Teledentistry: One dentist’s user guide

Teledentistry has been used by many dentists for more than 10 years to reach the most vulnerable and underserved patients, both rural and urban. Diagnosing and treatment planning patients remotely with a trained and trusted dental hygienist has been how I performed teledentistry for years. A well-calibrated team can confidently and accurately provide a much-needed way for people to access dental care.

When I began to use the technology, it was being used in about a dozen states where it was allowed. I was asked to present about my experiences a few times a year, but mostly for dentists in the public health setting. I had tried for years with no success to bring this tool to the attention of many leaders in the dental industry. I sent LinkedIn messages and cold-called people. I spent countless hours with manufacturers trying to convince them how existing products, with some modifications, could greatly increase functionality and be used for teledentistry. I had seen the potential in public health settings where I became aware of it. But now for the last two years I’ve been using teledentistry in my private practice to supervise the hygiene chair a couple of times a month. My estimate is that this technology for hygiene-only days added about 22 hours a month to my schedule, a 22% increase. It was working out great in my small practice; then COVID-19 swept across the world.

In March 2020, I had already been planning to use teledentistry to address COVID-19 in my practice. I was about to explain the plan in our Monday morning huddle when I got a call from one of the large dental insurance companies that needed help understanding this technology and wanted a “subject matter expert.” I had been in contact with most major insurance plans for years to try to get statements in regard to insurance coverage for teledentistry, with little success. In my public health work, many of these payers declined years of requests to fund pilot programs. This call was a turning point.

In the last several weeks since that call, I’ve had the opportunity to present on teledentistry to more than 5,000 dental professionals in groups including the American Dental Association (ADA), the National Dental Association, Henry Schein, DentaQuest Partnership, Arcora Foundation, and numerous other manufacturers plus state and national organizations. The majority of attendees are private practitioners who want to catch up with their peers in public health using teledentistry technology.

Luckily the ADA, in concert with the major dental insurance plans, moved quickly to clearly indicate that they would cover what many are now calling “virtual limited evaluations and triage.” This isn’t the type of teledentistry I’ve been teaching for the past few years—this is an entirely different animal and is limited, as the name indicates. It involves a dentist virtually extending his or her clinical practice to reach patients who are in quarantine. The main goal of this mobilization is to reach patients where they are and triage their needs. This has proven to be very useful for me and my patients, as well as all of the new patients I’ve been reaching as the only dentist in the area who provides this service.

As dentists make decisions about how to reopen, I’d like to share an important part teledentistry can play in the short term and long term. The immediate application is to mitigate risk in a world where a lot is uncertain. Teledentistry can do this by providing a safe environment for patients to reengage dental care. This can be explained in two applications.

Limited evaluation and triage

Recommendations from the ADA and the Centers for Disease Control and Prevention include thorough screening of patients before allowing them to enter the dental office. Most dentists whom I have helped set up a direct-to-patient teledentistry system have asked for a video conferencing solution called a synchronous or real-time interaction with the patient. This is the most genuine and real way to communicate with patients and do a teledentistry exam. When establishing relationships with new patients in particular, this is very helpful; however, I will add that it is not the most reliable or productive.

The power of all of telehealth is its ability to do an evaluation asynchronously. The common term for this is store-and-forward. I have patients booking video chat appointments with our office, and they fill out a detailed digital form prior to their visits. It is this form that determines emergent/urgent care as well as the patient’s COVID-19 risk level. In many cases, I can directly message patients and give them guidance without even having to hold that scheduled video chat. There is also scientific literature and articles to back up this claim both before and after COVID.^1-3 The key here is that regardless of what methodology you use to perform teledentistry, you have one layer of risk mitigation and more control over your precious personal protective equipment (PPE) resources.

Hygienist evaluation and intake of patients

The second application in response to teledentistry is what many doctors are considering their new normal workflow. In many states, prior to dentist interaction, a hygienist under general supervision could collect diagnostic data (radiographs, photographs, periodontal charting, digital scans, impressions, tooth charting, detailed notes, etc.) for both existing and new patients. This ability helped limit dentist movement between patients until necessary for treatment and this helped conserve PPE. In many cases, patients do need to come into the office for further diagnostic evaluation. Using this method can help a dentist with limited PPE more precisely determine a definitive diagnosis.

Using this workflow can help dentists with limited office space spread out their patient visits. Many offices are considering separating their teams into diagnostic or hygiene teams for intake and treatment with the dentist. These teams would not work at the same time and would align with Occupational Safety and Health Administration (OSHA) recommendations for a safe work environment.⁴ With the dentist on site for treatment only, the amount of patients and staff in the building at any one time is reduced by half or more, and high-cost PPE for potential aerosol-producing procedures is preserved.

There are other applications for teledentistry that can be applied in response to COVID-19, as well as to the future of dentistry. I use it to supervise my hygiene team so that my patients have uninterrupted access to their recall appointments. Managing stable, low-risk recall patients is a simple use case. Teledentistry has been tested, with great results, as a way to extend your practice outside of your four walls. For two years I have been doing this asynchronously and reviewing the records in the evening or the next day. Asynchronous teledentistry is very predictable when done with a well-calibrated team.

This technology has even more potential in the future as new communication tools are integrated into existing practice management solutions and artificial intelligence diagnostic tools are added to the workflow. I know that many dentists using teledentistry offer free screenings in schools, thus bringing families into their practices. Also, I recently helped a prosthodontist design a program to reach new patients in nursing homes in order to perform high-end treatment consultations. The benefit for outreach programs is that the cost to scale up a portable program is less than opening an additional location or expanding your space.

Several offices I have worked with use teledentistry to supervise dental hygiene at a satellite location or during weekend hours. There is also a lot of potential to directly connect a general dental practice to a specialty office and offer an on-demand consultation with a specialist or provide an asynchronous solution, which will save the patient time. Another exciting frontier of teledentistry is using connected smart devices to monitor patients’ dental health. This has some great potential in an uncertain future where regular maintenance and elective treatment may not be sought out by patients.

Telehealth services that include teledentistry have been rising in the public’s awareness.⁵Business Insider reports that global growth of the telehealth market is set to climb nearly 20% during the next five years. That is an increase from $38 billion in 2018 to almost $130 billion by 2025.⁶ More than half of that growth is reported to come from the United States. The April 20 COVID-19 economic tracking poll from the ADA Health Policy Institute indicated that over 25% of dentists are now offering some form of virtual, limited evaluation of patients.⁷

Demand among patients is what drives these trends, and with that, acceptance. In the coming months and years, it will likely be expected for dental offices to offer some sort of virtual communication tool for announcements, payment, reminders, education, and patient visits. As we move into a new chapter for the dental industry, it will be no surprise that in addition to enhanced PPE, teledentistry services will become more commonplace.

References

1. Queyroux A, Saricassapian B, Herzog D, et al. Accuracy of teledentistry for diagnosing dental pathology using direct examination as a gold standard: Results of the tel-e-dent study of older adults living in nursing homes. J Am Med Dir Assoc. 2017;18(6):528-532. doi: 10.1016/j.jamda.2016.12.082
2. Cardwell J. Asynchronous teledentistry: It’s like a DVR for patient care. Dental Economics. December 1, 2019. https://www.dentaleconomics.com/science-tech/oral-medicine-anesthetics-and-the-oral-systemic-connection/article/14073055/asynchronous-teledentistry-its-like-a-dvr-for-patient-care
3. Frew JS, Johnson DW. Health tech to the rescue: Combatting COVID-19 with virtual care and predictive analytics. 4sighthealth. April 20, 2020. https://mcusercontent.com/8a4bf5d1617f86a90e5a909f0/files/e0854836-5fb8-4afa-a923-ec37c9b72d5a/4sightHealth.HealthTechRescueCombattingCOVID.MCC.4_20_2020.pdf
4. Guidance for preparing workplaces for COVID-19. OSHA. https://www.osha.gov/Publications/OSHA3990.pdf
5. Muoio D. Report: Global telemedicine market will hit $130B by 2025. Mobihealthnews. March 26, 2019. https://www.mobihealthnews.com/content/report-global-telemedicine-market-will-hit-130b-2025
6. LaRock Z. The telemedicine boom is imminent, and it’s creating opportunities for providers. Business Insider. March 29, 2019. https://www.businessinsider.com/telemedicine-will-boom-but-barriers-persist-2019-3
7. Carey M. Third wave of HPI polling show dentists’ response to COVID-19. ADA. April 27, 2020. https://www.ada.org/en/publications/ada-news/2020-archive/april/third-wave-of-hpi-polling-shows-dentists-response-to-covid-19

NATHAN SUTER, DDS, is a private practice owner and the board chair of the Missouri Coalition for Oral Health. He is also a clinical advisor for MouthWatch LLC and is on the Enable Dental Group board of directors. Most recently he was recognized as a recipient of the 2020 ADA 10 under 10 Award. Dr. Suter spent most of his quarantine time as a consultant teaching dentists about teledentistry.

6 reasons why teledentistry is here to stay

By Brant Herman

As Nathan Suter states in this article, the many virtues of teledentistry have been recognized by the public health sector for more than a decade. Private practice dentistry, on the other hand, has been slow on the uptake. In fact, for several years teledentistry appeared to be on the same slow boat to critical mass as digital radiography and CAD/CAM once were.

Then along came coronavirus. Virtually overnight, private practice dentistry scrambled to find a solution to effectively connect patients to providers, offer virtual consultations, and provide safe access to emergency dental care. Fortunately, full-featured teledentistry solutions such as MouthWatch TeleDent were standing at the ready.

You may ask, “When this pandemic subsides, will I still need to consider teledentistry?” The answer is a resounding yes! In fact, post-pandemic practice growth, efficiency, and profitability will be propelled in part by teledentistry. Here are six reasons why that’s the case.

1. Dental teams and patients both want to limit their exposure to potential pathogens. Certain types of exams, referrals, and case presentations can be conducted via synchronous (live) or asynchronous (store and forward) virtual consultations.
2. “I love dentists’ waiting rooms!” said no patient ever.
3. COVID-19 is not the first or last concern that dentists and their at-risk patients will endure. Did I mention that cold and flu season is just around the corner?
4. Efficient, prioritized use of personal protective equipment will become a bottom-line priority. Please refer to number one on this list.
5. Teledentistry enables highly efficient workflows that incorporate internal and external care teams, including specialists.
6. You can offer flexible office hours and convenient scheduling. Patients could get used to this. But guess what, they already are!

COVID-19 may have quickly amplified the need for teledentistry and accelerated its adoption, but it is here to stay. During the past few months, teledentistry has officially moved from “nice to have” technology to “must have” technology.

BRANT HARMON is the CEO and founder of MouthWatch LLC, a leader in innovative teledentistry solutions, digital case presentation tools, and intraoral imaging devices. The company is dedicated to finding new ways to constantly improve the dental health experience for both patient and provider. Contact Harmon at [email protected].

A list of common solutions and cost ranges for dentists to consider when adding teledentistry. Some are upfront costs that are incurred monthly while adding teledentistry into your clinical flow, others can require a more long-term investment.