Teledentistry 101: A Primer for Dental Professionals for the New Normal

Parvati Iyer, DDS; Shuba Anantha, DDS; Amy Griffith, DDS; and Casey Farrand, BS

ABSTRACT As dental practices prepare to reopen after the COVID-19 pandemic, dentists have to overcome myriad challenges including low patient volume, shortage of PPE and additional operational expenses on top of lost revenue during the pandemic. Teledentistry could be a viable option to connect with patients and to triage before scheduling emergency appointments. This article provides essential tips to launch teledentistry in your office for the new normal and for the foreseeable future.

AUTHORS

Parvati Iyer, DDS, is an assistant professor in the department of diagnostic sciences and the course director for integrated clinical sciences I at the University of the Pacific, Arthur A. Dugoni School of Dentistry. She is a graduate of the University of Michigan School of Dentistry. Conflict of Interest Disclosure: None reported.

Shuba Anantha, DDS, is a part-time instructor in the department of preventive and restorative dentistry at the University of the Pacific, Arthur A. Dugoni School of Dentistry and works as a part-time associate. She graduated from the University of Illinois at Chicago’s international dentist program. Conflict of Interest Disclosure: None reported.

Amy Griffith, DDS, practices full time in Sunnyvale, Calif. She earned a degree in psychology from the University of California, San Diego and a Doctor of Dental Surgery from Creighton University School of Dentistry in Omaha. Conflict of Interest Disclosure: None reported.

Casey Farrand, BS, graduated summa cum laude from Arizona State University with a bachelor’s degree in health science. She is a consultant for dental practices. Conflict of Interest Disclosure: Ms. Farrand is a freelance practice consultant for dental practices.

Teledentistry is not new to the industry. In 1994, the Department of Defense [1] launched Total Dental Access (TDA) with the sole purpose of increasing access to care, continuing education and providing effective communication between dentists and specialists. Prior to the COVID-19 pandemic, teledentistry was used as a cost-effective measure [2] to improve oral health in nontraditional settings, nursing homes, schools in rural areas and in federally qualified health centers (FQHCs). Now more than ever, the COVID-19 pandemic has brought to light this underutilized option in dentistry.

The Oral Disease Burden and Prevention Report (2017) [3] for California cites a severe shortage of dental workforce in rural areas as an important factor in contributing to oral health disparities. About 59 million people living in these “health professional shortage areas” [4] have no access to oral health care. The COVID-19 pandemic may be the muchneeded catalyst for change. Patient flow has been disrupted and altered, and this might be the perfect opportunity for urban dentists to extend care to these underserved populations by using teledentistry. This type of delivery of care has been tested in public health settings and has proved to be effective in reducing oral disease [5] in high-risk populations.

Marko Vujicic, PhD, from the American Dental Association’s Health Policy Institute, hypothesized that based on preliminary data gathered from dental practices that reopened the first week of May, lack of PPE and perception of risk of transmission were the two important factors [6] that impacted the dental economics of the COVID-19 pandemic. Previously, a patient would be seen for a face-to-face consultation to discuss a concern before scheduling treatment. Now, with PPE constraints and other limitations, it is possible to optimize scheduling because these initial consults could be triaged and handled remotely with the same personalization, care and payment parity from insurances.

There has been research from the Center for Infectious Disease Research and Policy about the resurgence of COVID-19 infection [7] over the next 18–24 months. So, while some dental professionals may view teledentistry as a temporary solution for a temporary problem, it could easily, effectively and favorably be incorporated into the new normal. Dental practice staff could further utilize these teledentistry platforms for a more personalized remote appointment check-in than just a text or phone call, with utilization of virtual waiting rooms. Overall, teledentistry would increase patient satisfaction [8] and strengthen the connection to the practice by giving above-and-beyond service, while the practice gets loyalty and referrals.

While innovative, teledentistry could foster a collegial relationship with patients and deliver a personal touch similar to house calls from a physician. A virtual visit for a child in pain could be perceived as an invaluable service in the eyes of the parent. Other advantages for patients using teledentistry services would be immediate access to dental professionals for consultations, reduced anxiety, reduced travel costs, timely referrals to specialists, mobile applications to monitor and relay relevant health data and possibly reduced visits to the hospital emergency department for dental issues. [9]

Teledentistry Basics

Teledentistry is the use of technology and communications in the field of dentistry to provide services including screening, consultations, referrals and patient education. Teledentistry uses four different modalities [10] to deliver care and educate patients.

SYNCHRONOUS OR REAL TIME

Synchronous or real-time audiovisual conferencing is a two-way communication between the health care provider and the patient using telecommunications technology. For example, solo practices could start with slight modifications to their existing infrastructure by using affordable, HIPAA-compliant software and applications such as MS Teams, [11] Skype [12] for business, VSee, [13] Zoom for health care, [14] Doxy.me, [15] Google G Suite [16] and WebEx. [17] Patients could contact the office via the website or a phone call and schedule a teledentistry appointment with the dentist or a trained staff member. The patient would have access to paperwork on the website or a patient portal and would complete it prior to the appointment. During the teledentistry appointment, the dentist would ask relevant questions and also guide the patient to retract their lip or cheek to show the tooth/lesion in question. The dentist would then virtually evaluate the problem and make a referral to a specialist if needed.

ASYNCHRONOUS OR STORE AND FORWARD

The asynchronous or store-andforward method uses another telehealth provider to capture patient information such as photos, radiographs, etc., that are then forwarded to the dentist. The dentist would access the diagnostic records at a later time and make appropriate treatment recommendations to the allied dental personnel. In California, registered dental hygienists in alternative practice (RDHAP), registered dental hygienists (RDH) and registered dental assistants in extended function (RDAEF) are permitted to acquire diagnostic information such as charting, intraoral images, radiographs, etc., and upload it to a cloud software for dentist review at a later time. This type of asynchronous teledentistry is commonly used by large group practices and in public health settings to provide care to populations who may otherwise not have access to care. Teledentistry companies like TeleDent, [18] PBHS, [19] Dentulu, [20] Teledentix, [21] OperaDDS [22] and RevenueWell [23] offer comprehensive packages including a dashboard, encrypted chat, video-/audioconferencing, scheduling, payment, etc., that consolidate multiple components of this process.

When the allied dental team stores and forwards the diagnostic records, it is called the store-andforward method. Mobile vans offering preventive services to schoolchildren do not have axiUm software available. If the patient information needs to be transferred to the dental school for continuity of care, additional technological applications and support are required.

REMOTE PATIENT MONITORING

Remote patient monitoring (RPM) is a modality where the patient’s dental and medical data are collected from a telehealth provider in one location and transmitted to a provider in another location for treatment and guidance of care. With the oral systemic connection, elderly patients in long-term care facilities could benefit from this modality and prevent health complications during and after this pandemic. Compliance with sleep apnea appliances and blood glucose monitoring are examples where this modality could aid in the management of chronic diseases and help with timely interventions. This modality of telehealth could expand health services to rural areas and improve health outcomes for patients.

MOBILE HEALTH (mHEALTH)

Mobile health (mHealth) involves cellphones and other hand-held devices that monitor health statistics of patients and relay information to health care providers. Several applications for mobile devices are available to download to help motivate patients to improve their oral health and connect with a dentist when they have a question regarding an issue.

Decisions on Teledentistry

The first step is to decide which level of teledentistry service to implement in a practice based on the dentist’s beliefs, practice philosophy, budget and demand in their community. Once that decision is made, the next step is to set up the infrastructure, train the staff and then inform patients and the community that teledentistry is now an available option. The synchronous modality is easily adopted in any solo practice with minimal training of staff and utilizing existing resources. The asynchronous modality is an excellent option for group practices, dental support organizations (DSOs) and public health settings and may require set-up time and additional training.

Teledentistry for Solo Practices

The American Dental Association Health Policy Institute’s recent report showed that solo practitioners were slower to bounce back [24] from the COVID-19 restrictions to patient care compared to group practices. Teledentistry could be a big booster for patient flow in a solo practice. Teledentistry could be useful to screen and triage existing patients before giving them an appointment for treatment (TABLE 1, "Teledentistry for Solo Practices", SEE TABLE IN FULL ISSUE OF THE JOURNAL). With the shortage of PPE and staff members, it may be the best way to streamline patient care in the post COVID-19 pandemic era. It could help retain existing patients, acquire new patients and reach across geographical barriers to provide care. Hygiene hours could be extended with teledentistry consultations to increase patient volume. In California, dentists are allowed to supervise up to five hygienists at a time in satellite offices. By increasing hygiene to after-hours and by doing real-time or asynchronous dental examinations, more patients could be seen for recall care. This would also reduce dental emergencies from developing while patients are waiting to be seen. Teledentistry could be utilized after-hours to do treatment plan presentations to patients with complex restorative needs. This would be a great way to reconnect with inactive patients. Real-time audio-/videoconferencing with the dental lab for such patients would improve communication and accuracy, thereby minimizing redos [25] and increasing patient satisfaction.

Teledentistry for Group Practices

Teledentistry in group practices would facilitate better communication by coordinating care between general dentists, specialists, hygienists and support staff within group practices. Directors of larger dental practices could calibrate their associates and staff in satellite offices using teledentistry (TABLE 2, "Teledentistry Workflow for Group Practice: Key Consideration for Multi-Office Practices", SEE TABLE IN FULL ISSUE OF THE JOURNAL). RDHAPs could provide care for patients after-hours in long-term care facilities and virtual dental homes 26 and coordinate care with a licensed dentist synchronously or asynchronously.

Research shows that asynchronous teledentistry modality is equivalent to screening done face to face [27] in schoolbased programs, long-term care facilities and community outreach programs. DSOs could use this technology as a marketing strategy to attract patients who prefer the efficiency of quick referrals, shorter in-person visits and better collaboration with other nondental members. Teledentistry could also be used for training, continuing education and remote mentoring of younger associates in the organization.

Teledentistry for Dental Schools

During the COVID-19 pandemic era, dental institutions could incorporate teledentistry platforms to triage and collect information from emergency patients. This would preserve the personal touch patients expect and teach students how to communicate and develop decision-making skills. Teledentistry could expand the students’ abilities and prepare them for the future of dentistry. It could streamline patient care in the emergency department, minimize wait times, increase patient satisfaction and allow more patients to be treated for actual procedures. Teledentistry services have been in place at FQHCs and rural health clinics in California to successfully connect oral health care providers with patients who might otherwise not have access to care. More dental schools could form alliances with FQHCs to provide the communitydentistry experience to students and remove existing disparities in oral health. [28]

Teledentistry for Independent Contractors

An emerging trend [29] is teledentistry services offered by third-party organizations that have adopted the “Uber” business model. Dentists could operate as independent contractors and offer teledentistry services (both synchronous and asynchronous) through these platforms to mitigate the backlog of dental patients with urgent and nonurgent needs due to the pandemic. This would be a great service in urban and rural communities and would prevent unnecessary commutes to a dental office. The dentists could sign up, logon to the website and offer their teledentistry services to patients at their convenience; the company would take care of the rest of the process including referrals to licensed dentists for in-person treatment.

Current Health Policies in Teledentistry

On Jan. 31, 2020, the Department of Health and Human Services declared a state of emergency from the COVID-19 pandemic. As a result, the Office of Civil Rights waived the violations against the HIPAA Security Rule for health care providers who were acting in good faith using non-HIPAA-compliant platforms. [30] For example, a health care provider would not get penalized for using a platform that is not HIPAA compliant, such as Apple FaceTime, to perform a teledentistry consultation during the COVID-19 pandemic. These modifications were applicable only for synchronous and store-and-forward modalities in teledentistry and would not expire unless otherwise notified.

Teledentistry could also be used for training, continuing education and remote mentoring of younger associates in the organization.

Medicare and Medicaid services have relaxed their restrictions on reimbursement for telehealth services. This would allow members to get telehealth services from their home (origin site) and not have to travel to health care facilities to see providers enrolled in the Medicaid program.

The Drug Enforcement Administration has a regulation for prescribing controlled substances II-V, which mandates that the dental professional should evaluate a patient’s emergency in person before prescribing such medications. During the COVID-19 pandemic, this regulation, the Ryan Haight Pharmacy Consumer Protection Act of 2008, [31] was modified to accept two-way videoconferencing between the health care provider and the patient before prescribing medications. This change in the policy allowed dentists to serve more patients with dental emergencies.

Billing/Coding and Documentation for Reimbursement in Teledentistry

The ADA has specific guidelines [32] for teledentistry: The dental professional and the allied dental personnel offering teledentistry services must be licensed in the state where the patient receives services. The patient must be actively involved in all decisions regarding treatment and all services must be in alignment with evidencebased practice and in compliance with the privacy laws of the patient. All teledentistry services are required by law to be documented accurately by the dental professional or the allied dental personnel in the electronic health record (EHR). The documentation must also be readily available to the patient on request and also to any entity that is the dental home of the patient.

In a 2016 report on case studies of teledentistry [33] programs in five states across the nation, participants reported that in spite of many advantages as an innovative model, dentists were slow to engage in teledentistry practices due to the regulations and lack of parity in reimbursement. With the new direction the state policies have taken nationally and in California, it may be the best time to revisit this as a tool to extend across geographical barriers and serve those in need.

The two codes used nationally in teledentistry are:

■ D 9995: synchronous or real-time encounter with procedure codes D0190, D0140, D0170 and D0171.

■ D 9996: asynchronous or store-and-forward encounter with procedure codes D0190, D0140, D0170 and D0171. 34

Teledentistry CDT codes D9995 and D9996 are used in addition to the other CDT procedure codes (D0190: screening, D0140: limited oral evaluation/problem focused, D0170: reevaluation — limited, problem focused and D0171: reevaluation — postoperative visit) for billing.

TABLES 3 ("Documentation for Synchronous Teledentistry Modality") and 4 ("Documentation for Asynchronous Teledentistry (Store-and-Forward) Modality") are sample templates for a synchronous and an asynchronous teledentistry modality. TABLE 3 shows what a solo dentist would do to document a synchronous or a real-time consultation of an existing patient. TABLE 4 shows how documentation is done in a large group practice where the initial person triaging the patient acquires and stores the patient data in a cloud storage and forwards it to a specialist. Alternatively, this could be uploaded directly into the EHR and be available electronically for all providers.

In the sample for synchronous teledentistry service (TABLE 3), the dentist evaluated the patient, prescribed medications and referred to an endodontist. Note that the follow-up care is indicated after endodontic therapy.

In the sample template for asynchronous teledentistry modality used in group practices (TABLE 4), the first provider acquired patient information and stored it in a cloud storage or an EHR. The second provider, a periodontist, reviewed that information at a later time and scheduled the patient for crown lengthening. A follow-up appointment with the usual provider (general dentist) was noted for continuity of care.

Current Teledentistry Policies in California

The California Emergency Services Act [35] gave the governor the power to declare a state of emergency and make some important executive orders. This law will be in effect until the emergency is terminated.

Gov. Gavin Newsom’s executive order waived waiting periods between refills of prescription medication and allowed for more refills into a larger prescription. This order also permitted brand-name drugs to be prescribed when generic was not available and waived home delivery charges and preauthorizations. Insurance companies could waive or expedite the credentialing process for telehealth providers.

Gov. Newsom also relaxed various telehealth rules and laws pertaining to the relay of patient information including unauthorized access and disclosure of patient data. Consent requirements (oral or written) were also suspended for telehealth services for the duration of the emergency. Liability originating from such violations were suspended and disciplinary action for unprofessional conduct relaxed for telehealth providers.

As of now, most third-party payers in California will only reimburse the (diagnostic) procedure code and not pay for the teledentistry code separately. Documentation of the teledentistry code is still required on the paper or electronic claim when filing for reimbursement.

Assembly Bill 744, [36] which was passed in October 2019 (effective January 2021), requires that telehealth services covered under a health plan be subjected to the same rules as those services for an in-person visit. This means that all teledentistry services will have “payment parity” or will be reimbursed at the same rate as in-person visits. This bill applies to all health policies that will be issued, amended or renewed on or after Jan. 1, 2021. Though health plans for managed care had payment parity for teledentistry services before the pandemic, this new bill now requires all commercial payers to adopt payment parity as well.

Medi-Cal Dental 37 provides coverage for both synchronous and asynchronous or store-and-forward teledentistry modalities. For the synchronous modality, it is important to include the number of minutes spent in transmission and a procedure code along with the teledentistry CDT code. Reimbursement is allowed separately for the D9995 code with a limit of 90 minutes per member, per provider, per day for this service. For the asynchronous modality, only the diagnostic procedure code is reimbursed even though both codes are required to be documented.

Challenges and Barriers to Teledentistry

Most dental professionals are not comfortable [38] with modifying their technological infrastructure to implement teledentistry and may require a professional dental consultant to aid in set up, maintenance and training. Cybersecurity is an unwanted side effect of any new technology and could potentially cripple a practice. Dental professionals need to be flexible and quick to adapt and create a customizable workflow and train their staff to benefit from this mode of delivery. Resistance to change from staff members, lack of understanding of online presence, the power of social media and inadequate follow-up with virtual visits could result in unhappy patients and negative reviews and damage the reputation of the practice. Another challenge is that patients could now expect answers right away, not placing value on the necessary diagnostics needed to arrive at the proper diagnosis. Further research is needed to make the plunge because there is not sufficient evidence on the long-term utilization of teledentistry. [39]

Conclusion

The American Dental Association Health Policy Institute’s recent report on dental spending predicts a 38% reduction [40] this year and a possible 20% reduction next year. It makes sense to capitalize on other emerging platforms to retain patients, acquire new patients and be part of the solution in overcoming health disparities in the community. The surgeon general’s report scheduled to be released this fall is expected to give direction on emerging technologies that could change the outcome of oral health. Because teledentistry has the potential to evolve with new policies and with states expanding on the range of coverage through this service, it might become a part of mainstream dental practice. Teledentistry may very well be the crucial step that closes the gap between medicine and dentistry.

Testimonial From Amy Griffith, DDS

“Teledentistry has helped me tremendously to connect with my patients, comfort them, give them a sense of control over their lives during this pandemic. It has helped me preserve my stock of PPE, minimize exposure and risk of transmission of COVID-19. Patients have thanked me for their teledentistry consultation and commented that it was very simple and easy to use and they would do it again.”

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THE CORRESPONDING AUTHOR, Parvati Iyer, DDS, can be reached at piyer@pacific.edu.