Tele(oral)medicine: A new approach during the COVID‐19 crisis

Dear Editor,

The recent COVID‐19 pandemic and state's “shelter‐in‐place” guidelines have restricted patient's access to dental services, including oral medicine, as well as continuity of clinical education for oral medicine residents. This has required immediate attention from clinicians and educators.

Social distancing is considered to be the best preventative strategy available to reduce the number of newly infected individuals as we attempt to limit the numbers of patients in need of hospitalization at any one time, “buying” more time for the development of effective treatments and vaccine (Del Rio & Malani, 2020). Following the recent shelter‐in‐place orders across the United States, a majority of oral medicine clinics in hospitals, dental schools, and private practice settings are faced with the challenge of maintaining regular oral medicine services while keeping their patients, providers, and staff from being exposed to COVID‐19.

In response to this unusual situation, we believe that telemedicine, also termed more broadly telehealth, offers an opportunity to provide uninterrupted clinical and supportive care to many patients affected by oral mucosal conditions and the opportunity to triage more urgent conditions in need of face‐to‐face clinic visits. In addition, telemedicine offers the ability to continue clinical education of oral medicine trainees. During this COVID‐19 crisis, the federal government has waived penalties for HIPAA violations against providers that continue to see patients in good faith through video consults with several applications such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Skype, or Zoom (Notification of Enforcement Discretion for Telehealth Remote Communications during the COVID‐19 Nationwide Public Health Emergency, 2020). In addition, the American Dental Association has recently released helpful guidelines on coding and billing on teledentistry services (COVID‐19 Coding & Billing Interim Guidance, 2020).

At our institutions, we have recently implemented tele(oral)medicine practices for the diagnosis and management of oral medicine conditions. Face‐to‐face encounters are reserved for emergency cases only. To the best of our knowledge, tele(oral)medicine through video chats has not been used routinely in the dental/oral medicine realm and this is an initial effort to continue our mission as clinicians and educators. While the patient interview process is unaffected for the most part, the clinical examination preparation involves the need for adequate lighting source and a device to aid in soft tissue retraction on the patient's side. In addition, patients have to have access to the required technology (e.g., use of videoconferencing software on computer, tablet, or smartphone), including a stable Internet connection, and be educated regarding proper infection control practices such as sanitizing their hands before and after retracting their lips/cheeks during the televisit.

Briefly, prior to the televisit, patients are provided with specific instructions about how to prepare for the visit. Non‐medical technical personnel may participate in setting up a trial run prior to the consultation to aid in the video link with the oral medicine specialist. When using Zoom, patients are placed in a password protected virtual waiting room until the clinician is ready to admit them into the meeting, which prevents any risk of overlap with another patient visit and others from hacking into their session. They are instructed to set up the visit in a private space where an examination of the oral cavity is possible. In the actual telehealth session, the patient provides informed consent verbally at the beginning of the visit. Residents participate in our telemedicine consultations, under the supervision of the attending provider. Once the history has been obtained, the patient is asked to sanitize their hands and to retract their lips/cheeks with one hand or device (i.e., tongue depressor or handle of a spoon) while directing a source of light (preferably LED) to the examined tissue with the other. In some cases, providers may ask patients to submit photographs following the video visit, to be entered in the electronic health records together with the progress notes gathered during the televisit.

Although the telemedicine clinical examinations lack tactile assessment, the overall experience allows for a good system of continuity of care, the ability to prioritize patient's medical needs, and the potential to alleviate patient's anxiety related to delays in scheduling their office visit. After the COVID‐19 crisis is over, oral medicine specialists may want to consider incorporating telemedicine into their routine clinical practices to benefit patients who have to travel far distances or those who have to rely on family members or transportation to attend in‐person clinical visits. With this in mind, future research efforts should focus to better understand the sustainability, strengths, and limitation of an oral video visit and the process of integrating tele(oral)medicine into a healthcare system. While the COVID‐19 pandemic will have unfathomable consequences on most communities and on many aspects of our society, we feel it is important to pursue our efforts to provide care to our patients with oral diseases and educate our students and residents. Online for now.

AUTHOR CONTRIBUTIONS

Alessandro Villa: Conceptualization, Resources, Writing‐original draft. Vidya Sankar: Writing‐review & editing. Caroline Shiboski: Writing‐review & editing.