Understanding technology adoption by orthodontists_ A quantitative study

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ORIGINAL ARTICLE
Understanding technology adoption by
orthodontists: A quantitative study
Laura Anne Jacox,a Clare Bocklage,a Teresa Edwards,b Paul Mihas,b Feng-Chang Lin,c and Ching-Chang Kod
Chapel Hill, NC, and Columbus, Ohio
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Introduction: Digital scanning, treatment planning, 3-dimensional imaging, and printing are changing the
practice of orthodontics. These tools are adopted with the hope that treatment becomes more predictable,
efficient, and effective while reducing adverse outcomes. Digital tools are impacting care, but knowledge of
nationwide adoption trends and motivators is incomplete. Methods: We aimed to identify adoption decision-
makers, information sources, incentives, and barriers through the first nationwide survey of American
Association of Orthodontics members on their technology adoption habits, needs, and outcomes. Data were
assessed using descriptive and bivariate analyses. The survey was developed from a comprehensive
qualitative interview phase as part of a mixed methodology study. Results: Responses (n 5 343) revealed or-
thodontists make adoption decisions on the basis of advice from other dentists and company representatives
while rarely consulting staff or research literature. Continuing education and meetings are most effective at
disseminating information to practicing doctors, whereas journals generate less impact. Key adoption incentives
include added capabilities, practice efficiency, ease of implementation, and performance, whereas cost is the
main barrier to purchase. Early adopters with larger practices charge higher fees than other adopters to support
the costs of technologies. Treatment outcome is not a primary adoption incentive for specific technologies.
Conclusions: Orthodontists positively perceive the influence of intraoral scanning, cone-beam computed
tomography imaging, 3-dimensional printing, computer-aided design–computer-aided manufacturing
archwires, and clear aligner therapy on their practice and patient care. The orthodontic technological
transformation is underway, and knowledge of adoption can guide our transition into modern practice, in
which digital tools are effective adjuncts to the specialists' expertise. (Am J Orthod Dentofacial Orthop
2022;161:364-74)
ion of Craniofacial and Surgical Care, Adams School of Dentistry, University
rth Carolina, Chapel Hill, NC.
ard W. Odum Institute for Research in Social Science, University of North
na, Chapel Hill, NC.
rtment of Biostatistics, Gillings School of Global Public Health, University
rth Carolina, Chapel Hill, NC.
ion of Craniofacial and Surgical Care, Adams School of Dentistry, University
rth Carolina, Chapel Hill, NC; currently, Division of Orthodontics, College of
stry, The Ohio State University, Columbus, Ohio.
thors have completed and submitted the ICMJE Form for Disclosure of
tial Conflicts of Interest, and none were reported.
ork was supported by the National Institute of Dental and Craniofacial
rch at the National Institutes of Health (grant no. R01DE022816; award
ing-Chang Ko) and the University of North Carolina (UNC) Hale Professor-
und (award to Ching-Chang Ko). This work was funded by the American
iation of Orthodontists Foundation Martin ‘Bud’ Schulman Postdoctoral
ship (award to Laura Anne Jacox). This work was also supported by the
ate School Masters Merit Assistantship for study in Dentistry awarded by
NC Graduate School, the Southern Association of Orthodontics research
, and the Masters Research Support Grant awarded by the Office of the
iate Dean for Research at UNC Adams School of Dentistry and the Dental
ation of North Carolina (awards to Laura Anne Jacox).
ss correspondence to: Ching-Chang Ko, Division of Orthodontics, College
ntistry, Ohio State University, 4088A Postle Hall, Columbus, OH 43210;
l, ko.367@osu.edu.
itted, April 2020; revised and accepted, August 2020.
5406/$36.00
1.
//doi.org/10.1016/j.ajodo.2020.08.024
Technology is changing how orthodontists deliver
care.1,2 Traditionally, patients begin treatment
with alginate impressions; 2-dimensional radio-
graphs; and bonded straight wire appliances that require
monthly, chair-side modifications to achieve an ideal
finish.3 In a digital office, patients begin with an intrao-
ral and cone-beam computed tomography (CBCT) scan,
followed by a digital tooth setup and fabrication of
custom appliances including clear aligners (eg, Invisa-
lign, U-Lab, Orchestrate), computer-aided design–
computer-aided manufacturing (CAD-CAM) brackets
(eg, Insignia, Incognito), or prebent CAD-CAM archwires
(eg, SureSmile).4 The orthodontist spends nonpatient
hours digitally planning treatment. Subsequent patient
appointments can be shorter and more widely spaced,
especially with clear aligners. The doctor tracks progress
and compliance as the appliances execute planned
movements until intervention or revision is needed.
This change in workflow opens the door for remote
treatment monitoring, teledentistry, and market disrup-
tors like direct-to-consumer aligners.4
Jacox et al 365
Despite the excitement for and adoption of these
tools, it is ambiguous whether digital approaches improve
outcomes and efficiency, as results vary between products
and studies.5-10 CAD-CAM brackets were initially more
effective and efficient than standard appliances, but
subsequent studies have found minimal improvement
in outcome and treatment times.6,9,10 Robotically bent
archwires are associated with reduced treatment times,
but data on finish quality are conflicting.5,7,8,10 Although
much improvement is needed, future development is
likely to offer safer, more efficient, and effective
orthodontic treatment, necessitating the adoption of
the digital workflow.5-10
For digital workflows to improve care, orthodontists
must effectively integrate technologies and track
outcome metrics. Widespread adoption of digital tech-
nologies is occurring, but we have an incomplete under-
standing of how orthodontic practice is shaped by these
tools and which factors impact technology dissemina-
tion.11,12 To understand the current technology land-
scape, we conducted a 2-phase, mixed methodology
study to identify orthodontic decision-makers, informa-
tion sources, incentives, and barriers for technology
adoption. The first phase consisted of qualitative
semistructured interviews with 24 privately practicing
orthodontists, most affiliated as adjunct faculty in the
graduate orthodontic programs at the University of
North Carolina (UNC) Adams School of Dentistry and
Harvard School of Dental Medicine.13 These interviews
allowed us to identify key factors in the technology
adoption process. To test the generalizability of our
findings, we developed and distributed the first national
survey on technology adoption of American Association
of Orthodontics (AAO) members. Results provide quanti-
tative insight into the state of technology adoption by
orthodontists and can be used to guide innovation and
information dissemination.
MATERIAL AND METHODS
This survey is the second part of a 2-phase, mixed-
methods investigation in which we used qualitative in-
terviews to identify factors important to technology
adoption with the breadth and depth, followed by a
quantitative survey to measure the generalizability of
our findings.13
Results from our qualitative study guided the devel-
opment of an online survey to assess technology
adoption, influence, and future needs among the mem-
bership of the AAO. For example, we learned in qualita-
tive interviews that technology cost, performance, and
ease of use are key adoption factors, which we incorpo-
rated into the quantitative survey as options for why
American Journal of Orthodontics and Dentofacial Orthoped
technology was adopted or forgone. Because of a lack
of validated questions available for this topic, published
questionnaires were referenced,and questions were
developed from our qualitative findings by the authors
with significant input from a sociologist working in ed-
ucation (Paul Mihas), an expert in survey development
(Teresa Edwards), a biostatistician (Feng-Chang Lin),
and an orthodontic faculty member (Ching-Chang Ko)
to ensure representation of different viewpoints.2,14
The survey was fully pretested with probe questions by
8 orthodontic residents, 8 privately practicing doctors,
and 2 academic orthodontic faculty at UNC Adams
School of Dentistry following methods recommended
by Willis, 2005.15 Probes were used to explore the ques-
tion interpretation and identify points of ambiguity. The
survey was iteratively revised on the basis of feedback to
improve clarity.
The survey consists of 30 demographic questions
about the orthodontist and their primary place of
work. These first 30 questions are identical across re-
spondents, but later questions are customized using a
preprogrammed decision tree in Qualtrics to display
questions on the basis of which technologies doctors
had used or forgone. The decision tree presents 6-10
questions asking about adopted tools, the influence of
those tools, and avoided or abandoned technologies.
As a result, each participant did not answer all questions
about every technology but instead had a customized
survey experience on the basis of their adoption history.
This is reflected in a lower number of responses for
questions on specific tools than the total participant
pool. For example, if a doctor uses an intraoral scanner,
the participant was asked why the practice purchased the
scanner and how they perceived its influence in the of-
fice. Alternatively, if an orthodontist had not used a 3-
dimensional (3D) printer, they were asked why they
had not adopted this technology.
All methods were approved by the Institutional Re-
view Board and the Office of Human Research Ethics
of the UNC at Chapel Hill (Institutional Review Board
no. 16-2743).
Survey questions were submitted to the AAO Partners
in Research Program for review and approval. Once
approved, the AAO randomly selected 2,300 members
with registered e-mail addresses to be contacted with
informed consent documentation and a Qualtrics link
for survey participation. Recipients were randomly
selected from their total membership after nonqualifying
members were excluded (Table I). Our sample includes
actively practicing doctors in private or corporate clinics
in the United States and Canada, excluding all current
residents, retired doctors, recent graduates (\2 years
of practice), full-time academics, public health doctors,
ics March 2022 � Vol 161 � Issue 3
Table I. Survey inclusion and exclusion criteria
Criteria Description
Inclusion � An orthodontist who practices in a private
orthodontics clinic that is orthodontics-only
or a group multispecialty practice
� An orthodontist can be an associate, partner,
or sole owner of the practice in which they work
� A doctor must have been actively working in
private practice for .2 y and must provide
informed consent
� Member of the AAO
Exclusion � A doctor who does not practice privately
(eg, academic-only or public health orthodontists)
� An orthodontist who has been practicing for\2 y
in private practice
� Current orthodontic residents
� Retired doctors
366 Jacox et al
hospital-based orthodontists, and doctors in other
countries (Tables I and II; Supplementary Table I).
Screening questions ensured all participants met inclu-
sion criteria. Orthodontists who did not fill out the sur-
vey within a week received a second e-mail, distributed
at a different time and day to maximize responses. The
survey was conducted through the UNC Qualtrics li-
cense, and data was stored securely and deidentified.
After an initial distribution and reminder e-mail, the
AAO authorized an additional distribution to boost re-
sponses. An additional 2,300 members were randomly
selected from the total membership using the same inclu-
sion and exclusion criteria (Table I) while excluding all
previously emailed doctors. Therefore, a total of 4,600
AAO randomly selected members were emailed in both
distribution waves, with a total combined response rate
of 7.4% with 343 responses (Supplementary Table I).
Although our response rate is on the low end of recent
technology surveys, with average response rates of 7%-
11%, our survey was longer and more complex, leading
to a higher incidence of partial completion.14,16
Responses were categorized as being from an early,
middle, or late adopter on the basis of screening ques-
tions. Participants were asked how often they were
among the first people in their professional dental
network or community to try a new technology or prod-
uct. Early adopters self-reported as always or usually,
while late adopters self-reported rarely or never explored
new products. Self-reporting can be biased, so group-
ings were revised relative to 3 follow-up questions. Doc-
tors were asked if they are part of a corporate insider's
group and if they participate in beta-testing new prod-
ucts for companies, features of early adopters; if a doctor
answered yes to either of these questions, they were
moved to the early adopter group. Participants were
also asked which technologies they had tried. Doctors
who tried all technologies were moved to the early
adopter category, whereas doctors who tried no technol-
ogies were categorized as late adopters. Orthodontists
who tried more than half of technologies while
answering that they rarely or never explored new prod-
ucts were moved from the late to middle pool. Middle
adopters were practitioners who did not meet the criteria
for being late or early adopters. Participants were indi-
vidually reviewed to ensure group assignment was logi-
cally consistent with their adoption history.
Data analysis
Survey data were assessed using descriptive and
bivariate analyses. Descriptive statistics such as mean,
standard deviation, and percentage are reported for
collected variables. Bivariate association analysis
March 2022 � Vol 161 � Issue 3 American
between demographic variables and questions (scales)
were explored using t tests, F tests, and chi-square tests
when appropriate. Responses with continuous variables
were analyzed using unpaired t tests for pairwise com-
parisons and 1-way analysis of variance for the 3 adopter
groups. Categorical data were assessed using the chi-
square test. Multiple-choice questions in which respon-
dents could choose up to 3 answers or as many options
as desired are reported as frequencies with pairwise com-
parisons by chi-square test. Final analyses were weighted
by inverse probability weights that balance the sample to
represent the whole population.
RESULTS
To understand the adoption process, we surveyed
who is making purchasing decisions and where they
learn about new technologies. Consistent with qualita-
tive findings, 89% of orthodontic practice owners,
partners, and associates participate in purchasing
conversations, but adoption decisions are made with
minimal staff input, regardless of the adopter group
(Supplementary Table II). Assistants are consulted by
only 16% of respondents, whereas 16% of office man-
agers are included in discussions. Front desk, treatment
coordinators, financial staff, and laboratory technicians
are involved in purchasing choices by\10% of owners.
Our qualitative data revealed that doctors leave staff out
of the adoption process believing they are resistant to
change, but owners are committed to thorough training
with the goal of staff buy-in once a product is
purchased.13
To identify information sources for adoption, ortho-
dontists were asked how they first heard about technol-
ogies and what resources are consulted for more
Journal of Orthodontics and Dentofacial Orthopedics
Table II. Practice demographics
Demographics
Adopter group
P
Early adopter
(n 5 69)
Middle adopter
(n 5 177)
Late adopter
(n 5 97)
Total
(n 5 343)
Appliances used at practice, %
Traditional twin/edgewisebrackets 53 (77) 143 (81) 84 (87) 280 (82) 0.237
Self-ligating brackets 42 (61) 93 (53) 36 (37) 171 (50) 0.006
Clear aligners produced off-site (eg, Invisalign, ClearCorrect) 63 (91) 154 (87) 86 (89) 303 (88) 0.662
Clear aligners produced in-house, excluding active retainers
(eg, Orchestrate)
32 (46) 34 (19) 5 (5) 71 (21) \0.001
Custom CAD-CAM lingual brackets (eg, Incognito, Harmony) 10 (14) 6 (3) 3 (3) 19 (6) 0.004
Custom CAD-CAM buccal brackets (eg, Insignia) 3 (4) 7 (4) 0 (0) 10 (3) 0.101
Custom bent CAD-CAM archwires (eg, Suresmile) 14 (20) 8 (5) 0 (0) 22 (6) \0.001
Patients treated with clear aligners, % 27.6 (20.2) 18.7 (16.3) 13.4 (11.8) 19.0 (16.8) \0.001
Patients receiving CBCT scans, % 28.2 (39.0) 14.4 (28.8) 6.20 (17.3) 14.8 (29.5) \0.001
Practice organization 0.020
Private orthodontics-only practice 58 (88) 130 (80) 72 (76) 260 (80) 0.161
Private multispecialty group practice 5 (8) 19 (12) 5 (5) 29 (9) 0.216
Corporate/DSO orthodontics-only practice 3 (5) 7 (4) 8 (8) 18 (6) 0.365
Corporate/DSO multispecialty group practice 0 (0%) 6 (4%) 10 (11%) 16 (5%) 0.005
Practice setting, % 0.901
Large city 22 (33) 45 (27) 25 (26) 92 (28)
Small to medium city 12 (18) 33 (20) 17 (18) 62 (19)
Suburb 21 (32) 53 (32) 29 (31) 103 (32)
Rural 0 (0) 1 (1) 0 (0) 1 (0)
Small to medium town 11 (17) 33 (20) 24 (25) 68 (21)
Note. Values are percent mean (standard deviation).
Jacox et al 367
information. As in our interview sample, the majority of
doctors (72%) first hear about new technologies from
other orthodontists and turn to colleagues to learn
more about products (Supplementary Table III). Con-
sistent with our qualitative data, the importance of
person-to-person exchange extends to company repre-
sentatives, which act as the second most cited source
of initial and follow-up information for new tools
(42%; Supplementary Table III). Conferences and live
continuing education lectures are another significant in-
formation source (41%; Supplementary Table III). All
other sources were cited by less than one-third of re-
spondents. Only about a quarter of orthodontists turn
to academic journals to learn about technologies, similar
to our interview cohort in which 17% cited journals as a
resource.13 Social media reaches nearly as many ortho-
dontists as published literature (Supplementary Table
III). These data suggest conference continuing education
is a more effective way to disseminate knowledge to
practicing doctors than academic journals. Once some
orthodontists are aware of technology, information is
then dispersed to the dental community.
Technology acquisition varies greatly among early,
middle, and late adopters. To outline differences be-
tween groups, we looked at practice characteristics
and demographics. Notable trends emerged regarding
American Journal of Orthodontics and Dentofacial Orthoped
tech adoption, practice fees, and size. Early adopters
began more patients per year than other groups, and
early and middle adopters had significantly higher
fees than late adopters (Fig 1; Supplementary Table
IV). Late adopters' fees for nonextraction and extrac-
tion patients fall well below the national average for
comprehensive treatment of an adolescent ($5,748.17
6 $521.97; American Dental Association 2018 Sur-
vey), whereas early and middle adopters charge fees
consistent with the average for nonextraction (Fig 1;
Supplementary Table IV).17 A larger fraction of late
adopters is working in corporate offices, in which
they may lack purchasing autonomy (Table II). There
was no statistically significant difference in staff size
between groups, meaning early adopters start more
patients and charge more per patient, with similar
staff overhead, relative to later adopters (Fig 1;
Supplementary Table IV). Consistent with our qualita-
tive findings, differences in patient starts and collec-
tions per patient suggest that a more lucrative
practice is required to support the cost and time re-
quirements of technology integration.
No significant trends were found relative to an ortho-
dontists' age, gender, ethnicity, time in practice, resi-
dency program, or practice setting (eg, rural or
suburban) (Table II; Supplementary Table I).
ics March 2022 � Vol 161 � Issue 3
Fig 1. Average fee, patient starts, and staff size by adopter group. A, Average fees for a nonextraction
and extraction, comprehensive adolescent patient by adopter group.Arrow: The 2018 national average
for comprehensive treatment of an adolescent, published by the American Dental Association, is
$5,748.17 6 $521.97.17 B, Average patient starts per year by adopter group. C, Average staff size
by adopter group.
368 Jacox et al
Adopter categories vary greatly in their usage of
appliances and technologies. Early and middle
adopters are significantly more likely to use self-
ligating brackets than late adopters (Table II;
Supplementary Table V). Early adopters use CAD-
CAM wires (eg, Suresmile) and have begun producing
in-house clear aligners at a greater frequency than
others (Table II; Supplementary Table V). Early
adopters also order CBCT imaging and prescribe clear
aligner therapy for a higher fraction of patients (Table
II; Supplementary Table V). There is no significant dif-
ference in the current use of twin brackets and clear
aligners produced off-site (eg, Invisalign), indicating
some level of universal adoption. More early adopters
tried CAD-CAM brackets than middle and late adopters
at some time, but there is no significant difference in
the current use of custom buccal brackets, suggesting
early adopters abandoned these appliances. The prac-
tice of orthodontics differs between groups, with early
adopters using newer appliances and imaging modal-
ities than middle and late adopters.
March 2022 � Vol 161 � Issue 3 American
To understand what motivates a doctor to purchase
or forgo a technology, orthodontists were asked what
factors are most important when considering adoption.
We hypothesized that primary factors include cost, capa-
bilities, practice efficiency, ease of implementation, and
performance on the basis of our qualitative findings.13
As anticipated, cost and return on investment were
most frequently identified as important across all groups
(Table III). Effect on treatment outcome is commonly
cited, along with the impact on workflow and efficiency
(Table III). More late and middle adopters are concerned
with a product's user-friendliness, whereas early
adopters focus on patient preference. Middle adopters
consider reduced treatment time or office visits more
often.
Broadly considering factors for acquisition is
insightful, but to fully understand the adoption story,
we asked orthodontists specifics about technologies
they regularly use, why certain tools were acquired,
and others were never purchased. Across all groups
and technologies, the adoption barrier most commonly
Journal of Orthodontics and Dentofacial Orthopedics
Table III. Important adoption factors by adopter group
Adoption factors
Adopter group
P
Early adopter
(n 5 67)
Middle adopter
(n 5 169)
Late adopter
(n 5 96)
Total
(n 5 332)
Costs, overhead, and return on investment 50 (74.6) 125 (74.0) 78 (81.2) 253 (76.2) 0.389
Treatment outcome 47 (70.1) 119 (70.4) 63 (65.6) 229 (69.0) 0.706
Practice workflow and efficiency 29 (43.3) 68 (40.2) 42 (43.8) 139 (41.9) 0.825
User-friendly, easy to implement 15 (22.4) 42 (24.9) 25 (26.0) 82 (24.7) 0.875
Equipment performance (fast, accurate, reliable, no bugs) 13 (19.4) 28 (16.6) 23 (24.0) 64 (19.3) 0.327
Satisfies patient preferences or requests 15 (22.4) 24 (14.2) 14 (14.6) 53 (16.0) 0.279
Reduced office visits and/or total treatment time 9 (13.4) 31 (18.3) 12 (12.5) 52 (15.7) 0.452
Added diagnostic value 9 (13.4) 26 (15.4) 9 (9.4) 44 (13.3) 0.401
Additional capabilities 10 (14.9) 19 (11.2) 3 (3.1) 32 (9.6) 0.017
Marketing and word of mouth 4 (6.0) 12 (7.1) 2 (2.1) 18 (5.4) 0.197
Note. Values are percent mean (standard deviation).
Jacox et al 369
cited was cost and overhead, yet reducing overhead is asignificant incentive only for 3D printing and in-house
aligner production (Figs 2 and 3; Supplementary Tables
VI and VII). Cost is largely an impediment to acquisition
rather than a motivator for most tools. This is similar to
technology performance which dissuades the purchase
of 3D printers, intraoral scanners, and off-site aligners,
whereas excellent performance is rarely cited as an
incentive (Figs 2 and 3; Supplementary Tables VI and
VII). Space requirements for an intraoral scanner and
3D printer are also considerations.
Implementation of CAD-CAM appliances and in-
house 3D printing for aligners is difficult and potentially
detrimental to practice workflow. Effect on practice
workflow and efficiency is a frequent barrier and incen-
tive for most technologies, pointing to the importance of
workflow integration. Furthermore, CAD-CAM appli-
ances are perceived to offer the same or worse treatment
outcomes with higher overhead and inefficiency (Figs 2
and 3; Supplementary Tables VI and VII). However,
improved treatment outcomes were also a primary
incentive for CAD-CAM appliance adoption, suggesting
clinicians have markedly different experiences imple-
menting more complex technologies.
When asked broadly about adoption factors, addi-
tional capabilities are rarely an incentive, contrary to
our qualitative results (Figs 2 and 3; Supplementary
Tables VI and VII).13 However, when doctors are asked
about specific technologies, added capabilities are a
commonly cited incentive across all tools and adopters.
This suggests doctors are more aware of their motiva-
tors when considering specific examples and that our
interview sample was representative. Similarly, treat-
ment outcome is a regularly chosen factor when asked
broadly about adoption factors, but it is an infrequent
motivator for all tools except CAD-CAM brackets and
American Journal of Orthodontics and Dentofacial Orthoped
wires. Treatment outcome ranked eigth in importance
in our qualitative results.13 Treatment outcome is crit-
ical to orthodontists, but when considering specific
technologies, it is selected less often than cost, ease
of integration, and impact on efficiency. The patient
request drives esthetic treatment modalities and intrao-
ral scanning, as satisfying the customer leads to con-
versions. Orthodontists care for their patients, but
they are running businesses requiring optimization
for practice economics, efficiencies, and patient con-
versions. Data are consistent with our hypothesis that
primary adoption factors include cost, added capabil-
ities, practice efficiency, ease of implementation, and
performance.
Adopters of technology were asked to reflect on how
their digital tool influenced their practice and patient
care. Each doctor was asked about technologies they
recently adopted on the basis of the survey's decision
tree; as a result, the total number of responses for
each technology was lower than the total sample of
the survey, with more commonly adopted digital tools
having more responses (Supplementary Table VIII: in-
traoral scanner n 5 223; Supplementary Table IX: 3D
printer n 5 48; Supplementary Table X: CBCT n 5 46;
Supplementary Table XI: CAD-CAM archwires n 5 18;
Supplementary Table XII: CAD-CAM brackets n 5 16;
Supplementary Table XIII: laboratory-fabricated clear
aligners n 5 262; Supplementary Table XIV: in-house
fabricated clear aligners n 5 47). The intraoral scanner
and 3D printer were seen by most doctors as having a
positive effect on improving practice capabilities,
efficiency, and workflow while also addressing patient
preferences (Supplementary Tables VIII–IX). Both tech-
nologies provided a marketing advantage, whereas the
intraoral scanner improved the storage needs of practice
by eliminating plaster models.
ics March 2022 � Vol 161 � Issue 3
Fig 2. Barriers to adoption by technology. The primary barrier is the factor includedmost often for why a
doctor is not considering purchasing a technology. The secondary barrier is the factor selected second
most frequently for why a doctor is not considering a tool. The number in (parentheses) is the number of
responses associated with a factor for a particular technology. Each factor was associated randomly
with a color to aid in visual evaluation. Not all responders answered all questions because they had
adopted the technology or the display logic decision tree limited the number of questions.
370 Jacox et al
As imaging modalities, CBCT and intraoral scanning
were seen as improving orthodontist's diagnostic ability
and practice capabilities (Supplementary Tables VIII and
X). CBCT imaging also enhanced treatment outcomes
without impacting treatment time, office visits, or work-
flow (Supplementary Table X). CBCT increased operating
costs for a majority of doctors, whereas intraoral scan-
ning did not (Supplementary Tables VIII and X).
CAD-CAM archwires (SureSmile) were positively re-
viewed by most doctors and were seen as improving
treatment outcomes, practice workflow, and capabilities
while reducing treatment time and the number of office
visits (Supplementary Table XI). However, the feedback
on CAD-CAM brackets was markedly more negative
than for CAD-CAM archwires in survey responses and
prior interviews, although our sample size was small.13
The majority responded that custom brackets had no ef-
fect or a negative effect on practice workflow, treatment
outcomes, total treatment time, and the number of of-
fice visits (Supplementary Table XII). CAD-CAM brackets
did enhance practice capabilities and provided a slight
marketing edge for most doctors. With the sizable
March 2022 � Vol 161 � Issue 3 American
overhead associated with CAD-CAM technologies,
custom wires appear to be the preferable investment
over brackets: a topic worth exploring with a larger
cohort of CAD-CAM adopters.
Another promising CAD-CAM product is the nearly
ubiquitous clear aligner therapy. Laboratory-produced
clear aligners (eg, Invisalign, ClearCorrect) had
numerous positive repercussions, including reducing of-
fice visits, addressing patient requests for esthetic treat-
ment, and boosting practice capabilities, marketing, and
workflow efficiency (Supplementary Table XIII). For a
majority of orthodontists, lab fabricated clear aligners,
CAD-CAM wires, and brackets had a negative impact
on overhead and operating costs because of their sizable
laboratory fees (Supplementary Tables XI–XIII). In
contrast, manufacturing clear aligners in-house reduced
overhead, as practices bypassed laboratory costs
(Supplementary Table XIV). In-house aligners also satis-
fied patients' desires for esthetics and enhanced practice
capabilities. However, most doctors reported that in-
house aligners did not affect the number of office visits,
unlike laboratory-produced aligners. All aligners, both
Journal of Orthodontics and Dentofacial Orthopedics
Fig 3. Incentives for adoption by technology. The primary incentive is the factor included most often for
why a doctor is considering purchasing a technology. The secondary incentive is the factor selected
second most frequently for why a doctor is considering a tool. The number in (parentheses) is the num-
ber of responses associated with a factor for a particular technology. Each factor was associated
randomly with a color to aid in visual evaluation. Not all responders answered all questions because
they had adopted the technology or the display logic decision tree limited the number of questions.
Jacox et al 371
in-house and laboratory-fabricated, were seen as neither
helping nor hurting treatment outcomes and treatment
time by most doctors. Treatment was still guided by the
practitioner, not the appliance.
Across nearly all technologies, a greater fraction of
early and middle adopters viewed their digital tools as
positively influencing their practices than late adopters,
consistent with our qualitative results.
DISCUSSION
Mixed method studies are rare in the orthodontic
literature but allow us to answer nuanced social sciencequestions. To explore a topic as broad and multifaceted
as technology adoption, our study required methodo-
logical pluralism with a qualitative interview phase fol-
lowed by a quantitative survey. Our phase 1 interviews
identified factors important to technology adoption
because of this format's flexibility to explore topics
with depth and breadth.13,18 The results laid the founda-
tion for a successful survey, in which we tested the sta-
tistical generalizability of our findings with a larger
group of participants. This mixed-methods approach
American Journal of Orthodontics and Dentofacial Orthoped
proves powerful by merging the advantages of qualita-
tive research with the pros of quantitative surveys.18
The qualitative research phase generated numerous
inductive topics, which we were then able to measure
quantitatively using the survey.
Through our mixed-methods research, we found
practice owners and associates make purchasing deci-
sions independently of staff, on the basis of input
from other dentists, company representatives, and con-
ference continuing education lectures. Academic jour-
nals are referenced by only a quarter of doctors
looking to adopt a technology, suggesting published
data on product efficacy are not reaching private practi-
tioners or is reaching them after relevant decisions have
already been made. Because of the importance of
person-to-person communication, it is critical that sci-
entific evidence enters the knowledge food chain to
avoid marketing-fueled adoption of unproven technolo-
gies at the hands of companies and their representa-
tives.19,20 Evidence-based practice can flourish only
when evidence is reaching clinicians. As a field, we
must reflect on ways to infuse our standard of care
ics March 2022 � Vol 161 � Issue 3
372 Jacox et al
with up-to-date findings, as academic journals are not
fulfilling this role. When research is published in peer-
reviewed articles, there is a lag time of at least 6-18
months from data acquisition to publication. For highly
relevant findings, this may be too long. Conference
continuing education and improved social media and
online platforms could be more promising contact
points at this time; including a peer-review element to
ensure quality control in these formats is the unsolved
challenge.
Interesting trends emerge regarding features of
adopter groups. Early adopters prescribe CBCT scans
and clear aligner therapy for a greater fraction of their
patients (Table II). Early adopters also use more recent
appliances, including self-ligating brackets, CAD-CAM
wires, and clear aligners produced in-house with 3D
printers and positive pressure fabricators (Table II;
Supplementary Table V). CAD-CAM brackets have been
tried by significantly more early adopters, but there is
no significant difference between groups in current
use, which may suggest doctors abandoned these appli-
ances after trying them. In our small sample, the main
barrier to CAD-CAM appliances is increased cost with
no anticipated benefit to treatment outcome or effi-
ciency. This perception may stem from early adopters
who were dissatisfied with custom brackets, discontin-
ued use, and spread the word to their colleagues via
the communication hierarchy identified in our qualita-
tive study.13 Frequently, early adopters try new technol-
ogies and make recommendations to their community of
middle and late adopters. CAD-CAM brackets will need
notable advances in efficiency and effectiveness for
wider adoption to occur and compete with CAD-CAM
wires, which are more positively perceived by users
(Supplementary Tables XI and XII).
Early adopters tend to have privately owned practices
with larger patient pools and higher fees on average (Fig
1; Table II). Staff sizes were nearly equivalent between
groups, such that the ratio of the patient starts to staff
was highest with early adopters. These data could sug-
gest more lucrative businesses with more customers,
higher fees, and higher patient-to-staff ratios are needed
to cover the cost requirements of technology. Alterna-
tively, the implementation and adoption of new technol-
ogies may help to increase practice size and efficiency. As
orthodontics becomes more tech-heavy, there is
increased risk to lower-fee, lower volume practices that
cannot afford expensive digital tools and practices that
are uninterested in tech adoption.
Contrary to the qualitative study, which showed early
adopters are younger than late adopters, no notable age-
relationship was found in our quantitative results
(Supplementary Table I). This may be because younger
March 2022 � Vol 161 � Issue 3 American
doctors have less purchasing autonomy when working
as associates and have less available capital when own-
ing a recently transitioned practice, preventing them
from adopting expensive tools. As a result, young doc-
tors are no more likely to adopt a technology than older
practitioners, who are approaching retirement and have
established systems. Our qualitative interview sample
was small and included many doctors practicing in
growing or rural areas, who established lucrative prac-
tices within a few years of start-up or transition; most
doctors were also affiliated with the UNC and Harvard
School of Dental Medicine graduate orthodontic resi-
dency programs as part-time adjunct faculty, increasing
their exposure to new technologies. Therefore, our phase
I interview sample was not representative of the greater
United States, particularly in saturated urban centers
surveyed in our nationwide sample. Another variant be-
tween phases I and II occurred in the selection of adop-
tion incentives. When orthodontists were surveyed
about what, in general, motivates them to buy a tool,
the additional capability was rarely chosen while
improved treatment outcome was a common selection.
However, when doctors were surveyed about specific
technologies, similar to our interviews, these factors
reversed in importance, with the outcome being an
infrequent consideration and new capabilities moti-
vating purchase.13 In a sequential study, our qualitative
phase directs the quantitative phase, so comparisons are
interesting but secondary to our primary objectives.
Doctors care about treatment outcomes, but when
considering major purchases, cost, added capabilities,
workflow integration, and efficiency are considered
most often. Orthodontics is a business, and as such,
the cost is the most critical factor for adoption across
all groups. However, financial and performance consid-
erations are more of a barrier than an inducement for
most technologies. Effect of a new tool on office effi-
ciency is a major incentive and barrier, pointing to the
importance of easy onboarding and workflow integra-
tion. As hypothesized, primary adoption factors include
cost, added capabilities, efficiency, performance, and
ease of integration.
The survey sample consists of private practitioners
actively working in orthodontics-only, group multispe-
cialty, sole-ownership, partnership, or corporate prac-
tices. The sample was biased by including feedback
from orthodontists who pay membership dues to the
AAO and participate in an online survey; these are
more technologically savvy practitioners who are
comfortable with computers and, therefore, more likely
to adopt the technology. Data on the influence of tech-
nologies were also subject to recall bias. Late adopters
more negatively perceived the same technologies as early
Journal of Orthodontics and Dentofacial Orthopedics
Jacox et al 373
and middle adopters, suggesting confirmation bias;
adopters tended to interpret and recall information in
a way that confirmed their existing beliefs. Because the
survey was lengthy, the sample was also skewed toward
practitioners who had time to respond. The total number
of responding dentists cannot be fully controlled and
was at the low end of our anticipated range of 7%-
11%, on the basis of response rates of similar
studies.14,16 The length and complexity of our survey
were likely a deterrent,and the small sample size may
cause us to miss meaningful data on national trends
that could benefit from further investigation.
Despite these limitations, understanding the technol-
ogy adoption landscape is valuable to the future devel-
opment and adoption of digital dental tools. By
determining who is making purchasing decisions, what
information and incentives form the basis of decisions,
and what types of technologies orthodontists are hoping
to buy, we can help forward the digital revolution in or-
thodontics, as technologies prove themselves to be
effective adjuncts to practitioner expertise.
CONCLUSIONS
The first national survey of AAO membership on
technology adoption demonstrates:
1. Purchase decisions are made by practice owners af-
ter consulting other dentists, company representa-
tives, and conference continuing education.
Published literature and staff input rarely impact
adoption decisions.
2. Early adopters charge higher fees and have larger
practices than middle and late adopters.
3. Primary adoption factors include cost, added capa-
bilities, practice efficiency, ease of implementation,
and performance. The largest barrier to adoption is
cost.
AUTHOR CREDIT STATEMENT
Laura Anne Jacox contributed to project administra-
tion, supervision, funding acquisition, conceptualiza-
tion, investigation, formal analysis, visualization,
original draft preparation, and manuscript review and
editing; Clare Bocklage contributed to investigation,
visualization, and manuscript review and editing; Teresa
Edwards contributed to methodology, validation, and
manuscript review and editing; Paul Mihas contributed
to methodology, validation, and manuscript review
and editing; Feng-Chang Lin contributed to formal
analysis and manuscript review and editing; and
Ching-Chang Ko contributed to supervision, funding
acquisition, and manuscript review and editing.
American Journal of Orthodontics and Dentofacial Orthoped
ACKNOWLEDGMENTS
We thank all participating orthodontists for their
valuable time and willingness to participate in a lengthy
online survey. We appreciate the AAO Partners in
Research Program for their help and support.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2020.08.024.
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