23 minute read
Teledentistry: Opportunities and Recent Developments in Pediatric Dentistry
Jean Marie Calvo, DDS, MPH, is a health sciences assistant clinical professor in the division of pediatric dentistry, department of orofacial sciences at the University of California, San Francisco, School of Dentistry.
Paul Glassman, DDS, MA, MBA, is a professor and the associate dean for research and community engagement at California Northstate University College of Dental Medicine.
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Lisa Berens, DDS, MPH, is the John C. Greene professor in primary care dentistry; chair, division of oral epidemiology and dental public health; vice chair for research in the department of preventive and restorative dental sciences; and the chair of the summer research fellowship program at the University of California, San Francisco, School of Dentistry.
Enihomo Obadan-Udoh, DDS, MPH, DrMedSc, is an assistant professor and the director of the dental public health postgraduate program, division of oral epidemiology and dental public health in the department of preventive and restorative dental sciences at the University of California, San Francisco, School of Dentistry
Ray E. Stewart, DMD, MS, is a professor and chair of the division of pediatric dentistry, department of orofacial sciences at the University of California, San Francisco, School of Dentistry..
Conflict of Interest Disclosure for all authors: None reported.
ABSTRACT
Pediatric dentistry has experienced an increase in the utilization of telehealth advances to serve children’s dental needs. Teledentistry describes the umbrella of services that dentistry can provide through telehealth technology. The COVID-19 pandemic resulted in UCSF Pediatric Dentistry and many other dental practices in California applying teledentistry in their care models. This article describes the uses of teledentistry, motivation for its use and UCSF Pediatric Dentistry’s current and future plans to implement teledentistry in clinics and the community.
Keywords: Pediatric dentistry, public health, telehealtH
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The term teledentistry is a discipline-specific application of the more general term telehealth. In 2011, California adopted Assembly Bill (AB) 415, which converted all instances in California law referring to the older term telemedicine to telehealth. [1] These terms have often continued to be used interchangeably to describe a collection of technologies and strategies to virtually deliver a broad range of medical services, such as diagnosis and monitoring of health conditions, education and interprofessional communication. [2]
Telehealth is now described in California law as:
“The mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management and self-management of a patient’s health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes both synchronous interactions and asynchronous store-andforward transfers.” [3]
The Health Resources and Services Administration (HRSA) defines telehealth more broadly as:
“The use of electronic information and telecommunications technology to support long-distance clinical health care, patient and professional health-related information, public health and health administration.” [4]
Multiple definitions such as these and inconsistent adoption of enabling laws, regulations and guidance in state, regional and insurance organizations have resulted in significant variation in policy environments and created considerable confusion among health care providers regarding systems, practices, policies and regulations in teledentistry.
The COVID-19 pandemic has led to the rapid and broad acceptance of telehealth services as a means of providing safe and economically feasible services while simultaneously minimizing the risk of exposure to the SARS-CoV-2 virus by patients and staff. [5,6] Furthermore, the increase in virtual visits was inspired by the need to preserve personal protective equipment (PPE) and other resources that were under tremendous demand by the rapid spread of the SARS-CoV-2 virus across all populations. [7] Prior to the COVID-19 pandemic, there had been a limited and tepid acceptance of telehealth by patients, providers and third-party insurers such as private insurance companies and governmental agencies responsible for the administration of Medicare and Medicaid programs. [8–11] With the onset of the pandemic and all of the attendant shelter-in-place restrictions and avoidance of face-toface contact whenever possible, there has been a rapid transition to a broader acceptance of telehealth as a necessary and vitally important method of delivering acute and chronic care services as well as primary and specialty care services to patients and families who are unable or reluctant to have an in-person visit with their health care provider. With the one-year milestone of the onset of the COVID-19 pandemic behind us, there is no doubt that our entire health care system has experienced profound changes, many of which are reasonably expected to persist even with the resolution of the pandemic. With the endorsement of many professional medical and dental societies, which very rapidly pivoted to promote and provide their membership with guidelines and recommendations as to how to ethically and legally engage in the provision of telehealth services to their patients, it was only natural that dentistry would see the advantages of this technology and begin to adopt it. [12,13] Teledentistry has been a significant lifeline for many pediatric dental practices when many parents were reluctant to bring their children to the dental office for preventive and restorative care for fear of exposing the child and/or themselves to the SARS-CoV-2 virus. [14]
Teledentistry Use Cases
As the interest in teledentistry increases, it has been adapted to a variety of uses. A general description of the ways it is being used includes the following categories:
■ Triage advice and referral. This refers to the ability of patients or parents to capture records such as a photograph and send those records to a dentist who can review the records and provide advice. Most often these interactions result in a recommendation to seek care in a dental office.
■ The teledentistry call center. Several companies have developed business models where a patient or parent can go to a website and for a fee have a real-time video consultation with an on-call dentist. Again, these interactions often result in a recommendation to seek care in a dental office.
■ Records sharing/consultation. Teledentistry systems have facilitated the ability of dentist-to-dentist records sharing and consultation.
■ Increased office efficiency. Many practices have used teledentistry as an approach to increase office efficiency by transferring some patient interactions from in person in the office to teledentistry interactions.
■ Limited community care. Some companies and providers are using teledentistry to deploy some members of their team to community sites where they can perform limited data gathering and preventive procedures and facilitate a referral to a dental office for care.
■ Full-service community care. Some providers are using teledentistry to deploy members of their team to community sites, collect diagnostic records, have the practice dentist complete an examination and have the community team perform preventive and early intervention services in an effort to keep as many patients healthy in the community as possible.
Examples of adoption of some of these use cases in pediatric dentistry are presented below.
Increased Office Efficiency and Other Potential Advantages
Anecdotally, many practices rapidly turned to virtual care technology as a means of providing safe and socially distanced care that allowed them to maintain contact and interact virtually with their patients. Within a few months of the onset of the pandemic, the rapid policy changes adopted by third-party payers that accepted virtual dental visits as a valid modality of providing oral health services was critically important to the survival of many practices. This shift allowed them to maintain some cash flow, making it possible to retain staff and assist in covering some of the ongoing overhead expenses.
The extent to which teledentistry was adopted varied considerably among practices. Some simply triaged emergencies using asynchronous, storeand-forward technology wherein images, messages or other data are collected at the patient source by a parent taking and transmitting information, such as electronic photos of the problem or lesion, to the provider for interpretation and recommendations for care. [11] Other practices elected to engage more actively in fully synchronous visits including real-time telephone and/or live audio/ video interactions with families using smartphones, tablets or computer cameras to engage in more direct contact by viewing and coaching toothbrushing sessions and application of fluoride varnish by the parents at the direction of the provider. [11] Zoom became widely used due to the secure versions offered by that platform that are compliant with HIPAA regulations. [15] Some practices took teledentistry technology to a higher level by transmitting creative, age-appropriate, educational videos for patients adapted and attuned to distance learning so patients and families could receive messages about the importance of oral health and how to prevent disease.
Teledentistry should not and could not replace the need for all in-person visits with the dentist.
As teledentistry has become more popular and widely used, it has become apparent that this technology offers several advantages for a dental practice over the way in which dentistry was practiced prior to the COVID-19 pandemic. These potential advantages will certainly contribute to its continued growth and expanded utilization even after the pandemic ends. These advantages include:
■ Increased access for patients to dental care by omitting time and cost to travel to dental offices.
■ Cost savings to providers by reduced use of PPE and disposable supplies.
■ Increased access to specialists for consultation and diagnostic services that are not easily accessible in more remote or rural areas.
■ Better continuity of care by the use of teledentistry-based, postoperative follow-up care following surgery or other procedures.
■ Increased patient contact and engagement in between necessary in-person visits.
■ Reduced stress and desensitization for patients with special health care needs by having some aspects of their care in the comfort of their home.
Existing evidence has demonstrated some of the feasibility and benefits of incorporating telehealth into the practice of dentistry. Studies have demonstrated that the use of teledentistry for caries diagnosis can be comparable to the diagnosis of caries by traditional dental visits. [16] Beyond being an effective means of diagnosis, teledentistry has also been shown to increase access to care for children who have never seen a dentist and could be a viable option for providing early screening for dental caries. [17] Additionally, care with teledentistry has been shown to help individuals improve their oral hygiene through decreased plaque and improved gingival index. [18] Most recently, one study showed that over 90% of patients were satisfied with their dental visits through telehealth during the COVID-19 pandemic. [19] And another recently published report demonstrated teledentistry can be a cost-saving mechanism by reducing unnecessary in-person dental visits and triaging patients to prioritize those who need care most urgently. [20]
Teledentistry should not and could not replace the need for all in-person visits with the dentist. In an office-based practice, teledentistry can supplement face-to-face visits, the frequency of which is determined by the unique treatment needs and clinical conditions for each patient. As an example, the presence of an eruption hematoma or the ectopic eruption of a mandibular permanent incisor in a child could be diagnosed effectively using either real-time video or store-and-forward photographs of the area, depending on the availability of an internet connection and photography devices, and dealt with appropriately without an in-person visit.
Community-Based Care
One example of a full-service, community-based teledentistry care system is the virtual dental home (VDH). The VDH system of care uses allied oral health personnel, including dental hygienists and assistants, to bring care to community sites, involve dentists in the care through a telehealth system and maintain the oral health of most individuals through treatments provided at the community sites. [21] It has demonstrated the ability to keep most people healthy in community sites, refer people to dental offices when they need advanced surgical services that require that environment and increase patient and caregiver adoption of “daily mouth care” routines that are critical for maintaining oral health.
The VDH system was tested in a sixyear, state-authorized Health Workforce Pilot Project and showed that about two-thirds of low-income children could receive all the services they needed to remain healthy in a school environment through the VDH service model. [22] The program and policy considerations from this model have been summarized. [23] Results of several four-year, state-sponsored local dental pilot projects that included expansion and adoption of the VDH model and use of care coordination strategies were presented at a recent symposium. [24]
Teledentistry Platforms
The interest in and need for teledentistry technology during the recent COVID-19 pandemic has accelerated. This has resulted in the emergence of several companies that are designing and building software platforms designed for a telehealth environment and focused on disease-specific disciplines including dentistry. [25–27] HIPAAcompliant platforms such as these allow providers and affiliates to share, access and protect electronic data from dental visits without the burdensome steps of physically transmitting records. This allows for a network of providers and community partners to participate in teledentistry through cloud-based telehealth accessibility. These platforms are also encouraging direct-to-consumer participation in teledentistry by allowing patients to contact their providers through these platforms including sending photos for asynchronous review, self-scheduling video and in-person visits, completing online forms and data collection and even using these platforms for synchronous teledentistry video appointments with waiting room capacity.
Teledentistry Financial Considerations
As innovation has driven dentistry’s ability to provide care through teledentistry platforms, payers have also been advancing in their acceptance of virtual modes of dental care delivery. As of Sept. 27, 2014, AB 1174, Dental Professionals: Teledentistry Under Medi- Cal, was approved by the California governor. Following this legislation, several procedures were made billable to the Medi-Cal Dental Program through the use of teledentistry including examinations and radiographs. Medi- Cal Dental also acknowledges dental codes for synchronous and store-andforward methods of teledentistry and has also increased the teledentistry resources available on its website as a result of the COVID-19 pandemic. [28]
Private payers have also initiated reimbursement for care delivered using teledentistry. Delta Dental of California reimburses for dental examinations completed using teledentistry. [29] Furthermore, Delta Dental of California is exploring the future role of teledentistry in the provision of dental care by initiating its own direct-to-consumer teledentistry service. As of February 2021, Delta Dental of California announced a new offering for its members. This new program offers store-and-forward and live video consultation with Delta Dental dentists for its PPO and Premier plan members. [30]
Teledentistry has the ability to not only increase access to care for patients by allowing them to access dental care but to also become an additional production source for dental providers. Dentists have the ability to partner with community sites, such as schools and day cares, and for nonpediatric dentists, other adult residential facilities. Allied dental personnel can collect dental radiographs, photographs and notes on-site to be forwarded for review by the dentist at a later time. These are all billable procedures. The use of teledentistry has the potential to become an additional source of production for dental practitioners without using in-office chairtime. It is encouraging to see payers providing reimbursement mechanisms for synchronous and asynchronous delivery of teledentistry services, as the payment for these services will only further drive their implementation to increase access to care.
Teledentistry at UCSF
UCSF Pediatric Dentistry, like many other practices in California and the nation, embraced telehealth technology out of necessity during the COVID-19 pandemic. UCSF Pediatric Dentistry has applied this technology to several areas of its practice over the past year with plans of expanding its use in the future using synchronous and asynchronous methods.
We have implemented the use of synchronous telehealth consult visits for patients with special health care needs and/or those who live a significant distance from San Francisco who are referred for advanced pediatric dental care. Using synchronous live visits with the patient and parent, we are able to gather medical history, dental history and chief complaint and perform a limited oral exam of the child. Often, the referring dental provider has also provided dental radiographs prior to the telehealth visit. Through this application of the teledentistry technology, we are in most cases able to recommend a treatment plan for the patient such as in-office with nitrous oxide, oral conscious sedation or treatment with general anesthesia. This use of synchronous telehealth precludes the need for the family to travel a significant distance to San Francisco for an initial consultation and reduces the number of in-person visits needed while conserving PPE, disposables and auxiliary staff time. Furthermore, evidence has shown that the use of teledentistry is effective for accurately recommending treatment modalities for pediatric dentistry. [31,32] This methodology is especially important for patients with special health care needs who face an increased expense and inconvenience of having to travel for medical and dental visits. [33]
For children with autism spectrum disorder and other neurodevelopmental disorders (ASD/NDDs), UCSF Pediatric Dentistry has used an integrated hybrid approach to desensitize children to the dental environment and improve their home oral hygiene. [34] UCSF Pediatric Dentistry uses telehealth visits for initial consultations with parents and children with ASD/NDDs who have been referred due to difficult behavior in the dental office. In this consult, providers learn about medical history, dental history, the patient’s existing educational and behavioral supports, communication styles, patient preferences and patient sensitivities. These visits are conducted jointly by UCSF pediatric dental providers and a board-certified behavioral analyst. UCSF also uses live and prerecorded videos of the pediatric dental clinical space to desensitize patients to the clinic before their first in-person visit. Telehealth is also used to improve home oral hygiene. During synchronous and asynchronous oral hygiene coaching sessions, providers work with parents/ caregivers and children with ASD/NDDs to observe how oral hygiene is provided in their home environment and provide instruction and guidance on how to improve. Observing how oral hygiene is done at home by the family and child is extremely valuable in helping to provide specific individualized interventions to improve oral hygiene and prevent oral disease for children with ASD/NDDs. These video visits are used to supplement in-person visits at the pediatric dental clinic. The goal of this hybrid approach of in-person and teledentistry visits for children with ASD/NDDs is to enable all children to complete a traditional dental visit and guide them toward optimal home oral hygiene regimens.
Expanding UCSF’s Teledentistry Systems to Community Sites
UCSF Pediatric Dentistry initially embraced the value and effectiveness of teledentistry to enhance its clinicbased activities. UCSF is now expanding its use of teledentistry to support oral health care for children in community settings. One such example is the development of a virtual dental home system that will use store-and-forward asynchronous telehealth through a grant-funded project (HRSA grant #D88HP37553) in partnership with UCSF Dental Public Health. In this project, UCSF is collaborating with the California Northstate University College of Dental Medicine and Paul Glassman, DDS, MA, MBA, the developer of the VDH system of care, and his team who are providing consultation and educational support for this grant.
As part of this project, UCSF is developing a VDH program with a rural-based elementary school as a pilot site. Through this model, a communitysite provider team composed of an advanced practice dental hygienist (RDHAP) and dental assistant will be on-site at the school and will collect complete diagnostic records including intraoral photos, radiographs, charting, health history and consent information. UCSF is using Teledentix, [25] a cloudbased teledentistry platform, in this pilot project to enable an effortless communication and review of records from the school-based site and pediatric dental providers. The community team will also provide preventive care such as prophylaxis and fluoride varnish at the guidance of pediatric dental faculty. Once the diagnostic records are reviewed by UCSF pediatric dental faculty and residents, when appropriate, they will make recommendations for additional noninvasive treatment at the school site such as sealants, silver diamine fluoride and interim therapeutic restorations to be completed by the dental hygienist. Children with advanced and urgent dental needs will be referred to a partnering local dental provider. Through this use of the VDH, children in rural California with extremely limited access to dental care will be provided specialized pediatric dental services at their school through teledentistry. This model of integrating pediatric dental providers, RDHAP dental hygienists and local dental partners could be implemented in many rural areas to increase access to provide preventive and early interventional dental services without having to relocate dental providers into rural areas. Furthermore, UCSF has integrated a training component to teach pediatric and dental public health residents about the VDH model and how to function in the model with the hopes that they can apply their knowledge and experience to the future use of this revolutionary technology to increase access to care for underserved children in California.
Future Expansion
In spite of the advantages and growing interest, full acceptance of teledentistry faces significant challenges, both by the profession and by the public at large. [35] If the concept is to be widely and generally accepted and adopted as a standard of care, it should be made available to all members of society, regardless of their access to broadband internet or smartphone technology. While there are still vast access-to-care barriers for dentistry in the United States today, teledentistry has the potential to reduce these barriers and increase access to care for remote and vulnerable populations. Although teledentistry has been broadly accepted and is convenient to both providers and consumers, it is not yet readily accessible to large segments of the population. [36] Currently, nationwide only 43% of families have access to video-based technology and many do not have access to high-speed internet required to support most platforms. [37] In these situations, a text-based model of telehealth could provide a compromise and permit some access to virtual services for families who have limited access to videoconferencing capabilities. [38] In addition, there are potential issues with security, privacy and HIPAA compliance with the numerous video-based platforms that have been used by providers in their efforts to provide telehealth services to their patients. [15] An additional potential barrier will be the problems in navigating the ever-evolving reimbursement policies, which vary from state to state. [39] It is always prudent for providers to contact their principal third-party payer’s provider service department and inquire regarding their teledentistry policies.
It will also take a concerted effort by all stakeholders to increase awareness of the benefits of the telehealth systems described here and continued advocacy efforts to create an optimal policy environment. Finally, even with broad awareness and an optimum policy environment, deploying effective teledentistry systems, especially fullservice, community-based systems, can be complex. There will be a continued need for education, consultation and technical support as the use of this technology expands.
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ACKNOWLEDGMENT
The virtual dental home is part of a project supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $3.2M with 0% percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. government.
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THE CORRESPONDING AUTHOR, Ray E. Stewart, DMD, MS, can be reached at Ray.Stewart@ucsf.edu.
