Teledentistry: An Adjunct for Delivering Dental Care in Crises and Beyond

Dentists are advocates for oral health, yet finding solutions to address the needs of the nation's most vulnerable individuals who may have limited access to care remains a challenge. Teledentistry is a mode of dental care delivery that has the potential to address health inequities while increasing revenues and patient volume. The idea of televisits is not new to healthcare. References to telehealth were made as early as 1879 with discussions focused on the use of the telephone to reduce the number of office visits.¹ At large medical centers such as Oregon Health and Science University and the University of Washington, medical doctors are utilizing telehealth to conduct visits. OHSU had 1,100 digital health visits during February 2020; these visits soared to nearly 13,000 in March 2020.² This trend is expected to endure after COVID-19.²

The implementation of these systems has the potential to improve health outcomes and access to care and reduce healthcare costs. Patients who have barriers to access, be it geographical, economical, or social, can have continued access to primary care to meet their needs. The United States spends much more money, receives much less return on its spending, and has poorer healthcare outcomes than similar high-income countries.³ The United States spends nearly twice as much and has the highest chronic disease burden, and Americans had fewer doctor visits and the most hospitalizations from preventable causes.³

This article is intended primarily to improve dental professionals' understanding of teledentistry and increase its implementation through the introduction of core elements. This article also aims to address oral healthcare inequities, improve healthcare outcomes, and enhance dental practice for both providers and patients as teledentistry becomes routine practice. Finally, the article will offer guidance to dentists in private practice, hospitals, and academic institutions, as well as allied healthcare professionals regarding incorporating a teledentistry system into practice.

COVID-19 presents a unique challenge to society, especially for healthcare providers. SARS-CoV-2 is a highly infectious viral infection that has spread globally, with signs and symptoms including fatigue, cough, fever, hemoptysis, headache, sputum production, diarrhea, and pneumonia.⁴ Transmission of the infection occurs primarily through direct contact or aerosols released by an infected person.⁴ This is particularly important to dental providers who encounter droplets associated with aerosol-generating procedures daily. SARS-CoV-2 has been detected in the saliva of infected patients, alerting dental providers and requiring vigilance in infection control.⁵ In addition, the pandemic has greatly impacted the business aspect of dentistry, with up to 38% fewer patients visiting dental offices due to fears of transmission and risk of both patients and dental personnel.⁵

With the many challenges presented by COVID-19, teledentistry has emerged as a practical adjunct for care delivery. Teledentistry is beneficial for social distancing, triaging, medical history interviewing, virtual examination, building a differential diagnosis, coordination of care, and appropriately keeping oral healthcare within the realm of dental care providers and not emergency rooms.

Telehealth offers significant economic advantages both from a patient and a managerial perspective. Estai et al conducted a study that estimated what the scale of resource transfer would be when using teledentistry to screen low-risk children in Australia compared to traditional visual dental examinations.⁶ The allocation of dental care resources was suboptimal, revealing that children living in high socioeconomic regions with low disease burdens utilized half of all estimated resources in a universal visual dental screening system.⁶ As such, switching to teledentistry would potentially free $40 million per year, which could be reallocated to address more vulnerable populations.⁶ Patients also are able to save on costs; a study conducted in four district hospitals in Mali that adopted telehealth demonstrated that patients saved an average of US $25 and a maximum of US $70.⁷ In a country where the per capita gross domestic product is US $1300 per year, these savings are significant.⁷ Dental specialists at the Royal Children's Hospital in Australia used models to show that for orthodontic or pediatric consultations, the utilization of teledentistry cost AUS $294.35, compared to the traditional face-to-face consultation that cost AUS $431.29.⁸ This represents savings of AUS $136.95 per appointment, which correlates to 36.7 days of clinic time that may be freed up to treat other patients and expand capacity.⁸

Data from the American Dental Association shows that dentistry's recovery from the pandemic leveled off by October 2020; biweekly polls surveying dentists show that as of the week of October 5, 2020, 99% of dental offices in the United States were open, and patient volume was estimated at 80% of pre-pandemic levels.⁹ Over the course of several weeks these values showed little change, suggesting that dentistry has reached a new normal for economic activity.⁹ Recruiting for dental staff has become difficult, with nearly 80% of owner dentists reporting that it was extremely challenging to recruit dental hygienists and roughly 70% stating the same for dental assistants.⁹ Furthermore, recent modeling of the impact of the pandemic has predicted that US dental care spending could decline by up to 20% in 2021.¹⁰ With financial uncertainty in the future, difficulty in recruiting dental staff, and a potentially diminished patient volume, teledentistry is a way for dentists to maintain and/or bolster their practices. It can serve as an adjunct to addressing the deficiency in patient volume and an opportunity to increase revenues.

Definitions

Telehealth - "A collection of means or methods for enhancing healthcare, public health, and health education delivery and support using telecommunications technologies."¹¹

Synchronous - Live video that happens in real-time and is extremely useful for a provider, offering face-to-face encounters and interaction with a patient.

Asynchronous - Interaction that does not take place in real-time; also referred to as "store-and-forward." It involves an electronic health record (EHR) and a HIPAA-secure two-way messaging platform, where a healthcare provider can review all health records and information pertaining to the patient and communicate via photographs and information accessed from a remote location, and this does not need to happen simultaneously during a virtual visit.

Requirements

The first of several components required for teledentistry is a secure HIPAA-compliant platform for patient-provider communication that ensures that the office can provide and receive communications such as virtual visit invitations, consent forms, and other patient information. While OHSU utilizes Mailgate SC^™, numerous other services provide HIPAA-compliant messaging, such as Virtru^©, MD OfficeMail^©, and LuxSci^®.

The second necessary component is a HIPAA-compliant virtual visit system. Many virtual visit systems are available, including Zoom^©, Doxy.me^©, and WebEx^™. OHSU uses WebEx, and UW uses Zoom. The HIPAA-compliant system should be user-friendly and allow for interfacing with various kinds of mobile devices such as phones, tablets, or computers.

The third component is audio-visual equipment. In order to communicate, both provider and patient require a device to access the virtual visit, along with microphone and speaker capabilities. Devices can be computers, tablets, or phones. In conjunction, a strong internet connection will be needed to support audio and visual capabilities.

Procedure

Initial communication - The first step in a teledentistry visit is to have the front desk conduct triage over the phone, beginning with current COVID-19 screening questions (eg, any cold/flu like symptoms in the past 14 days, travel in state or international, or contact with a confirmed COVID-19 case, etc). Next, questions regarding the chief complaint are asked, such as whether the patient is experiencing pain or swelling. Lastly, it should be ascertained whether the patient has access to virtual resources (ie, internet connection and audio-video device). If appropriate, a virtual visit may then be used to address the patient's emergent needs.

Patient onboarding - Should a virtual visit be considered necessary, the front desk sends an email message to the patient through a HIPAA-compliant system and directs the patient to create a temporary account. Once completed, the patient can access communications with the providers and staff through the interface, reply, and return signed consent forms. The next step is scheduling the patient. In addition, the front desk should set expectations with the patient regarding the relatively limited scope of service that can be provided during a virtual visit and that, pending the consultation, an in-person follow-up visit for treatment may be required. Furthermore, the front desk should communicate to the patient any details regarding how to sign in.

The televisit - The patient should log in to the portal at the time of the appointment. Depending on the virtual visit system, either the patient is checked in by the front desk and placed into a virtual waiting room or this process may be automated. When the provider is ready, the patient's name and date of birth are confirmed, and the provider's proof of licensure (name badge or license) is shown to the patient.

History and examination - A large amount of valuable information can be gathered from the patient during the virtual visit, which will save in-office time. The provider reviews the patient's chief concern. One thorough and simple method of breaking down the chief complaint is "OPQRST": onset, palliation/provocation, quality, radiation, severity, and timing. A detailed health history or update is performed. This can be advantageous, as the patient may have better access to their medications at home.

The extraoral examination can be done easily, with the clinician checking for signs of swelling, trismus, and/or lymphadenopathy. Questions asked may include whether the swelling extends periorbital or sublingually, or whether there is clear facial drooping and difficulty breathing. The patient or a caregiver may also be provided with instructions to palpate structures to test for pain and swelling.

The intraoral examination can be achieved with instruction, especially if presented in a tell, show, and do format. Patients can use a utensil or toothbrush to help with retraction to ensure better visibility. Flashlight options on a smart phone or mobile device can help aid the examination of the area of concern, although the use of less direct forms of lighting with the patient positioned close to the camera may prevent overexposure. A utensil also may be used to assess the percussion response of specific teeth. The dentist then decides the next course of action and can prescribe necessary medications as needed.

Decision tree - The following decision tree can be used to determine the course of action once the patient has been examined:

- If there are no obvious signs, symptoms, or pain, and the patient responds negative to all questions = no need for intervention.

- If there is evidence of localized abscess or infection = prescribe antibiotics/pain medication case by case and schedule the patient to be seen in urgent care for definitive treatment; if the patient cannot be seen in person, continue to follow-up with them virtually.

- If there is evidence of severe swelling extending beyond the dentition and/or visible difficulty breathing = instruct the patient to immediately go to a hospital emergency department.

Front office communications - Coordination with scheduling personnel is a key component of success in order to set up appointments, answer logistical questions, and follow-up with patients on treatment after a telehealth visit. The office team needs an efficient and clear communication method integrated into the EHR platform, such as Microsoft^® Teams or other messaging software that is HIPAA-compliant. Examples of elements to include post telehealth visit are: (1) referral needed? (y/n), (2) next visit (type, proximity, length), (3) COVID testing? (y/n), (4) prescription status, and (5) interpreter needed? (y/n). With this information, a designated team member can contact the patient with the next steps.

Billing and documentation - Teledentistry is not billed independently as a service; it is billed as a method of delivery for a covered service that is within the scope of practice. In the authors' experience, with the proper coding and documentation, reimbursement for teledentistry visits has been at the same level as in-person visits. This may vary by state and insurance carrier, however. There is a focus on billing for procedures within the dental field that differs compared to the rest of healthcare. It is the authors' opinion that advocacy toward reimbursement for time is needed and would greatly improve the quality of care for dental patients. The two teledentistry modifier codes are D9995 for synchronous, real-time encounter, and D9996 for asynchronous store and forward. They must be paired with a service that can be provided via teledentistry. For example, most often especially during triage, these codes are paired with D0140 Limited Exam for a problem-based examination.

Unlike teledentistry, telephone calls are billed as a service. Though historically not reimbursable, the D9992 code for triage and care coordination was added to support dental care at the time of the COVID-19 pandemic.

When completing notes, specific elements need to be included, such as: (1) location of the patient, (2) location of the provider, (3) names and credentials of all individuals involved in the appointment (eg, observers, dental assistants, caregivers, etc), and (4) type of encryption used.

Consent forms for telehealth, while not required by Medicaid, are required in many states and should include consent at the beginning of the visit for the presence of other possible observers.

At the outset of the COVID-19 pandemic, knowledge about the virus and ways to decrease transmission was limited. As such, broad shutdown orders were put in place, which affected dental practices. Recognizing the importance of ensuring that patients with dental issues could continue to seek care and avoid emergency rooms, OHSU and UW quickly implemented teledentistry to address a burgeoning need for dental care. Teledentistry was optimal in complying with public health directives, ensuring that providers could have continuity of care with patients and helping to address emergency dental needs of the population. Challenges to teledentistry pertained to the virtual visit itself, as not all patients possess a high-speed internet connection or the proper audio-visual equipment necessary to conduct a successful teledentistry encounter. Furthermore, patients may not possess adequate technical knowledge needed to log in and connect with providers. Despite these considerations, teledentistry is not only a means of addressing current emergent needs, but also an adjunct for potentially reaching people in the United States with limited access to care.

Key findings from the 2014 National Healthcare Quality and Disparities Report show that while the rate of the uninsured decreased substantially and quality improved in areas such as patient safety and person-centered care, few disparities were eliminated, and many challenges remain.¹² People in lower socioeconomic groups generally have less access to care, and the care itself is of poorer quality.¹² The US surgeon general's report in 2000 highlights that oral health is essential to general health, yet not all Americans are achieving the same level of care.¹³ Barriers such as geographic distribution, the high cost of dental care, and cultural differences make it difficult for the vulnerable to obtain care.¹⁴

The number of Americans with private dental insurance coverage has been on the decline, the cost of dental care is increasing, and adult benefits through state Medicaid programs have been cut. Factors such as dental practice organization as well as increased student debt also bring significant challenges.¹⁵ Although the Affordable Care Act does expand dental benefits for children, it does not address critical adult access-to-care issues such as finding a practitioner willing to take Medicaid because of unacceptable below-cost reimbursement, as well as being at risk of having funding cut significantly in times of crisis.¹⁶ As a result, dentistry primarily serves the wealthiest and healthiest proportions of the population, leaving entire demographic groups at risk. Although significant obstacles to care exist, California's virtual dental home (VDH) model of care demonstrates that implementing teledentistry can help address deficits in care, ensuring that up to two-thirds of children and half of adults seen in a VDH system were able to receive all the care needed.¹⁷ The results show that teledentistry interventions can improve oral health and ensure that oral healthcare professionals are able to serve a wider array of patients.

The workflow outlined in this article demonstrates promise, and initial testing at OHSU and UW shows that teledentistry visits are not only possible to implement and conduct but, in some cases, desirable. The next stages include testing on a wider scale, expanding capabilities, and including teledentistry as part of routine practice. Future key steps to developing this modality include: helping dentists learn and utilize teledentistry in either private practice or an institution; creation of a safety net to refer patients who dentists screen and examine but cannot see in an office setting for a variety of reasons; and training predoctoral students and practicing dentists in how to conduct telehealth visits. Teledentistry is not only an important adjunct to meet current challenges of the pandemic, but it can also be beneficial for non-urgent care such as oral health instruction and/or care monitoring.

Dentistry cannot afford to be complacent; the previous "normal" and status quo have failed to address health inequities and left the most vulnerable people without adequate care. Change is happening, and only through innovation, adaptation, and evolution can dentists truly begin to ensure care for everyone. The use of available technology to address health disparities can improve access to care, during times of both crisis and normalcy. Ultimately, teledentistry offers a way to optimize usage of limited healthcare resources, increase revenue, and address health disparities affecting the vulnerable.

Kevin Chung, DDS
Former General Practice Resident, Oregon Health and Science University, Portland, Oregon; Oral Medicine Fellow, University of Washington, Seattle, Washington

Jacqueline Wong, DDS, MSD
Clinical Instructor, Department of Oral Medicine, University of Washington School of Dentistry, Seattle, Washington; appointed Director for Teledentistry at the beginning of the pandemic

Joana Cunha-Cruz, DDS, MPH, PhD
Professor and Director of Practice-based and Community-based Research, Division of Behavioral and Population Sciences, School of Dentistry, University of Alabama at Birmingham

David Carsten, DDS, MAGD
Assistant Professor in Hospital Dentistry, Oregon Health and Science University, Portland, Oregon; Fellow, Academy of Dentistry International; Fellow, American College of Dentists