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While the popularity of teledentistry had been increasing long before COVID-19 hit, it certainly has received a greater amount of attention since the onset of the pandemic. Recent systematic reviews have shown consistent evidence on the use of teledentistry in the dental profession within both general dentistry and many specialty areas. Numerous research reports have indicated that areas such as operative dentistry and oral pathology have explored this modality somewhat extensively to study the accuracy of diagnosing caries and/or oral pathologies using teledentsitry1-8 with other specialties following suit.
Since the global onslaught of COVID-19 began in March 2020, the role of teledentistry has shifted from "accessory" to "essential" in order to help mitigate the spread of infection.9 General dentists have a unique opportunity to provide appropriate triage in determining which patients must be seen immediately and which patients can be managed with a virtual consultation. Through the use of teledentistry many patients' questions can be answered, and/or the patient may be further referred to a specialist.
Various studies have reported that virtual visits may be sufficient at triaging such scenarios as: distinguishing between normal and abnormal pathologies,9 screening of early childhood caries,1 triaging of maxillary anterior trauma,2 and assessing rehabilitation needs of dental prostheses.3 These are only a few of the possible scenarios, and considering further technological developments, it would seem that many other dental needs may be able to be met through the use of teledentistry.
Telehealth Versus Teledentistry
An important component in a variety of healthcare professions, telehealth has been used in medicine to address the disparity in access to care for rural area patients or people who have limited mobility/access to care. Most recently, telehealth has expanded further to facilitate the sharing of health records among multiple healthcare professionals. In addition, some of the features of telehealth allow patients access to a portal that they can use to schedule appointments or review their medical history.10
With the rise of telehealth and policy changes around televisits and insurance claims, it has become important to distinguish between telehealth and teledentistry. Telehealth-the umbrella term-is defined as any technologies used to provide care and services at a distance. Four modalities of telehealth have been identified: live video, store and forward, remote patient monitoring, and mobile health.11 Teledentistry, meanwhile, is defined as the provision of dental care and services at a distance with the use of technology; it is typically used to improve access to care.12
Opportunities for the use of teledentistry exist in all specialties of dentistry to varying degrees (Table 1). According to the American TeleDentistry Association, the use of teledentistry increased from 250,000 patients in 2013 to a projected 3.2 million in 2018.13 Furthermore, a 2019 report from mHealthIntelligence noted that 78% of patients interviewed reported that they would consider using teledentistry in the next 5 years.14 In 2020, with the onset of the pandemic, a survey of dentists conducted by the American Dental Association (ADA) showed that about 25% of participants were using virtual technology/telecommunications to conduct remote problem-focused evaluations.15 This statistic translates to possibly more than 50,000 dental practices providing teledentistry in the United States.
Considering that general dentists have the responsibilities of providing patients a dental home and being a referral source for all of a patient's oral health needs, the use of telehealth and teledentistry has a variety of applications. These include referral to a specialist and, with it, the secure transfer of charts, including the patient's medical and dental history. In addition, after a virtual consult, general dentists can provide patients nutritional counseling, salivary stimulation prescriptions, and fluoridated toothpaste prescriptions.16
Data indicates that teledentistry has been successfully used in many dental specialties and seems to have numerous benefits. Periodontists can effectively monitor a patient's oral hygiene and provide oral health literacy training. Oral medicine specialists can use teledentistry to effectively diagnose conditions and diseases.4 A common use of teledentistry by oral and maxillofacial pathologists is diagnosing normal versus abnormal pathology, which can be done with almost the same rate of accuracy as during an in-person visit.5 Furthermore, the simple use of digital photographs can even allow pathologists to detect oral cancers with a virtual visit.6
Specific applications of teledentistry for prosthodontics may include evaluating a fractured dental prosthesis.3 In orthodontics, advancements in technology and software development/design are opening new avenues for teledentistry. In addition to virtually monitoring a patient's cooperation with elastic wear via remote dental monitoring software and media, orthodontists can check initial leveling and alignment of patients' teeth digitally and consult on the rate of maxillary expansion and its completion.17
Limited evidence is available regarding the use of teledentistry in the fields of endodontics and oral and maxillofacial surgery. Because the use of radiographs is a minimum standard of care in these two specialties, the use of teledentistry is thus limited. Anecdotally, though, experienced clinicians have reported specific instances in which patients have been able to self-evaluate for the appearance and disappearance of sinus tracts or even detect swelling with self-palpation.
Lastly, teledentistry, which was started as a public health initiative, remains prevalent in dental public health today. Studies show that teledentistry is being used to help care for oncology patients who cannot commute to the clinic.7 Additionally, teledentistry is being utilized to further improve children's oral health using the school system as an access point.8
Benefits of Teledentistry
There are clear advantages to the use of teledentistry in most specialties as scientists continue to develop vaccines for COVID-19. These benefits apply to both patients and practitioners (Table 2). Available evidence reports that many patients had begun accepting teledentistry visits long before the era of the COVID-19 pandemic, and, in fact, virtual visits are shown to reduce patient anxiety.18 This reduction in anxiety typically associated with a dental visit can now be expanded to include, for example, the potential anxiety of traveling to and from the dental office using public transportation, as the virtual visit offers the benefit of limiting exposure to COVID-19 because travel is eliminated.
Since patients may be more comfortable and calm during a virtual dental visit versus an in-person visit, many practitioners are optimistic regarding teledentistry usage. Specifically, practitioners show an increase in appreciation of teledentistry after attending a workshop or training,19 and with newly expanded teledentistry insurance policies20 and an expected surge of dental need post COVID-19, it is vital that practitioners prepare themselves for teledentistry to ensure sufficient access to care for the general population.21 Furthermore, teledentistry can be especially crucial during times of personal protective equipment shortages.16
Additionally, as mentioned previously, practitioners can confidently use teledentistry for remote diagnosis of traumatic dental injuries, screenings of early childhood caries, diagnosis of occlusal caries, diagnosis of oral pathology, evaluation of dental prosthesis rehabilitation needs, and basic oral examinations or history taking.
Barriers to Teledentistry
Despite its many benefits, teledentistry also presents various barriers (Table 2), not the least of which involves technological issues. These encompass such potential drawbacks as inadequate internet speed and lack of computer literacy on the part of either or both the practitioner and patient.18 Moreover, there is a trend of slow adaptation of teledentistry due to concerns over privacy, accuracy, and practitioner technical literacy.22 Even if these hurdles are passed, practitioners must decide how to store large amounts of data and determine which platform to use to organize televisits.9 Aimed at addressing this concern, many platforms are available to guide practitioners in the implementation of teledentistry.
While teledentistry can be quite successful for some virtual visits, such as diagnosis of moderate and advanced disease or lesions, there is low accuracy in the detection of initial caries,23 and video/image quality is of significant importance when conducting such a visit. Even if the patient provides quality images, clinicians typically are uncomfortable making a diagnosis without in-person clinical examination.24 As a result of these barriers and other potential obstacles, teledentistry is not frequently used for diagnostic purposes; however, the onset of COVID-19 has created a strong incentive to address and overcome the barriers to implementing teledentistry.25
Lastly, there is a social and ethical vantage point to teledentistry. Its proliferation may reveal education and socioeconomic disparities in technical literacy and availability of high-quality technology that hinder some patients from receiving telecare.26
Implementation of Teledentistry
Many free resources are available to help dentists and specialists self-educate in the field of teledentistry. The ADA provides resources to guide practitioners. Examples include a webinar on teledentistry and virtual evaluations during COVID-19 and a continuing education course on bringing teledentistry into the private practice. In addition, the American College of Physicians provides a free telehealth module that is created for physicians but has a plethora of applicable information that overlaps with dentistry. There are also teledentistry services that exist for patients. Some websites give patients the opportunity to obtain a virtual consultation or virtual second opinion. The expansion of digital software and technologies is making the implementation of teledentistry much easier for dentists and specialists.
Depending on the need of the general dentist's or specialist's practice, appropriate software can be utilized. Dental monitoring software is available that provides a platform for remote consultations, facilitates patient recruitment by producing hyper-realistic models of patients' current teeth, and allows for remote monitoring of patients' progress. Such software can be a beneficial tool for orthodontists or general dentists who work heavily with aligner trays. Other software products may allow for cloud collaboration with other dental professionals.
Private Practices: Corporate Dentistry/Dental Service Organizations
Compared to an in-person visit, a televisit has additional considerations-before, during, and after the visit-that must be kept in mind. Data from multiple studies can be organized into the five stages of a teledental visit: preparing, beginning, conducting, wrap-up, and post (Figure 1).
Preparing for the televisit. In the preparation phase, it is important for the clinician to have practiced with the computer/device equipment and software before beginning a televisit. This will allow for more time with the patient and less time spent trying to solve technical challenges. It is also recommended for providers to use a virtual background if they are not in their office or home office when conducting the visit in order to project a professional environment. The patient needs to have a secure link that is accessible only by the patient, and a verification method should be in place to confirm that the correct patient is receiving information. Checking equipment and records 15 minutes before the start of the appointment can allow for a smooth and successful visit.27 The patient should also understand that any time wasted during the call takes away from the valuable time of both the patient and provider. The help of a family member may be recommended if the patient does not feel comfortable managing the technical aspects of the virtual visit.20 Lastly, prior to the televisit, both the practitioner and patient should turn off features that may compete with the visit, such as email and text notifications, and both parties should ensure good lighting of themselves.28
Beginning the televisit. Once the preparation is complete, the virtual visit may begin. It may be beneficial to use the "mute" feature while waiting for the patient to enter the meeting. For the comfort of the patient and the sake of transparency, any other professional healthcare member involved in the virtual session, such as an assistant, should be included in the screen view, and the head practitioner should introduce all colleagues/specialists on the call to the patient.27
Conducting the televisit. While conducting the appointment, if there is background noise at the patient's location, the healthcare professional should encourage the patient to mute themselves when they are not speaking.20 However, in general, the televisit should resemble an in-person appointment as much as possible, and the patient should be made to feel as comfortable as possible.
Wrapping up the televisit. As the appointment is finishing, it is paramount that the patient know what symptoms or signs are indications of the immediate need for medical/dental attention. Next, it is essential to inquire if the patient, family member assisting, and/or home health provider is satisfied with the consultation. Once the televisit is deemed satisfactory or other feedback is received, the clinician or assistant should make sure that a follow-up appointment is scheduled. As the televisit comes to an end, it is appropriate to let the patient leave the virtual conference first.27
Post televisit. Once the patient has left the conversation, the televisit needs to be properly documented. In addition to the normal notes that would be taken for an in-person visit, notes for a televisit should also include the location of both the provider and the patient, the duration of the visit, and the method of televisit used (eg, videoconference, phone, live chat).29 Finally, if any technical issues were encountered during the visit, they should be reported to the respective information technology (IT) personnel.27
Insurance Considerations for Teledentistry
When it comes to insurance, the treating dentist overseeing the teledentistry event and diagnosis, treatment planning, and evaluation submits one of two current dental terminology (CDT) codes: synchronous teledentistry (D9995) or asynchronous teledentistry (D9996). The primary difference between the two is that D9995 is used for a live two-way interaction, whereas D9996 is used when the interaction is not in real-time live but is prerecorded.30 A submitted claim must include all required information as described in the completion instructions for the ADA paper claim form and the HIPAA standard electronic dental claim. Coverage and reimbursement for D9995 and D9996 are likely to vary between commercial benefit plan offerings and by state for government programs (eg, Medicaid). The ADA's position is that current dental benefit plan coverage and reimbursement provisions should apply to services delivered via teledentistry.30
Teledentistry and Dental Schools
Despite all efforts, dental-related issues will arise even during the closure of dental clinics. Thus, the need for formal training in teledentistry is paramount. With that said, teledentistry seems to be an appropriate solution both for now and the distant future. The current dilemma, however, is that teledentistry requires formal training and constant adaptation to technological advancements. A practical approach to this dilemma would be to incorporate teledentistry as part of the predoctoral dental school curriculum. By doing so, dental students will be exposed to and, thus, more likely to be at least somewhat comfortable using teledentistry once they start practicing and/or join postgraduate programs using it already.
As academic institutions consider integrating teledentistry into their curriculum it is recommended to use an educational model framework. Educational models have proven to be an effective way of planning and evaluating courses and programs. Educational model evaluation can be formally defined as the systematic collection and analysis of information related to the design, implementation, and outcomes of a program, for the purpose of monitoring and improving the program's quality and effectiveness.31 Many models can be found throughout the literature. One model in particular, the logic model, plays a vital role when planning to incorporate a new course into a curriculum. Melle defined the logic model as "a diagram that shows how a program is thought to work; that is, how resources (inputs) produce key processes (activities), and how the products (outputs) produce desired results (outcomes)."32 In other words, the logic model draws a map of where the program currently stands, what it plans to do, and what it intends to achieve. It is clear by now that teledentistry can play a role in not only the care of patients, but also the education of students and residents. In addition, some schools, such as the University of Pacific Arthur A. Dugoni School of Dentistry and University of Minnesota School of Dentistry, have already incorporated teledentistry into their curriculum.33
Conclusion
The heightened use of teledentistry during the COVID-19 pandemic may prove to be a silver lining for dental professionals. Although it is no replacement for a clinical examination, teledentistry can be utilized by general dentists and specialists for various useful purposes. This article has highlighted the level of evidence available for individual specialties and proposed models of how teledentistry may be integrated in a meaningful way in both private practice and dental schools.
Acknowledgment
The authors acknowledge the expertise and insight of the following Tufts University School of Dental Medicine professors who provided multiple scenarios in which they plan to use, have used, or have seen teledentistry used within their specialties: Samah Bukhari, BDS, MSD, Department of Endodontics; Hugo Campos, DMD, DDS, MS, Division of Oral and Maxillofacial Radiology; and Lily Hu, DMD; Director of Pain Control.
About the Authors
Priyanka Kumar, BSc
DMD Candidate at Tufts University School of Dental Medicine, Boston, Massachusetts
Abdulaziz F. Banasr, BDS
Faculty of Dentistry, Oral and Maxillofacial Surgery Department, King Abdulaziz University, Jeddah, Saudi Arabia; Master of Science Candidate at Tufts University School of Dental Medicine, Boston, Massachusetts
Irina F. Dragan, DDS, DMD, MS
Adjunct Associate Professor and Former Director, Faculty Education and Instructional Development, Department of Periodontology, Tufts University School of Dental Medicine, Boston, Massachusetts
Queries to the author regarding this course may be submitted to authorqueries@aegiscomm.com.
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