Telehealth, Telemedicine and Teledentistry

Ira Lamster DDS, MMSc

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Telehealth, Telemedicine and Teledentistry

Digital technology has transformed all aspects of modern life, including the work environment, education and leisure time. In that context, digital technology is transforming healthcare. The transformation affects both providers and patients, and offers a way to expand services and improve efficiency in the delivery of health care. This includes providing access to both generalist and specialist care services in rural and remote areas, as well as for patients with limited mobility.

“Telehealth” can be defined as the merger of information in digital form with communication devices to improve health care. For patients, telehealth can enhance communication with providers, and aid in the management of chronic diseases, which often occur over decades, by reminding patients of the need for appointments, evaluation of lifestyle behavior change, and expediting renewal of prescriptions.

“Telemedicine” can be defined as the use of digital information and communication technology to provide healthcare when direct provider-patient interaction is inefficient or not possible. Telemedicine continues to evolve and offer new opportunities for improved healthcare. One important aspect of this advance is the development of electronic health records (EHR). Ideally, these records contain a complete health history available to providers who can access the record. Having all healthcare data available to a provider will improve care by allowing access to the patient’s history, including diagnoses and treatment, and use of prescription and non-prescription drugs.

The use of telemedicine can also enhance communication between patients and providers via personal health portals, and among providers caring for a patient. Further, widespread use of smartphones and wearable devices has led to development of many health-related apps that can both track exercise data and health indicators.

The use of technology in dentistry (“teledentistry”) is emerging, and offers one answer to the problem of access to care that exists for many populations in developed and developing countries. The application of telehealth to dental care also is in synergy with the introduction of new technology in clinical dental care, including digital radiographic techniques, as well as cone beam computed tomography, use of digital scanning to capture clinical images, and computer assisted design/computer assisted manufacturing of dental restorations. According to Jampani et al 1Jampani ND, Nutalapati R, Dontula BS, Boyapati R. Applications of teledentistry: A literature review and update. J Int Soc Prev Community Dent 2011;1:37-44., the concept of teledentistry was introduced in 1994, when the U.S. military sought ways to improve communication among dentists and dental laboratory technicians, thereby enhancing patient care.

A number of systematic reviews examining the outcomes and costs associated with teledentistry have been published. An early review 2Daniel SJ, Wu L, Kumar S. Teledentistry: a systematic review of clinical outcomes, utilization and costs. J Dent Hyg 2013;87:345-352. suggested improved clinical outcomes and high provider and patient satisfaction, as well as cost savings with this technology. Three more recent reviews have examined efficacy and cost effectiveness in greater detail.

Clinical trials that evaluated teledentistry versus traditional clinical contact have found that teledentistry is efficacious for pediatric dentistry, orthodontics and oral medicine. Cost savings (cost minimization) was also evident with the use of teledentistry, but more high quality studies are needed 3Estai M, Kanagasingam Y, Tennant M, Bunt S. A systematic review of the research evidence for the benefits of teledentistry. J Telemed Telecare 2018;24:147-156.. Another recent review concluded that teledentistry was a viable technique for distance assessment (screening, examination and diagnosis), consultation and planning for treatment, as well as distance education and training. Acceptance of this technique was high among both patients and providers. This review emphasized that remuneration for participating clinicians must also be considered in order for any program to be successful 4Irving M, Stewart R, Spallek H, Blinkhorn A. Using teledentistry in clinical practice as an enabler to improve access to clinical care: A qualitative systematic review. J Telemed Telecare 2018;24:129-146.. A third recent review identified specific settings that would benefit from teledentistry, including in-school programs, rural environments, long-term care centers, and areas with poor access to care. Teledentistry is particularly useful for identification of oral diseases, subsequent referral and patient consultation 5Alabdullah JH, Daniel SJ. A Systematic Review on the Validity of Teledentistry. Telemed J E Health 2018;24:639-648..

Individual studies highlight the value of teledentistry in different clinical settings and for different populations.

School-based screenings:

One application of teledentistry that holds great promise is school-based dental screenings. A comparison of findings from a clinical examination and photographs taken with a smartphone, revealed that both dentists and dental hygienists could accurately identify dental caries from digital photographs. There were no differences between dental hygienists and dentists in their diagnostic accuracy 6Daniel SJ, Kumar S. Comparison of dental hygienists and dentists: clinical and teledentistry identification of dental caries in children. Int J Dent Hyg 2017;15:e143-e148.. In Australia, a preliminary study employed a smartphone as a means of capturing clinical images that could be used to identify dental caries. Sensitivity ranged from 60 to 68% and specificity from 97 to 98%, with high inter-rater reliability 7Estai M, Kanagasingam Y, Huang B, et al. The efficacy of remote screening for dental caries by mid-level dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016;44:435-441.. Further, the same investigators examined the cost-effectiveness of using teledentistry to improve resource allocation for dental care. They determined that using teledentistry in affluent areas where the caries risk was low could save millions of dollars. Those funds could then be allocated for higher risk populations 8Estai M, Bunt SM, Kanagasingam Y, Kruger E, Tennant M. A resource reallocation model for school dental screening: taking advantage of teledentistry in low-risk areas. Int Dent J 2018;68:262-268..

Other oral pathologic disorders:

In addition to dental caries, teledentistry has been used to aid in the diagnosis of other oral pathology. Smartphone cameras have been used to identify potentially malignant oral lesions 9Haron N, Zain RB, Nabillah WM, et al. Mobile Phone Imaging in Low Resource Settings for Early Detection of Oral Cancer and Concordance with Clinical Oral Examination. Telemed J E Health 2017;23:192-199., with a sensitivity greater than 70% and specificity of 100%, as compared with direct assessment by specialists in oral medicine. This approach has also been used to evaluate the status of teeth that sustained traumatic injury 10de Almeida Geraldino R, Rezende L, da-Silva CQ, Almeida JCF. Remote diagnosis of traumatic dental injuries using digital photographs captured via a mobile phone. Dent Traumatol 2017;33:350-357.. Versus on-site evaluation, the diagnostic accuracy was 83% when only the image was available, which rose to 93% when additional clinical data were provided.

Other applications:

Studies have demonstrated that teledentistry can be used in a variety of other ways to enhance oral health. A smartphone application was shown to be effective in educating smokers about their children’s oral health 11AlKlayb SA, Assery MK, AlQahtani A, AlAnazi M, Pani SC. Comparison of the Effectiveness of a Mobile Phone-based Education Program in Educating Mothers as Oral Health Providers in Two Regions of Saudi Arabia. J Int Soc Prev Community Dent 2017;7:110-115.. Other innovative applications include use of teledentistry in a prison setting to identify individuals needing emergency care 12Giraudeau N, Inquimbert C, Delafoy R, Tramini P, Valcarcel J, Meroueh F. Teledentistry, new oral care tool for prisoners. Int J Prison Health 2017;13:124-134., as well as assess oral health care needs of adolescent offenders 13Morosini Ide A, de Oliveira DC, Ferreira Fde M, Fraiz FC, Torres-Pereira CC. Performance of distant diagnosis of dental caries by teledentistry in juvenile offenders. Telemed J E Health 2014;20:584-589..

As in other aspects of healthcare, teledentistry offers an effective means of identifying persons with dental disease in environments that are challenging to provide traditional dental services. In this way, individuals with extensive needs can be identified and care provided, without expenditure of resources for persons who have minimal or no problems. Further, the application of teledentistry in long term care facilities is a logical use of this technology. A study of the economic impact of this approach revealed that a real-time teledentistry assessment was the most costly approach (Au $41.28) per visit, followed by a traditional clinical evaluation (Au $36.59), with a delayed remote evaluation being the least expensive (Au $32.33) 14Marino R, Tonmukayakul U, Manton D, Stranieri A, Clarke K. Cost-analysis of teledentistry in residential aged care facilities. J Telemed Telecare 2016;22:326-332..

Acceptance of teledentistry by patients and providers

The successful application of teledentistry depends on availability of appropriate technology, as well as acceptance by patients and providers. This approach is a significant change from the traditional patient-provider interaction, and there can be barriers to this new type of care.

A study of patient behavior associated with remote dental consultation indicated that examining a range of patients with certain health problems, patients with psychiatric disease were less accepting of this remote approach. Older adults with dependency demonstrated variable acceptance, more so when less dependent, and less so when more dependent 15Petcu R, Kimble C, Ologeanu-Taddei R, Bourdon I, Giraudeau N. Assessing Patient's Perception of Oral Teleconsultation. Int J Technol Assess Health Care 2017;33:147-154.. These studies suggests that groups of patients need to be individually evaluated when a teledentistry program is being considered.

From the provider’s perspective, a detailed analysis of dentists’ thoughts about teledentistry were in general very favorable, specifically as a means of improving communication with other health providers in regard to new patient referrals and clinical/procedural guidance. There was also a general sense that teledentistry could enhance patient satisfaction. However, concerns were expressed about a number of issues, including reliability of the technology, different cost factors including the initial outlay to purchase the technology, and patient confidentiality/privacy concerns 16Estai M, Kruger E, Tennant M. Perceptions of Australian dental practitioners about using telemedicine in dental practice. Br Dent J 2016;220:25-29.. One modification to reduce cost is the use of smartphone cameras versus dedicated intraoral cameras specific for use in teledentistry. An analysis of this approach (assistants taking the clinical photographs using a specialized smartphone application, uploading to a server and evaluation of the images by a panel of 5 dental practitioners) indicated generally favorable opinions, with suggestions to improve technical aspects of the process (optimization of the image capture, standardized orientation of the image and use of retraction when taking the pictures). All of these concerns were felt to be easily addressed with continued upgrading of the technology and appropriate training17Estai M, Kanagasingam Y, Xiao D, et al. End-user acceptance of a cloud-based teledentistry system and Android phone app for remote screening for oral diseases. J Telemed Telecare 2017;23:44-52..

The challenges presented by implementation of teledentistry have been reviewed by Estai et al 2017 18Estai M, Kruger E, Tennant M, Bunt S, Kanagasingam Y. Challenges in the uptake of telemedicine in dentistry. Rural Remote Health 2016;16:3915.. The use of teledentistry is often precipitated by difficulties with access to dental care. Of particular concern, and an example of the impact of a lack of dental services on the larger healthcare system, is the need to manage acute dental disease (usually an acute endodontic infection) for which affected individuals seek relief from non-dental providers in non-dental settings, including hospital emergency departments or from a local pharmacist 18Estai M, Kruger E, Tennant M, Bunt S, Kanagasingam Y. Challenges in the uptake of telemedicine in dentistry. Rural Remote Health 2016;16:3915..

Estai et al 18Estai M, Kruger E, Tennant M, Bunt S, Kanagasingam Y. Challenges in the uptake of telemedicine in dentistry. Rural Remote Health 2016;16:3915. provide lists of both benefits and barriers to the use of teledentistry (see Tables 1 and 2). The advantages of teledentistry are clear, as evaluation and diagnosis of oral disease are possible, extending dental services to underserved, difficulty to access and remote communities. With a tiered delivery system, care can be delivered by providers based on pre-identified need. This approach does not solve all problems, but does improve efficiently and help clarify the most common problems faced by certain groups of patients. If the technical and financial concerns can be addressed, this is a step-wise advance. Care algorithms need to be developed to maximize efficacy, and licensure and scope of practice questions need to be addressed, especially if the hub and remote sites are in different states/regions. This is particularly true for services such as diagnostic radiology 19Simon L, Friedland B. Interstate practice of dental teleradiology in the United States: The effect of licensing requirements on oral and maxillofacial radiologists' practice patterns. Telemed J E Health 2016;22:541-545..

A recent series of papers reviewed the current status of telemedicine. Systematic reviews suggested that telemedicine interventions were equivalent to traditional face-to-face care. The focus was on mental health, rehabilitation services, dermatology and general consultations. Other reviews supported the use of telehealth for management of anticoagulant therapy, nutrition guidance and care of diabetic foot ulcers 20Shigekawa R FM, Cobett G, Robby DH, Coffman J. The current state of telehealth evidence: a rapid review. Health Affairs 2018;37.. However, data from the American Medical Associations Physician Practice Benchwork Survey from 2016 indicated that only 15.4% of physicians were in practice settings that employed telemedicine 21Kane CK GK. The use of telemedicine by physicians: still the exception rather than the rule. Health Affairs 2018;37.. In that same year, 11.2% of physicians were in practice settings that used telemedicine for communication between physicians and other healthcare workers. Of particular interest to the dental profession, this survey found that larger medical practices were more likely to use telemedicine than smaller practices, and that the cost of implementing telemedicine would be a burden for small practices.

One of the papers in this series reported on the experiences of a dental educational institution on the use of teledentistry 22Kopycka-Kedzierawski DT MSaBR. Advancement of teledentistry at the University of Rochester's Eastman Institute for Oral Health. Health Affairs 2018;37.. Their conclusions were similar to what was reported earlier – demonstrating benefits for children who are disadvantaged and for those who live in rural communities, accompanied by better utilization of resources, and improved outcomes. Interestingly, these authors proposed the use of teledentistry in dental education. Specifically, this technology could be used to supervise the care provided by dental students and dental residents in remote sites. This use can help address the chronic shortage of faculty in dental schools.

Conclusions

It is evident that teledentistry offers important answers to some of the more vexing problems facing the delivery of dental services to underserved populations. Further, new and innovative use of teledentistry will continue to be proposed. At present, teledentistry can offer the opportunity to remotely screen and/or examine patients who have difficulty accessing dental services. This can be real-time, allowing the clinician to ask the patient questions, and also request the person operating the camera to review specific areas of concern. This evaluation can also be asynchronous, where the clinician evaluates the archived video or still photographs recording of the patient’s oral cavity at a later time. As noted previously, the delayed approach was determined to be less expensive as compared to both live evaluation using teledentistry and traditional clinical evaluation with the dentist and patient in the same location.

Further, the use of electronic dental records is increasing in developed countries23Acharya A, Schroeder D, Schwei K, Chyou PH. Update on electronic dental record and clinical computing adoption among dental practices in the United States. Clin Med Res 2017;15:59-74.. However, linkages to a patient’s electronic medical record generally does not exist, the exception being a limited number of health care systems such as the Marshfield Clinic in Wisconsin24Acharya A. Marshfield Clinic Health System: Integrated care case study. J Calif Dent Assoc 2016;44:177-181..

In the future, teledentistry offers the possibility of improved communication between oral healthcare providers and patients via email communication, wearable devices and specific apps for smartphones. This communication can improve patient compliance by monitoring oral hygiene practices and sending reminders about scheduled appointments.

The application of technology in dental practice is clearly a trend that will continue. The widespread application of teledentistry still requires additional research on clinical efficacy as well as cost effectiveness.

Table 1: Advantages of Teledentistry
Patient:

  1. improved access to primary and specialty dental services
  2. timely (non-delayed) diagnosis of oral diseases
  3. improved communication between the oral health care team and the patient
  4. promote patient education, and assess patient progress (i.e. oral hygiene efficacy)
  5. avoid cost of travel to location for face-to-face examination
  6. schedule appointments, update health history
  7. availability of dental records if a problem is encountered when away from home
Dental Care Provider:

  1. increases capacity of individual providers
  2. efficient triage
  3. reduces waiting time
  4. reduces unnecessary referrals
  5. better interprofessional communication
  6. facilitates local referrals
  7. enhances interprofessional communication for geographically-isolated providers
Quality of Care:

  1. enhances efficiency
  2. better oral health outcomes
  3. reduces complications due to delayed diagnosis
  4. improved patient monitoring
Society:

  1. reduces caregivers time away from their primary office
  2. for children, reduces number of absences from school
  3. address inequality of oral healthcare services
  4. address the needs of underserved populations

Adapted from Estai et al (2016)

 

Table 2. Barriers to the Adoption of Teledentistry
Individual:

  1. patient acceptance not well defined
  2. challenges if patient has limited technology literacy
  3. resistance to technological innovation (i.e. elderly)
  4. absence of direct provider to patient contact
  5. concern for security of data/health records
  6. accuracy and quality of the information
  7. increased workload for providers
  8. cost of practice will increase
  9. risk of fragmented care
Infrastructure:

  1. limited internet access in certain regions
  2. lack of hardware/software compatibility
  3. technology required is complex
  4. reimbursement/funding not well-defined
  5. lack of information technology support
  6. lack of provider/patient training
Organisational

  1. lack of compatibility of technology with other digital records
  2. lack of reimbursement/funding
  3. absence of copyright, licensure and financial guidelines
  4. medical/legal issues
  5. bureaucratic difficulties
  6. coordination difficulties between hub and remote sites

Adapted from Estai et al (2016)

References

  • 1.Jampani ND, Nutalapati R, Dontula BS, Boyapati R. Applications of teledentistry: A literature review and update. J Int Soc Prev Community Dent 2011;1:37-44.
  • 2.Daniel SJ, Wu L, Kumar S. Teledentistry: a systematic review of clinical outcomes, utilization and costs. J Dent Hyg 2013;87:345-352.
  • 3.Estai M, Kanagasingam Y, Tennant M, Bunt S. A systematic review of the research evidence for the benefits of teledentistry. J Telemed Telecare 2018;24:147-156.
  • 4.Irving M, Stewart R, Spallek H, Blinkhorn A. Using teledentistry in clinical practice as an enabler to improve access to clinical care: A qualitative systematic review. J Telemed Telecare 2018;24:129-146.
  • 5.Alabdullah JH, Daniel SJ. A Systematic Review on the Validity of Teledentistry. Telemed J E Health 2018;24:639-648.
  • 6.Daniel SJ, Kumar S. Comparison of dental hygienists and dentists: clinical and teledentistry identification of dental caries in children. Int J Dent Hyg 2017;15:e143-e148.
  • 7.Estai M, Kanagasingam Y, Huang B, et al. The efficacy of remote screening for dental caries by mid-level dental providers using a mobile teledentistry model. Community Dent Oral Epidemiol 2016;44:435-441.
  • 8.Estai M, Bunt SM, Kanagasingam Y, Kruger E, Tennant M. A resource reallocation model for school dental screening: taking advantage of teledentistry in low-risk areas. Int Dent J 2018;68:262-268.
  • 9.Haron N, Zain RB, Nabillah WM, et al. Mobile Phone Imaging in Low Resource Settings for Early Detection of Oral Cancer and Concordance with Clinical Oral Examination. Telemed J E Health 2017;23:192-199.
  • 10.de Almeida Geraldino R, Rezende L, da-Silva CQ, Almeida JCF. Remote diagnosis of traumatic dental injuries using digital photographs captured via a mobile phone. Dent Traumatol 2017;33:350-357.
  • 11.AlKlayb SA, Assery MK, AlQahtani A, AlAnazi M, Pani SC. Comparison of the Effectiveness of a Mobile Phone-based Education Program in Educating Mothers as Oral Health Providers in Two Regions of Saudi Arabia. J Int Soc Prev Community Dent 2017;7:110-115.
  • 12.Giraudeau N, Inquimbert C, Delafoy R, Tramini P, Valcarcel J, Meroueh F. Teledentistry, new oral care tool for prisoners. Int J Prison Health 2017;13:124-134.
  • 13.Morosini Ide A, de Oliveira DC, Ferreira Fde M, Fraiz FC, Torres-Pereira CC. Performance of distant diagnosis of dental caries by teledentistry in juvenile offenders. Telemed J E Health 2014;20:584-589.
  • 14.Marino R, Tonmukayakul U, Manton D, Stranieri A, Clarke K. Cost-analysis of teledentistry in residential aged care facilities. J Telemed Telecare 2016;22:326-332.
  • 15.Petcu R, Kimble C, Ologeanu-Taddei R, Bourdon I, Giraudeau N. Assessing Patient's Perception of Oral Teleconsultation. Int J Technol Assess Health Care 2017;33:147-154.
  • 16.Estai M, Kruger E, Tennant M. Perceptions of Australian dental practitioners about using telemedicine in dental practice. Br Dent J 2016;220:25-29.
  • 17.Estai M, Kanagasingam Y, Xiao D, et al. End-user acceptance of a cloud-based teledentistry system and Android phone app for remote screening for oral diseases. J Telemed Telecare 2017;23:44-52.
  • 18.Estai M, Kruger E, Tennant M, Bunt S, Kanagasingam Y. Challenges in the uptake of telemedicine in dentistry. Rural Remote Health 2016;16:3915.
  • 19.Simon L, Friedland B. Interstate practice of dental teleradiology in the United States: The effect of licensing requirements on oral and maxillofacial radiologists' practice patterns. Telemed J E Health 2016;22:541-545.
  • 20.Shigekawa R FM, Cobett G, Robby DH, Coffman J. The current state of telehealth evidence: a rapid review. Health Affairs 2018;37.
  • 21.Kane CK GK. The use of telemedicine by physicians: still the exception rather than the rule. Health Affairs 2018;37.
  • 22.Kopycka-Kedzierawski DT MSaBR. Advancement of teledentistry at the University of Rochester's Eastman Institute for Oral Health. Health Affairs 2018;37.
  • 23.Acharya A, Schroeder D, Schwei K, Chyou PH. Update on electronic dental record and clinical computing adoption among dental practices in the United States. Clin Med Res 2017;15:59-74.
  • 24.Acharya A. Marshfield Clinic Health System: Integrated care case study. J Calif Dent Assoc 2016;44:177-181.