Advancement Of Teledentistry At The University Of Rochester’s Eastman Institute For Oral Health

Abstract

Dental caries is the most prevalent infectious disease among US children. National surveys have shown that poor and minority-group children are not only disproportionately affected by dental caries but also have limited access to oral health care. Following successful exploratory applications of both synchronous and asynchronous models at the Eastman Institute for Oral Health, teledentistry has been demonstrated to be a practical and cost-effective way to improve oral health care for rural and disadvantaged children. These models support the role of teledentistry in reducing the costs of and barriers to accessing oral health care, improving oral health outcomes, increasing use of oral health care resources, and leading to the establishment of a dental home for underserved children. The advancement of teledentistry underscores the need for its integration with local, regional, and national telehealth programs and the role of policy makers in establishing a balanced framework for teledentistry within the overarching health care system.

Telemedicine is defined as the use of technology to deliver health care services at a distance; telehealth includes telemedicine and patient and health professional education, as well as public health and administrative activities.¹ The use of telemedicine was initiated in rural and remote communities and in federal health programs. It is now being used in various medical specialties and subspecialties in the US and other parts of the world.² The digital transformation of medical health care redefined many aspects of clinical practice and related daily business activities, including practice management, payment, and marketing strategies. Since the immense explosion in computer and mobile device technology, telemedicine services can reach large segments of the general population.¹ Dentistry has embraced telemedicine more slowly and on a smaller scale. Nevertheless, teledentistry has been demonstrated to be a practical and cost-effective way to improve access and increase oral health care use, especially among rural and disadvantaged children.^3,4 Teledentistry has been shown to reduce the costs of and barriers to accessing oral health care, improve oral health outcomes, increase the use of oral health care resources, and lead to the establishment of a dental home for underserved children.

The first entity to explore teledentistry was the US Army. Two US Army pilot projects were begun in 1994, and they demonstrated that teledentistry could save patient travel and evacuations.^5,6 Subsequently, teledentistry has slowly evolved and is currently used for patient screenings, specialty consultations, referrals, education, and emergency care in various dental specialties (including pediatric dentistry, oral medicine, orthodontics, and maxillofacial and oral surgery).^4,7-15 The first virtual dental home program to deliver dental care to underserved and vulnerable patients was created in California in 2010.¹⁶ The virtual dental home is an innovative model for delivering dental care in locations where underserved and vulnerable populations receive integrated oral health and general health services along with educational and social services. Recently, six teledentistry programs operating with varying success in Colorado, Georgia, Minnesota, New York, and Oregon have been described and evaluated.¹⁷ Teledentistry can take one of three forms: asynchronous (the transmission of a patient’s oral images that are not used in real time; that is, store and forward), synchronous (the use of real-time interactive technologies, such as two-way interactive video), and mobile health care services (the use of mobile technology, such as smartphone apps and text messages, to manage and track dental health conditions or promote healthy behaviors).

The Centers for Disease Control and Prevention reports that dental caries is the most prevalent infectious disease in US children.^18,19 Data further show that socially and economically disadvantaged US children have limited access to oral health care.

The purpose of this article is to describe the advancement and uses of teledentistry at the University of Rochester’s Eastman Institute for Oral Health (EIOH) as an integral component of the oral health care system and its relation to the general telemedicine initiative within the university’s Medical Center as a whole. Additionally, we discuss the relevant policy applications, including the organizational changes within the facilities that offer teledentistry services, and we present the encouraging outcomes of the existing teledentistry initiative. We describe the development and implementation of the program in the context of policy-based health care initiative at the local, state, and federal levels. A few of the policy-relevant issues addressed here are related to personnel and administrative responsibilities.

The Teledentistry Initiative

Teledentistry at EIOH was originally envisioned as a way to screen large numbers of children for oral disease, mainly dental caries. Following two small-scale feasibility studies to test the hypothesis that teledentistry could reduce or eliminate the need for a dentist or dental hygienist to perform a visual/tactile oral examination, a longitudinal comparative-effectiveness teledentistry study using a store-and-forward (asynchronous) method to examine Medicaid-eligible children ages 1–6 years for dental caries was undertaken.^3,7 Subsequently, the success of the asynchronous model led to the development and implementation of a synchronous teledentistry program involving EIOH and a community health center in an underserved rural region of New York State.

ASYNCHRONOUS TELEDENTISTRY

In the spring of 2004 EIOH conducted a pilot project to assess the feasibility of the store-and-forward method, using intraoral images to screen for and diagnose oral disease—mainly dental caries in preschool children.²⁰ Each child received two dental examinations. The first, a visual/tactile oral examination, was performed by a calibrated dental examiner (trained systematically by a gold-standard examiner); the second, a teledentistry imaging examination, was performed by a trained telehealth assistant. After a two-week washout period, the images were assessed by the first examiner. Each child was scored as having caries experience or not, as a primary measure, and the number of decayed and filled tooth surfaces due to caries in primary tooth surfaces (dfs) was calculated for each child. The diagnostic quality of the intraoral images was assessed by comparing the results of the traditional visual/tactile examination to the images obtained using an intraoral camera. Sensitivity of the teledentistry examination was 100 percent, and specificity was 81 percent, given that the oral visual/tactile examination was used as the gold standard. The mean dfs scores for the teledentistry images and the visual/tactile examinations were not significantly different. The results showed no difference between asynchronous teledentistry examinations and visual/tactile oral examinations performed by a calibrated dental examiner, thus demonstrating the potential for teledentistry to supplant the standard visual/tactile examination by a dentist or dental hygienist. Intraoral images were captured using the Dr. Camscope intraoral camera. This camera provided bright and clear images; furthermore, various magnifications and focus adjustments could be made as needed during the process. Usually, six intraoral images were completed for each dental screening, and two anterior and four posterior images were transmitted for distant evaluation by the dentist. Initially, we used Second Opinion software. However, in our next teledentistry screening project, we transitioned to the web-based software Teleatrics.

Our asynchronous teledentistry screening projects complemented the existing pediatric telehealth model that began in 2001 at the University of Rochester Department of Pediatrics. The Health-e-Access telehealth program had trained and certified employees at a child care center as telehealth assistants. The assistants were in charge of performing telemedicine screenings for ill children as they presented at the center. Before the commencement of the teledentistry project, the assistants were trained to image children’s teeth for a dental assessment. Initially, a PowerPoint module was presented to the assistants to familiarize them with the first signs of oral disease—predominantly early childhood caries. To obtain clinically acceptable intraoral images, the training modules included a synthetic dental model (typodont) and adult volunteers. The final step included imaging children’s teeth and transmitting the images to the dentist for assessment.

Encouraged by the results of the initial feasibility project, in conjunction with the Monroe County Department of Health, we initiated a dental screening program for urban child care centers located in Rochester, New York. Almost two hundred preschool children ages 12–60 months who attended such child care centers were screened in 2004–06 for the presence of dental caries (especially early childhood caries) by means of teledentistry. All children who participated in the screening program were eligible for Medicaid or Child Health Plus (the state’s Children’s Health Insurance Program). Forty-three percent of the screened children had dental caries experience (dfs > 0). Furthermore, twenty-eight children were classified as having severe early childhood caries. These results were especially troubling, as we observed only a minimal indication of dental treatment. Detailed results of this screening project have been presented elsewhere.²¹

In 2007 we initiated a longitudinal study to assess caries prevalence, incidence, and dental utilization patterns in preschool children ages 12–60 months who were enrolled in selected child care facilities in Rochester. We screened almost 300 preschoolers and followed them for twelve months. At the initial screening, about 28 percent of the children had caries experience in the primary dentition, and—based on the responses of parents or primary caregivers to a questionnaire—almost 50 percent of the children had never visited a dentist. Perhaps the most important observation was that children with dental caries who were screened by means of teledentistry accessed and used dental care significantly more than children screened via visual/tactile examinations, as evidenced by the presence of dental restorations (fillings) for decayed teeth.^3,7 We hypothesized that the difference could be attributed to the fact that the intraoral images served as motivational agents when presented to the children’s parents or primary caregivers.

SYNCHRONOUS TELEDENTISTRY

The success of the asynchronous model led to the implementation in 2010 of a synchronous teledentistry program involving EIOH and a community health center in an underserved rural region of New York State to diagnose, plan the treatment of, and facilitate the care and appropriate treatment of Medicaid-eligible children with oral disease (mainly dental caries) in real time—thus saving two or more trips to Rochester for these initial services. Concomitantly, a teleanesthesia program was established to facilitate care in the hospital setting for children who required treatment in the operating room.

In 2010 EIOH was contacted by Finger Lakes Community Health (FLCH), a federally qualified health center with multiple locations that serves people in the Finger Lakes region of New York State. FLCH has seven dental clinics in its locations in addition to a seasonal facility based on agriculture seasons and a school-based program. These dental clinics serve the entire population and are staffed by general dentists. The dentists who provided care at the clinics often noticed that children referred for specialized pediatric dental services rarely had their treatment completed. An internal review of 158 records demonstrated that approximately 15 percent of the children who had a referral for pediatric dental care actually completed treatment. This observation led to a discussion with EIOH’s Division of Pediatric Dentistry about establishing a teledentistry initiative. It was decided that a live-video (synchronous) teledentistry program would be started to help facilitate oral care for the children of the Finger Lakes region.

The planning for teledentistry services at FLCH required significant ongoing organizational changes, including the commitment and availability of administrative and support personnel. FLCH requires that a care coordinator be assigned to ensure appropriate follow-up for patients who receive teledentistry examinations. An information technology position was created to manage and maintain telehealth applications, and a scheduler was assigned to assist the care coordinator with the large volume of services. FLCH provides the majority of the administrative work that is needed at the front end of patient care, a dental home for the patient, and follow-up services.¹⁷ FLCH’s outreach program uses a team approach that includes care coordinators, patient advocates, and community health workers to assist patients and determine their needs. Telehealth and teledentistry services at FLCH are provided through portal-to-portal connections.

Before the teledentistry initiative at FLCH was established, the barriers to oral health specialty care were abundant.¹⁷ They included lack of dental insurance, limited or lack of transportation options, considerable geographic distance to specialty oral health care providers, cultural and language differences, and the inability to take time away from work during the day. Telehealth services are now an integral part of FLCH, including specialty consultations in mental health, otolaryngology, dentistry, and diabetic retinopathy.

Given the extensive oral health care needs of the children served by FLCH, a synchronous model was chosen to help facilitate the appropriate scheduling of patients for definitive dental treatment. Equipment purchased to initiate a synchronous teledentistry program included a Tandberg 1700 HD monitor, webcams, laptop computers, and an Oracam ST-111 intraoral camera.

When a child is seen in one of the FLCH clinics and identified as having pediatric dentistry needs that require a pediatric dentistry specialist, the parents or primary caregivers are informed. A care coordinator meets with the family to complete permission slips. The patient’s dental records and paperwork are uploaded to the electronic dental record. A description of the synchronous teledentistry program is provided to the parents or primary caregivers, and an initial teledentistry appointment is scheduled. The care coordinator at FLCH works with the care coordinator at EIOH to identify an appointment time for the teleconsultation.¹⁷

On the day of the initial consultation, the parent or primary caregiver signs a consent form for teledentistry examination. An internet connection is established, and the participants are introduced and their roles explained. A typical teledentistry appointment would involve a pediatric patient, their parent or primary caregiver, the telepresenter, a community health worker assigned to the case, and a pediatric dentist at a remote site. The pediatric dentist then conducts a brief medical history review with the parent or primary caregiver. Any questions are answered, and the teledentistry examination begins. The video feed is switched from the webcam to the intraoral camera. The telepresenter systematically shows the pediatric dentist views of the hard and soft intraoral tissues. After completion of the intraoral examination, the video feed is switched back to the webcam. The findings of the examination are discussed with the parent or primary caregiver, and treatment recommendations are discussed along with risks and benefits of the various treatment modalities. The treatment plan is recorded in the patient’s FLCH chart by the community health worker, and a teledentistry appointment note is recorded in the e-dental record by the pediatric dentist.

Monthly meetings are scheduled between the pediatric dentist at the remote site and the teledentistry program coordinator at FLCH, to discuss the progress of treatment of every enrolled child. If further interventions are needed to facilitate treatment completion, the community health workers are notified. If the community health workers are unable to facilitate the removal of treatment barriers, social workers at EIOH are engaged.

To date, over 850 rural pediatric patients have been seen remotely via a live-video teledentistry module. Over 95 percent of the children screened for oral disease had significant treatment needs and could not be accommodated in the rural community dental clinic. The recommended treatment pathways (for example, treatment in EIOH’s pediatric dental clinic, treatment using nitrous oxide anxiolysis, treatment with oral sedation, treatment in the operating room with general anesthesia, or teleconsultation) were identified via the live-video teledentistry module.

An initial review of treatment progress for the first 251 patients who were enrolled in the synchronous teledentistry program was completed in 2014.⁴ This review showed a treatment completion rate of approximately 93 percent for children identified as having oral health needs and requiring oral rehabilitation under general anesthesia. Almost half of the patients required such oral rehabilitation. The remaining children required treatment using oral sedation (this group had a treatment completion rate of 87 percent), treatment with nitrous oxide anxiolysis (56 percent), treatment at EIOH with local anesthesia (100 percent), or a consultation (90 percent). Our initial data review suggested that the rates of treatment completion, irrespective of the treatment modality, were much higher than the original 15 percent observed in the initial record review that was conducted before the initiation of the synchronous teledentistry program.^4,22

Additionally, our review of the program’s initial 251 patient records showed that the initial treatment modality as recommended in synchronous teledentistry consultations was not changed 88 percent of the time. The 12 percent of the treatment modalities that needed to be changed usually involved patients who were initially scheduled for restorative treatment with nitrous oxide anxiolysis who instead received oral rehabilitation under general anesthesia. Thus, live-video teledentistry consultations have been demonstrated to be a practical and potentially cost-effective way to facilitate the use of appropriate treatment pathways and to increase oral health care use when treating complex pediatric dental cases.

Teledentistry is the most common telehealth service provided at FLCH. Teledentistry services are considered a great value-based activity at FLCH, as they have established professional relationships among providers, improved the quality and availability of oral health care for rural pediatric patients, and promoted the use of follow-up services at local general dentistry clinics and the establishment of a dental home at FLCH for rural pediatric patients.

Discussion

Since its inception in 2004, the teledentistry program at the Eastman Institute for Oral Health has reached almost 1,500 disadvantaged urban and rural preschool and elementary school children in New York State. All of the children screened in either an asynchronous or synchronous teledentistry module were eligible for Medicaid and Child Health Plus. Many of them had never seen a dentist and had significant untreated dental disease. Our program—especially the synchronous module—clearly demonstrated that teledentistry screenings assisted in establishing a dental home for disadvantaged rural children.^4,22 As described by Margaret Langelier and coauthors, the beneficial outcomes of teledentistry services at Finger Lakes Community Health include significantly shorter waits to obtain specialty consultations; higher treatment completion rates; lower no-show rates for appointments; and improved work-flow efficiencies for patients, providers, and support staff.¹⁷ The teledentistry consultations help establish patient-provider rapport. Children and parents who present at FLCH for a teledentistry consultation in the presence of a familiar dental hygienist are more comfortable when they meet the pediatric dentistry specialist in person in Rochester. Parents are receptive to the convenience of teledentistry services, as it fosters treatment completion by accurately triaging children into the specific treatment modality while saving time, mileage, and resources.

As clearly demonstrated by the asynchronous and synchronous teledentistry models, teledentistry screenings helped increase completion rates of recommended dental treatment in rural and urban underserved pediatric populations. Teledentistry holds promise to improve access to care, especially among disadvantaged children; improve patient satisfaction; potentially reduce costs to the oral health care system, including reducing dental staff members’ and patients’ time and mileage; and foster treatment completion. As was reported recently, delivering telemedicine or teledentistry services does not require expensive equipment, and the initial cost of establishing telehealth services at FLCH did not exceed $15,000.¹⁷ To leverage our teledentistry program for better integration with FLCH and the University of Rochester, we need to develop an effective marketing plan and a solid, comprehensive, and transparent business plan to manage our resources. Furthermore, the creation of an advisory board with well-connected and committed oral health champions would help us be successful and sustainable.

For teledentistry to become a viable adjunct to mainstream clinical dentistry, various challenges to the widespread use of teledentistry should not be discounted. They include dissimilarities in state and federal laws, limited reimbursement, logistical encounters, and concerns about data quality and security. To date, our teledentistry program has been funded by research grants, including those from the Aetna Foundation, Monroe County Department of Health, National Institutes of Health, Health Resources and Services Administration, and US Department of Agriculture. In 2015 New York State’s Medicaid program expanded its telemedicine coverage to include article 28 facilities that provide dental services (for example, freestanding health care facilities such as EIOH) and federally qualified health centers. Telemedicine consultations (including teledentistry) are covered when medically necessary and when several requirements are met, including patients being physically present at the originating “spoke” site and the consulting practitioner being located at the “hub” site. The practitioner at the hub site who is performing the consultation must be licensed in New York State, enrolled in New York State Medicaid, and credentialed and privileged at both the hub and spoke sites according to the applicable setting-specific standards.

The request for a telemedicine consultation and the findings of the distant-site practitioner must be documented in the patient’s medical record. Lastly, the telemedicine consultation must be in real time and provided via a fully interactive, secure, two-way audiovisual telecommunication system. At present, the asynchronous store-and-forward modality is not covered by New York State Medicaid. With the establishment of a well-adjusted and thoughtful framework for the practice, use, and reimbursement of teledentistry in a mainstream clinical dentistry operation, patients, dental providers, and oral health care systems will be able to realize the full potential of teledentistry. Thus far, efforts at EIOH to implement teledentistry modules have been limited to underserved urban and rural pediatric populations. However, teledentistry has substantial potential to serve other populations, including geriatric populations and patients with special needs or those who have mobility or other barriers that impede access to care. Clearly, populations that lack access to oral health care—especially people who reside in assisted living facilities, group homes, or nursing homes where dental care is limited or not available—would benefit from the availability of teledentistry.

Moreover, a synchronous teledentistry consultation module has substantial broader implications for improving access to oral health care, especially among rural pediatric populations. This undertaking supports the expanded role of teledentistry in reducing barriers to oral health care delivery, enhancing and improving oral health outcomes, increasing use of oral health care resources, reducing costs, and leading to the establishment of a dental home for underserved children. The live-video consultation modality might also allow multiple providers to interact with a rural patient simultaneously. The advancement of teledentistry underscores the need for its integration with local, regional, and national telehealth programs to establish a balanced framework for teledentistry services within the overarching health care system.

Possible future uses of teledentistry include the ability of licensed professionals to supervise the care provided by dental students, residents, or midlevel providers (that is, dental therapists) at distant sites. State laws and practice norms would need to be followed. However, applications such as the use of teledentistry may help facilitate the care of underserved populations. They may also help alleviate the documented faculty shortages that many institutions report, by allowing one faculty member to supervise multiple distant learning or care sites at the same time.

The teledentistry initiative at EIOH is not yet integrated with the Center for Health + Technology (CHeT) in the University of Rochester Medical Center. The CHeT telemedicine team runs both clinical studies and patient care programs centered on virtual visits. Our short-term goal is to leverage the successful application of our current models and integrate teledentistry with the CHeT telemedicine program to become part of a multidisciplinary telehealth initiative. Merging with CHeT could give the teledentistry program much-needed institutional support and increase its visibility and sustainability; it would also strengthen CHeT. Our long-term goal is to expand teledentistry services to other populations of patients, including geriatric patients and those with special needs. The first national teledentistry conference, in conjunction with the American TeleDentistry Association, will be held in June 2019 in Rochester. This conference will focus on topics relevant to incorporating teledentistry into the overarching health care system and will discuss regulatory and operational challenges, including the development and promotion of policies to guide the expansion and sustainability of teledentistry.