Interview with Fabian Hable and Sherif Kandil

Fabian: In my study, I'm aiming to find out how professionals perceive and react to the introduction of a new technology in the market. Therefore, I've approached you as you have been working in the field for many years, and as you can illustrate with concrete stories how technology can affect your work. Additionally, I'm interested in which aspects of the technology in your work are relevant for understanding the development of this technology. The technology I want to talk about today is concerning telemedicine. You know how your experience in the field of orthodontics is of great value for my research in the field of telemedicine. Therefore, I would like to start with the technology itself. When you think of the technology of telemedicine, which allows professionals to treat the patient remotely, what is your opinion about it?

Sherif: Telemedicine is one of those things that is quite undervalued and underestimated, in my opinion. I see it from my own vantage point of view as something if related to this millennia as like the telephone in the last millennium. The reason for that is that it still does the same function as the telephone, but it copes with the fourth industrial revolution, like the unfolding of essential technologies of the future as the internet of medical things, and artificial intelligence and so on. However, I think it does have more of a really substantial effect in driving many technologies alongside with it.

So, if we compare it somehow through analogy with the phone, the normal phones that were developed at the start of the last millennium, we'll see that in general, the patients that were used somehow to always go to the doctor and see the doctor physically, this has changed. It started to put the first steps towards more of a remote and wireless connection. Then this was developed even further when screens came in and then mobile phones and then with screens and voice communication.

This developed the first seed in the telemedicine era, which I think I've read it somewhere it was like almost 1926 when the first real telemedicine that started to happen was like through just radiowaves used by radios to connect doctor to patient. That was how the patients used to ask the doctor about their condition and so on. So, putting it in a nutshell, I think that telemedicine has a huge potential in the market in the future and it will definitely furnish a better path for other technologies that come with it that I just mentioned a while ago, like artificial intelligence and internet of medical things.

Fabian: What kind of experience do you have with this technology?

Sherif: Well, the first time I encountered on such technology was basically when I was back still in Egypt and had my clinic. I was one of those ones who were fortunate to do clear aligners in 2008. In Egypt, back then I was almost the first one to bring it to public demand. I mean, a lot of people didn't know what that is and I had the burden to educate the market about this amazing technology. I had an American patient, she, if I recall correctly, she was like 28 years old or something and from Wisconsin. She just approached my clinic online and she wanted to straighten her teeth with aligners without going to a doctor. She wanted to follow up everything through just remote connection with me. Back then I thought this is kind of joke or something.

I found it quite interesting back then because at that time, tele-orthodontics was still not really known at all. It was still at the absolute start. The case went magnificently well. The patient was so happy with the end results. I, myself was also quite astonished that the end results came up like that. However, when we fastforward in time, I'm located in Germany, so the geographical location somehow hinders to which extent you could practice telemedicine or tele dentistry.

It’s quite still a grey zone, but we're somehow trying to expand this step by step by at least those who are not located in areas where they could visit a doctor. That they could communicate through our doctors, work at the company, or even our doctors in the network of doctors that we have remotely with them.

Fabian: Okay. Cool. What do you think? What are the benefits or what are the pitfalls of this technology?

Sherif: Well, one of the major benefits here is that it gives two one of the most important advantages in our times for patients, which is one is accessibility and two is still affordability. So, these two things, I mean, if you look online at the newly established startups specially in SAARS, you will see how these two beneifts are the key component for their business model. Everything that has more accessibility, that gives more of a remote kind of follow up, and still is affordable, which by the way, they go one to one, hand in hand, this is one of the biggest advantage that you patients will benefit from.

A benefit for the technology itself on the other side is that as I said earlier that it pushes with it more technologies. So, one of those things that maybe if the time allows in a while we'll talk about is the Internet of medical things and how to monitor teeth movement or how to monitor the status of teeth. Telemedicine has had a huge leap in the monitoring. However, tele-dentistry is still lagging a little bit behind and just depending on just only video communication to see how the teeth looked like and so on. However, when we look at tele-orthodontics, it is catching up really well and I guess that's where, or let's say, the space where many technologies will unfold afterwards.

Monitoring is one of the most important things that tele-orthodontics will be depending on. It's inevitable. It will come definitely. I mean, we will definitely see tele-orthodontics or tele-dentistry taking over normal current practice. But I always say tele-orthodontics and tele-dentistry because there is a huge difference between both. I mean, you cannot say that tele-dentistry is going to be from start till end is going to be amazing or is going to be without any pitfalls because with tele-dentistry, you don't have anything to be done basically, except just to see the patient remotely, see the teeth, ask a couple of questions, get replies and so on, but you are not conducting a dental surgery nor operations remotely.

There is no kind of concrete, let's say, symptoms or prognosis that you could give just through a screen, remote connection. But when it comes to tele-orthodontics, that's a totally different game. In tele-orthodontics, it opens just again the gates for better monitoring to know exactly where are the teeth positions every single time. You could do diagnosis. You could do prognosis. You could do even the treatment planning and do the treatment and conduct it through remote connection with the patients.

I think the only thing that would sound as a pitfall is something that comes with every emerging technology. It is just built upon inital empirical results, just gathering patterns of results from the previous and just trying to apply it on the future candidates. Having one standard and trying to apply it to everyone.

That's one thing that I see already now, especially in regards to tele-orthodontics where the current monitoring methods are not well suitable yet to give really good follow up. I see that, especially with the direct to consumer DTC businesses in the market. I've had the chance to work with a couple of those companies and see how they think. What kind of mentality do they have when they plan the teeth movements? What are the plans for monitoring? I was kind of surprised to see that some of them take quality really serious, especially the smaller ones, let’s say, like middle to small businesses, they stand behind quality and customizable services seriously inspite most of them have little or no technical insight in orthodontics.

While whenever you scale up and look at the big business providers for clear aligners, it's more about quantity. You start to lose the focus on quality. You have to hit the target and make the bell ring! That's where I find, in my opinion, the most demeaning part is to have just one standard technique and just throw it at everyone without getting sufficient data for monitoring or any feedback from the patients throughout the treatment.

Fabian: Okay. Now we are in the field of the orthodontics. The technology-enabled companies such as the SmileDirectClub, for example, in the United States with the help of telemedicine to treat the patients remotely without ever seeing an orthodontist physically, what you mentioned before. With this master thesis, I would like to find out how orthodontists perceive these companies and the technology of telemedicine itself. When you think of the services provided by these telemedicine companies in comparison to the provided services of an orthodontist, what do you consider make the services of orthodontist unique and special?

Sherif: A very good question. I certainly believe that we've been seeing the field of orthodontics going through many stages of evolution. So, we've seen orthodontics where there was the edge-wise brackets technique where you have to, as an orthodontist, bend the wire every single time the patient comes in the practice in order to exert the right forces at the right place. Then after straight wire came into the market, they started to kick in what I call ortho 2, straight wire techniques, they changed orthodontics totally. It made it somehow like a kind of a McDonald's concept, where an orthodontist has many chairs and there's assistants all day, putting the O-ties or putting the elastics or changing the wire. The orthodontist has a very limited function of just taking a look at the progress.

Where we stand now, where more and more orthodontists start to implement clear aligners in the practice, the function of the orthodontist became more and more redundant. Lately, with the introduction of more of DIY, or direct to consumer or B2C, whatever you call it, kind of businesses, it made orthodontists even more redundant and opened somehow, in my opinion, the eyes for orthodontist that the future of orthodontics is going to change a lot in the next 10 years.

If you ask me, especially I believe that at least I will not encourage my kids to be orthodontists in the future because from my own belief, at some point, we will not have the real orthodontist anymore. Or an orthodontist will have to go back doing dentistry, normal dentistry once again and just the difficult cases, really tough cases will be the ones that go to the orthodontist. Where they need either braces or intervention with interdisciplinary methods or extra oral devices, etc., any kind of sophisticated treatments.

So, this is where the orthodontic specialty will still remain, and I don't find that there is a substitute for it in near or far term, where the tough cases, the severe cases will still go to the orthodontist and still get the service from the orthodontist. However, all the simple mild or moderate cases in my opinion, they will choose to have an alternative.

Fabian: Then when we change the angle of perspective, what arguments do you have for telemedicine companies being better or worse than orthodontists?

Sherif: I will put it in a different perspective, which is that the companies that do that, we could consider them as software’s because I mean, at the end of the day, everyone uses just software's. They all use the same technique exactly. Make the same method for manufacturing aligners. I mean there is nothing different between all of them, almost. So, whenever the software is getting more and more intelligent, the treatments get more and more better. Whenever the monitoring gets better and couples with a good treatment, then the whole service gets way much better.

So, they are on the right path, some of them, others are still taking it for granted as just a business tool. This is something also normal to see in any business. I mean, again, if you compare it to others in the market, like for example, Uber, I mean it made so many taxi drivers redundant and not useful anymore. The thing is that we've seen how Uber was, and still is till now opposed by many in so many different countries, whether through legislation, whether through taxi drivers, etc. But now we've seen many other companies that have been hopping into the same field and they've discovered this potential as well.

At the start it was very chaotic. It was super chaotic at the start. Now, there are more rules. Companies started to implement more control on their drivers. Countries started to put more legislations that are just fitting this kind of business model. Whenever telemedicine in every country starts to also change the legislations and put more rules, that is going to help a lot telemedicine to evolve further.

Fabian: What do you think when you think of, let's say, Germany. How is the legal side regarding these telemedicine companies?

Sherif: Well, in Germany, it still maybe as I said earlier, it's kind of a still gray zone where telemedicine itself is catching up and we've seen a lot of investments from venture capitalists and so on in such companies. However, when it comes to tele-orthodontics, it's, I would say, approved and not approved at the same time. So, it's approved to follow up the treatment monitoring through tele-orthodontics. However, there are still some important measures to take like first, there must be at least one single physical contact that happens throughout the whole treatment. There must be that the doctor approves the treatment plan by themselves and that the doctor delivers the aligners by themselves. This part is not a part of that is imperative to be done, but the most important part is the first part that there must be at least one physical contact that happens between the doctor and the client or the patient.

Fabian: Now, if you look at the website of such companies like the SmileDirectClub, they say, okay, you don't have to see an orthodontist anymore. So, this is not like what you said or this [inaudible 00:18:26] to be --?

Sherif: [Inaudible 00:18:27] club in Germany or in the US?

Fabian: In the US.

Sherif: Yeah, I mean, in the US it’s different. My answer is related to Germany. 00:18:36

Fabian: Okay. What do you think are the differences then between the US and the German SmileDirectClub?

Sherif: Well, if you, for example, observed the SmileDirectClub website for Germany, you'll find it is mandatory that you go to one of their scan centers. For sure, you could buy an impression kit, but at the end of the day, you have to visit a doctor at least once because I mean, again, the doctor takes the full responsibility for the treatment and the Dental Union Chamber is still putting also a lot of stress and pressure on the doctors to really monitor that quite carefully. That's why, it's not just only in Germany, I think in many different European countries, you still have to do that. You have to go at least once to the doctor. However, in the US and the UK, it's a different story where this is not mandatory anymore. So, telemedicine and tele-dentistry, again, I'm just focusing here on US and the UK, they've gotten more of one step further ahead of the of the European market till now.

Fabian: Do you think also in Germany it will be possible in the future that you don't have to go to an orthodontist anymore?

Sherif: Well, I do think so. However, how fast, that's a different story. I mean, in Germany you have to be 10 times safer. So, I cannot predict exactly when this will be or reach the stage where SmileDirectClub is at in the US. Maybe off the record, I mean, if you also look at how the B2C companies in Germany, they start [inaudible 00:20:30] start like two years ago, when they started to implement this business first. It was basically, send out impression kits, impression kits, impression kits and just everything is done remotely. Then all of a sudden things change and some companies start to change their name and started to apply totally different business model and so on because the law started to evolve really fast and they reacted really fast on that and fostered the model where the patient has to go at least once to the doctor.

Fabian: When you think regarding the quality or let's say the service quality, what is your opinion about it when you compare orthodontist with these telemedicine companies?

Sherif: At the current time as we speak, I would say that it's somehow like a race. Till now still orthodont is the service that you get as an orthodontist office. It's still ahead of telemedicine or tele-dentistry, but the gap is decreasing really fast. How tele-dentistry again, will adopt better monitoring methods is only the thing that's going to decide how far or how fast it will come to the level where it would be almost at the same level where you could get the same service from an orthodontist, or even better.

Fabian: Have orthodontist the possibility to fight against this development?

Sherif: They are already. I mean, they are not waiting for any right moment. They are already using the possibility and the chance of now and you could see it for yourself on media. You could see on whatever TV or social media, whether blogs, to name a few. Even not just only in Germany but also in the UK and the US, it's like every dental orthodontic union is either suing these companies questioning their reliability.

Fabian: So, it sounds to me like they are totally rejecting this technology. Am I right?

Sherif: Yeah. I'll tell you something quite funny. I'm a member of the European Aligner Society and due to the Corona situation, unfortunately, the Congress in Malta last March did not happen. However, I was one of those lecturers that should have given a lecture about something related to a new technology that monitors and helps actually tele-dentistry a lot. Maybe if we have time I could give you a quick glimpse on it. There was like this option where you could give like a survey or a poll to all the members of the society and ask them what do you think of tele-dentistry? If it keeps evolving further, will you be opposing it or you will jump or hop in and say, “I'm with it”?

I've got 96% of the poll results. They're almost all against it. It's quite typical, and I totally understand it. But it still means that also we're not ready yet to adopt new technologies, especially in the dental orthodontic. field. I'll relate quickly to analogy and it's something quite not so important for now. But orthodontics is one of the selective few sectors that does not care about the plastic usage. We've seen now how aligners are catching up so fast and the market is increasing like between 17% to 24% per year. Orthodontists for them is like the more plastic we sell, the more money we get and we're creating this huge bubble off plastic economy, and very few are talking about it.

That's quite astonishing that almost nobody is talking about this problem at all. We're the only sector that is just increasing the plastic usage vertically, and we're not even addressing the problem at all, like at least with opinion or anything at all.

Fabian: Yeah, you're right. When we think of the climate change and plastic -- yeah, you're right. Another question, do you see parallels regarding when you think of the aligner introduction from Invisalign in the past and now, telemedicine companies, the new technology regarding that orthodontist reject new technology?

Sherif: Parallels in terms of Invisalign to adopt such a technique or such a business model you mean?

Fabian: Or there were only brackets and now there are aligners and what were your experiences when aligner were introduced into the market and now, there is a new technology like the telemedicine which is also rejected by orthodontist? Are there parallels in your opinion?

Sherif: You mean like analogy between both? Yeah, absolutely. I mean, absolutely. You're totally right. I see it also the same, they were totally against aligners when aligners started. Now, after 20 years since clear aligners were digitized and introduced by align, you could see now a huge portion of orthodontists using aligners whether in-house, whether using other companies out there. It's almost the same. Yeah, I totally agree with your opinion. It's almost the same that there is a lot of analogy or parallelism between this and in the last 20 years, and in the coming maybe 10 years, not 20 years for telemedicine.

Fabian: Cool. When you think of the moral ethical aspects of the services of telemedicine companies, what is your opinion about it?

Sherif: That's a good question. Maybe I highlighted that a while ago that I've been working with different companies in this sector because we're basically a supplier for some companies practicing this model. I've seen how they do business. Some things just like, let me just stop here for a second, just think how on earth do you want to treat a cross bite without any bite raising? How do you want to expand teeth at the front zone like over five or six millimeters? I mean, these are just very minor examples, but sometimes it gets really out of any rational thinking.

As from my part, we tell them, “Hey, this is not indicated for such a treatment method.” They reply and be, “Okay, if you don't want to do it, there are others who would do it for us.” So, this just highlights how some of them think. On the other side, I don't want to blame others. There are many others that have this moral part that is really highlighted and they work with very high quality. So, it's kind of like it's a field where morals or ethics are very important to be controlled here.

I think that that's where legislations in governments, if they want to really improve telemedicine that they should put laws that entitle direct to consumer companies to apply further measures in diagnosis and monitoring.

Fabian: Yeah, you’re right. For me, it sounds like they only can treat easy cases. But in your experience, what do you think if there comes more difficult case, do they reject the case or do they try to pull back the case, let's say it this way?

Sherif: It's very much related to who's doing it but many of them say no at a certain point, but in many tims honestly -- you cannot see the thin-lined borders. The borders are really difficult to see.

Fabian: Yeah, I think so too. When you think of the pricing, what is your opinion about it of the services of this telemedicine companies to compare to the prices of orthodontics? Because when you go on the website, they say, okay, it costs you only a third of the normal treatment of an orthodontist. How do you think is this possible and what do you think about it?

Sherif: Affordability and accessibility, as we said at the start, that's the driving factor even for me myself. I give you a small example. Like there's this website called Fiverr, for example, it's like a website for freelancers and I'm loving it. I'm using it now since I discovered it only like only a couple of weeks ago, inspite is has been there for a long time. I've been using it very effectively. In spite, you barely know the ones you are freelancing the tasks to, you're just relying on the reviews, nothing more than that. You don't have any kind of back experience about these people at all or how they work, but they offer this accessibility and affordability.

Fabian: Do you think that the transparency regarding the pricing of orthodontist will change because they say, okay, it cost you only a third with the certain number?

Sherif: Yeah. We're definitely seeing that. It's changing the whole price structure at the orthodontist office and many dental practices. They're moving more towards in-house production because this would allow them to decrease the price even further. So, if you look at the market from top, you'll find that the D2C or B2C are catching up really fast with a soaring market size potential. While you see now, on the other side orthodontists moving away from B2B providers like whatever Invisalign, K Clear from K Line, or whatever, you name it, and they're moving to more of in-house production so as to cope with this price decrease.

The B2B companies are the ones supplying B2C companies now. You could see that even in Aligntech, at some point, but not anymore, but there were supplying plastic aligners to SmileDirectClub before. I don't know how many B2C companies they're providing right now. We're providing also a handful of B2C companies. I've seen some companies in the market who even totally changed the business model for B2B to pure B2C.

Fabian: So, you see a possibility for orthodontists to do for, example, an in-house production to fight against these telemedicine companies?

Sherif: Yeah, absolutely. That's definitely the only way, is to decrease the prices through in-house clear aligner manufacturing, but yet, you can't beat accessibility with that, but you could feed the prices for sure.

Fabian: Okay. I see. So, now we come to the last topic. How do you think the telemedicine companies will change the orthodontists market in the future?

Sherif: They will definitely change. It's unevitable that this will change and they're realizing currently how important monitoring is. So, we see already something like dental monitoring now improving further and catching a lot of interest in the market. There will be more monitoring methods in the coming future. Like something what we developed here at K Line Europe, for example, the aligner booster coupled with the ClearX mobile app that could monitor sings and symptoms of the patient while also assessing the aligner fit. All these informations are gathered on regular basis and feed the database to decide on the next steps to be taken in the treatment pklan without the need for doctor visits at all.

So, we have to get the signs and symptoms from the patient. We have to get the actual position of teeth, whether through visual recording methods, whether through empirical data that we have, but this is definitely key and they're all pushing further towards that. We see already some companies now that start to apply more and more monitoring methods, especially in the US and in the UK as well.

It's somehow like customizing automation. That's the simplest way of saying it. Customizing automation, that is basically what internet of medical things does. So, for example, my smart watch here it takes always enough recordings of my vital signs and symptoms and uses them to give me a suggestion to move or stand up.

That's what I think the aligner booster through something like the 4D aligners could do in the future through controlling the mechanism of the treatment and the movements of teeth according to the teeth tracking throughout the treatment.