strategy.

DKB, Santos MCC, Normando D -Is teledentistry effective to monitor the evolution of orthodontic treatment? A review and meta-analysis 34 Dental Press J Orthod. 2023;28(4):e2322195 Database Search performed in the selected database
Orthodontic Appliances[MeSH Terms]) OR (Appliance, Orthodontic[Title/Abstract] OR Appliances, Orthodontic[Title/Abstract] OR Orthodontic Appliance[Title/Abstract]) OR Orthodontic Appliances, Removable[MeSH Terms] OR "Removable Orthodontic Appliance"[Title/Abstract] OR "Removable Orthodontic Appliances"[Title/Abstract] OR "Clear Aligner Appliances"[Title/Abstract] OR "Appliance, Clear Aligner"[Title/Abstract] OR "Appliances, Clear Aligner"[Title/Abstract] OR "Clear Aligner Appliance"[Title/Abstract] OR "Invisalign"[Title/Abstract] OR (Orthodontic Appliances, Fixed[MeSH Terms]) OR (Orthodontic Appliances, Fixed[Title/Abstract] OR Appliance, Fixed Orthodontic[Title/Abstract] OR Appliances, Fixed Orthodontic[Title/Abstract] OR Fixed Orthodontic Appliance[Title/Abstract] OR Fixed Orthodontic Appliances[Title/Abstract] OR Orthodontic Appliance, Fixed[Title/Abstract] OR Fixed Functional Appliances[Title/Abstract] OR Appliance, Fixed Functional[Title/Abstract] OR Appliances, Fixed Functional[Title/ Abstract] OR Fixed Functional Appliance[Title/Abstract] OR Functional Appliance, Fixed[Title/Abstract] OR Functional Appliances, Fixed[Title/Abstract] OR Fixed Retainer[Title/Abstract] OR Fixed Retainers[Title/Abstract] OR Retainer, Fixed[Title/Abstract] OR Retainers, Fixed[Title/Abstract] OR Bonded Retainer[Title/Abstract] OR Bonded Retainers[Title/Abstract] OR Retainer, Bonded[Title/Abstract] OR Retainers, Bonded[Title/Abstract] OR Fixed Appliances[Title/Abstract] OR Appliance, Fixed[Title/Abstract] OR Appliances, Fixed[Title/Abstract] OR Fixed Appliance[Title/Abstract] OR Permanent Retainer[Title/Abstract] OR Permanent Retainers[Title/Abstract] OR Retainer, Permanent[Title/Abstract] OR Retainers, Permanent[Title/Abstract]) OR Orthodontics[MeSH Terms] #2 (Mobile Applications[MeSH Terms]) OR (Mobile Applications[Title/Abstract] OR Application, Mobile[Title/Abstract] OR Applications, Mobile[Title/Abstract] OR Mobile Application[Title/Abstract] OR Mobile Apps[Title/Abstract] OR App, Mobile[Title/Abstract] OR Apps, Mobile[Title/Abstract] OR Mobile App[Title/Abstract] OR Portable Electronic Apps[Title/Abstract] OR App, Portable Electronic[Title/Abstract] OR Apps, Portable Electronic[Title/Abstract] OR Electronic App, Portable[Title/Abstract] OR Electronic Apps, Portable[Title/Abstract] OR Portable Electronic App[Title/Abstract] OR Portable Electronic Applications[Title/Abstract] OR Application, Portable Electronic[Title/Abstract] OR Applications, Portable Electronic[Title/Abstract] OR Electronic Application, Portable[Title/Abstract] OR Electronic Applications, Portable[Title/Abstract] OR Portable Electronic Application[Title/Abstract] OR Portable Software Apps[Title/Abstract] OR App, Portable Software[Title/Abstract] OR Apps, Portable Software[Title/Abstract] OR Portable Software App[Title/Abstract] OR Software App, Portable[Title/Abstract] OR Software Apps, Portable[Title/Abstract] OR Portable Software Applications[Title/Abstract] OR Application, Portable Software[Title/Abstract] OR Applications, Portable Software[Title/ Abstract] OR Portable Software Application[Title/Abstract] OR Software Application, Portable[Title/Abstract] OR Software Applications, Portable[Title/Abstract]) OR Distance counseling[Title/Abstract] OR Teledentistry[Title/Abstract] OR Telemonitoring[Title/Abstract] OR Distance monitoring[Title/Abstract] OR Teleorthodontics[Title/Abstract] OR Tele-orthodontics[Title/Abstract] OR home teleassistance[Title/Abstract] OR dental monitoring[Title/Abstract] OR remote monitoring[Title/Abstract] OR (Smartphone[MeSH Terms]) OR (Smartphone[Title/Abstract] OR Smartphones[Title/Abstract] OR Smart Phones[Title/Abstract] OR Smart Phone[Title/Abstract] OR Phones, Smart[Title/Abstract]) Final search: #1 AND #2