Abstract
Purpose:
Non-traumatic dental condition visits (NTDCs) represent about 1.4% to 2% of all Emergency Department (ED) visits and are limited to palliative care only, while associated with high cost of care. Feasibility of establishing a tele-dental approach to manage NTDCs in ED and Urgent care (UC) settings was undertaken to explore the possibility of utilizing remote tele-dental consults.
Methods:
Participants with NTDCs in ED/UCs were examined extra and intra-orally: 1) directly by ED provider, 2) remotely by tele-dental examiner (trained dentist) using intra-oral camera and high-definition pan-tilt-zoom (PTZ) camera, 3) directly by treating dentist post ED/UC visit (if applicable) and, 4) secondary assessment by tele-dental reviewer. Comparisons were drawn between differential diagnoses and recommended managements provided by ED/UC providers, tele-dental examiner, treating dentist, and tele-dental reviewer.
Results:
Thirteen patients participated in the study. The overall interrater agreement between the tele-dental examiner and tele-dental reviewer was high while it was low between tele-dentists and the ED providers.
Conclusions:
Preliminary testing of tele-dental intervention in the ED/UC setting demonstrated potential feasibility in addressing the NTDC landing in ED/UC. Larger interventional studies in multi-site setting are needed to validate this approach and especially evaluate impact on cost, ED/UC workflow and patient outcomes.
Keywords: Teledentistry, Feasibility, Dental, Emergency Department, Urgent Care
1. Background
Emergency Departments (ED) and Urgent Care (UC) represent a medical safety-net and first line early response target for patients with medical emergencies. Diversion of ED resources from managing of life threatening conditions and immediate emergencies to address non-urgent and preventable oral health problems is a growing public health concern1–5. Preventable non-urgent ED visits jeopardize the ability of the ED personnel to accommodate immediate emergencies in timely manner4,6.
Dental emergency (DE) visits to EDs represent about 1.4% to 2.1% of all EDs visits2,7,8. While the majority of dental conditions such as periodontal diseases and dental caries are preventable and treatable in dental office setting, if neglected, these conditions may be associated with development of acute pain or swelling that compels patients to seek care at ED. However, treatment of dental emergencies at ED/UCs usually results in temporary and palliative care without addressing the underlying pathological issues which generally still require management by a dentist to achieve proper diagnosis and definitive treatment9,10. In some cases, dental pain may preclude ability of these patients to attend their jobs. Epidemiological evidence indicates that the number of individuals presenting in ED for non-traumatic dental conditions (NTDC) continues to increase1,5,11. The 2014 American Dental Association (ADA) Research Brief reported that most of the emergent dental related visits at the EDs can be diverted to dental offices for treating the underlying dental cause12. Moreover, another report noted a possible cost saving of up to $1.7 billion annually; if 79% of these visits are to be diverted to appropriate dental setting13. The authors further proposed that the projected saving could be used to support more effective approaches to manage NTDC. Even though the cost incurred from DE visits to EDs is substantially high8, the average charge per visit for dental conditions assessed was $1430.35 in 201413. Studies have shown that a majority of the medical providers are not trained to provide definitive diagnoses and treatment for oral and dental problems10,14,15. Justifying a dental provider within EDs is financially challenging for most of the hospitals. Historical data suggests that DE visits to EDs were made most frequently by Medicaid patients followed by uninsured patients with no access to routine dental care10,16. The previously mentioned ADA report estimated that Medicaid alone spent about $520 million annually for these visits12. Lack of dental access and ED visits in the context of NTDCs continues to drive up cost of care.
Tele-dentistry can be facilitated by a number of venues and platforms including: live video, ‘store and forward’ telecommunication, remote patient monitoring technology, and mobile health technology17–19.
The primary objective of this study was to assess the feasibility of utilizing tele-dental approach to manage NTDCs presenting in ED/UCs. If this approach is validated, tele-dental outreach could provide regional coverage to several ED/UCs to address NTDCs with improved patient outcomes including appropriate dental triage, while reducing ED burden caused by NTDC visits.
2. Material and methods
The study underwent an expedited review and approved by Marshfield Clinic Research Institute’s Institutional Review Board.
2.1. Participants and setting
Marshfield Clinic Health System (MCHS) is one of the largest multispecialty group practices in the country that are involved in patient care, research and education and serving rural population20–24. There are more than 52 MCHS medical centers and the service area spans over northern and central Wisconsin. Family Health Center of Marshfield. Inc. is a federally qualified health center serves low-income, underinsured and uninsured people to provide integrated dental care delivery. This study was conducted over a two months period at two regional locations of MCHS: Lakeview Medical Center Emergency Room and Marshfield Clinic Urgent Care, respectively. The study targeted patients presenting with a chief complaint of any NTDC (for example toothache, gum pain, swelling, jaw pain) to either of these regional locations5. For the purpose of this study Emergency room and Urgent care were grouped under ‘ED’
2.2. Eligibility criteria
Patients with more than 2 years of age and who presented with a primary chief complaint of NTDC were considered eligible for the study. Patients who had an overlapping medical condition (a medical condition with oral manifestation that was undiagnosed at the time of filling the ED registration form) were also included. Exclusion criteria included non-English speakers and adults lacking the capacity to consent.
2.3. Tele-dental setup
The tele-dental unit included the following: 1) High Definition (HD) Camera (Cisco TelePresence Precision) with pan-tilt-zoom (PTZ) function to allow the tele-dental examiner to exam and interact with the patients, 2) Telehealth cart to encompass all parts of tele dental unit in a single movable unit, 3) vitals measuring devices (sphygmomanometer, pulse oximeter and thermometer), 4) a monitor to enable the patients to see the tele-dental examiner, and 5) intra-oral camera (Mouthwatch) to exam intraoral conditions. Figure 1 shows the tele-dental set-up
Figure 1:
Components of the tele-dental set-up
2.4. Work flow and tele-dental protocol
Trained research coordinators monitored the ED patient tracking board for any NTDC. The patients were approached privately by the research coordinators to explain the study and to obtain a verbal informed consent for participation, the participants were also offered $25 gift cards to compensate for their time. Data collection included; age, gender, ethnicity, race, medical and dental insurance status, day in the week the patient was seen, waiting time before evaluation by ED provider, time spent within ED exam room from time of entry in ED and triaging, current medical history, social history including tobacco use, vitals (blood pressure, pulse rate, temperature, oxygen saturation and respiratory rate), chief-complaint and triaging level (ED only)..
The data was entered in REDCap online database that was supported by a clinical decision support system (CDSS) with capacity to calculate age-specific vitals and alert the research coordinator about danger zone vitals that may herald development of emergent life-threatening situations25. Following data entry in REDCap, an interview was commenced using a high definition conference camera. The tele-dental examiner collected information on the patient’s medical and family histories and chief complaint and examined the patient extra-orally (using the (PTZ) function) and intraorally (using intraoral camera).
Figure 2 shows an example of the evaluation carried out by the tele-dental examiner.
Figure 2:
shows the evaluation carried out by the tele-dental examiner
Based on the examination and the collected data, the tele-dental examiner noted a preliminary diagnosis and an interventional management strategy. Figure 3 demonstrates the tele-dental examiner evaluation of an intra-oral image and its entry into the study smart form.
Figure 3:
shows the evaluation carried out by the tele-dental examiner
The diagnoses and interventional approach were not disclosed to the patients or ED provider. Each patient underwent evaluation and management by the ED provider following usual clinical care (either before tele-dental assessment or after, depending on the ED provider availability).
If the ED provider recommended a dental follow-up visit with a dentist, the patients were encouraged by the study team to follow-up with a dentist. The diagnosis and management data from the ED and treating dentist (if applicable) were collected from Data Warehouse. The information of the tele-dental assessment, ED provider and treating dentist and all related data were statistically analyzed.
2.5. Data management and statistical analysis
An exploratory approach employing an observational study design was undertaken, wherein data were collected surrounding the patients’ direct interaction with primary ED provider, tele-dental examiner and treating dentist (if applicable). Additionally, another dentist (tele-dental reviewer) conducted a secondary assessment of the data collected by the tele-dental examiner, which included; medical history, history of chief complaint and video records of tele-dental examiner assessment, to arrive at a diagnosis and recommended treatment. All diagnoses and recommended treatments (by ED provider, tele-dental examiner, tele-dental reviewer and treating dentist) were compared to assess the ability of tele-dental examiner to establish a preliminary diagnosis utilizing a tele-dental approach.
Demographic data were analyzed to determine most common characteristics of the participants, waiting time before ED provider encounter, and total time spent in ED exam room were analyzed to calculate average NTDC ED waiting time, and average time spent by those patients at ED.
Clinical qualitative data were converted into questionnaire format with Yes/No response options to measure the level of agreement, sensitivity (Sensitivity was defined as: The ability to accurately detect presence/describe/recommend a qualitative variable) and specificity (Specificity was defined as: The ability to accurately exclude presence/not recommend a qualitative variable) between the tele-dental examiner, tele-dental reviewer, ED provider, and treating dentist, and expressed in terms of percentages, mean and standard deviation. Inter-rater reliability was measured between the tele-dental examiner and the tele-dental reviewer using Kappa coefficient (K), observed agreement (OA) and Prevalence-Adjusted Bias-Adjusted Kappa (PABAK) coefficient surrounding diagnoses and management. Sensitivity (Sen) and specificity (Spe) assessments surrounding diagnoses and management strategies were made between the first tele-dental examiner and the ED provider, as well as between the tele-dental reviewer and the ED provider.
Analyses were conducted based on two scenarios: in the first scenario the ED provider evaluation was considered the Gold Standard (GS) of care for assessing presence/absence of an overlapping medical condition, the recommendation of seeing a medical provider, treatment at the ED, antibiotic administration at the ED, Rx pain medication administration at the ED, and discharge. For this scenario, the tele-dental examiner and the tele-dental reviewer noted recommendations were tested for accuracy based on the ED provider evaluation. In the second scenario, the tele-dental examiner, treating dentist and the tele-dental reviewer evaluations were considered the GS for assessing: presence/absence of a dental/oral condition, recognition of involved tooth # (if applicable), presence/absence soft tissue involvement, presence/absence hard tissue involvement, presence/absence dental infection, definitive dental diagnosis, antibiotic Rx recommendation, and narcotics Rx recommendation. In this scenario, the ED provider evaluations were tested for accuracy based on the tele-dental examiner, treating dentist, and the tele-dental reviewer noted evaluations. The most common diagnoses (based on the tele-dental examiner assessment) were summarized in percentage values.
3. Results
3.1. Demographics
A total of 13 patients (7 males and 6 females) were eligible and included in the study. The most common reason for visit was “Toothache” (mentioned 8 times) followed by; “Gum Pain”, “Dental abscess” and “Facial Swelling” (each mentioned 3 times) The average age was patient was 39 ±15 years, ranging from 25 year to 77. Majority of the patients were White/Caucasians (92%), with medical insurance (private 46%, Medicaid 8%, Medicare 23%) and dental insurance (private 38%, Medicaid 31%).
a. Inter-provider comparisons
All the patients who completed the study were examined directly by the ED provider, and remotely by the tele-dental examiner. The ED provider diagnosed three patients with medical conditions in addition to the dental condition. Among these patients; a patient with a dental CC (toothache) who was not diagnosed with a dental condition by the ED provider and was excluded from the inter-provider sensitivity/specificity analyses. Tele-dental reviewer assessed 12 patients records (medical history, history of chief complaint and video records captured during the visit); only due to a technical issue with video record of patient #11, which precluded inclusion of this patient from interrater agreement analysis between the tele-dental examiner and tele-dental reviewer; the same patient was also excluded from inter-provider sensitivity and specificity assessment between the ED provider and tele-dental reviewer.
In the first scenario; when the ED provider evaluation was the GS, the analysis resulted in high overall agreement, sensitivity and specificity (Tele-dental examiner vs. ED provider; OA=97%±4, Sen=83%±41, Spe=82%±40, and tele-dental reviewer vs. ED provider; OA=93%±8, Sen=61%±44, Spe=83%±41). While, in the second scenario; when tele-dental examiner and the tele-dental reviewer evaluations were the GS, the analysis resulted in lower overall observed agreement, and lower sensitivity and specificity values (Tele-dental examiner vs. ED provider; OA=65%±33, Sen=55%±36, Spe=59%±47, and tele-dental reviewer vs. ED provider; OA=60%±30, Sen=52%±36, Spe=62%±44). Table 1 shows inter-rater agreement
Table 1:
Inter-rater agreement and Kappa values
| Qualitative variables | Tele-dental Examiner Vs Tele-dental Reviewer | Tele-dental Examiner Vs ED Provider | Tele-dental Reviewer Vs ED Provider | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observed Agreement | Kappa | PABAK | Observed Agreement | Sensitivity Value | Specificity Value | Observed Agreement | Sensitivity Value | Specificity Value | ||
| Presence of a Dental (or an Oral) condition (TD-GS) | 100% | * | 1.00 | 92% | 92% | 0% | 92% | 92% | 0% | |
| Presence of a Medical condition (ED-GS) | 83% | 0.43 | 0.67 | 100% | 100% | 100% | 83% | 33% | 100% | |
| Tooth # (TD-GS) | 100% | 1.00 | 1.00 | 17% | 9% | 100% | 18% | 10% | 100% | |
| Soft tissue involvement (TD-GS) | 100% | 1.00 | 1.00 | 42% | 13% | 100% | 45% | 14% | 100% | |
| Hard tissue involvement (TD-GS) | 100% | 1.00 | 1.00 | 42% | 40% | 50% | 45% | 44% | 50% | |
| Presence of a Dental Infection (TD-GS) | 83% | 0.43 | 0.67 | 92% | 90% | 100% | 82% | 80% | 100% | |
| Definitive Dental Diagnosis (TD-GS) | 91% | ** | ** | 39% | ** | ** | 33% | ** | ** | |
| Seeing a Dentist (TD-GS) | 100% | * | 1.00 | 92% | 92% | 0% | 91% | 91% | 0% | |
| Seeing Medical Specialist/Physician (ED-GS) | 83% | 0.43 | 0.67 | 100% | 100% | 100% | 83% | 33% | 100% | |
| Antibiotic Rx (TD-GS) | 58% | -0.15 | 0.17 | 92% | 92% | 0% | 73% | 100% | 25% | |
| Narcotics Rx (TD-GS) | 83% | 0.64 | 0.67 | 75% | 67% | 78% | 64% | 40% | 83% | |
| Treatment at the ED (ED-GS) | 100% | 1.00 | 1.00 | 92% | 100% | 91% | 100% | 100% | 100% | |
| Antibiotic Administration at the ED (ED-GS) | 100% | 1.00 | 1.00 | 100% | 100% | 100% | 100% | 100% | 100% | |
| Rx Pain medication Administration at the ED (ED-GS) | 100% | * | 1.00 | 92% | 0% | 100% | 91% | 0% | 100% | |
| Discharge (ED-GS) | 100% | * | 1.00 | 100% | 100% | 0% | 100% | 100% | 0% | |
| TeleDentist Gold Standard (TD-GS) |
Mean | 91% | 0.65 | 0.83 | 65% | 55% | 59% | 60% | 52% | 62% |
| Standard Deviation | 14 | 0.46 | 0.30 | 33 | 36 | 47 | 30 | 36 | 44 | |
| ED provider Gold Standard (ED-GS) |
Mean | 94% | 0.71 | 0.89 | 97% | 83% | 82% | 93% | 61% | 83% |
| Standard Deviation | 9 | 0.33 | 0.17 | 4 | 41 | 40 | 8 | 44 | 41 | |
| Total | Mean | 93% | 0.68 | 0.85 | ||||||
| Standard Deviation | 12 | 0.39 | 0.25 | |||||||
Unable to calculate Kappa (due to kappa limitation)
Unable to calculate Kappa, PABAK, the Sensitivity and the Specificity (too many variables)
Sensitivity was defined as: The ability to accurately detect presence/describe/recommend a qualitative variable
Specificity was defined as: The ability to accurately exclude presence/not recommend a qualitative variable
Additionally; the overall interrater agreement between the tele-dental examiner and the tele-dental reviewer was high (OA=92%±12, K= 0.68±0.39, PABAK=0.85±0.25). A total of four patients (out of thirteen) were seen by MCHS dentists post their ED visit, the limited analysis showed high overall agreement, sensitivity and specificity between the tele-dental examiner, tele-dental reviewer and treating dentist (tele-dental examiner vs. MCHS dentist; OA=96%±9, Sen=100%, Spe=67%±52, and tele-dental Reviewer vs. MCHS dentist; OA=93%±12, Sen=95%±13, Spe=78%±40) and lower overall agreement, sensitivity and specificity between the ED provider and MCHS dentist (ED provider vs. MCHS; OA=64%±38, Sen=67%±52, Spe=58%±49). Table 2 shows the sensitivity analysis of evaluations of the Tele-dentists and ED providers in comparison with the treating dentist for four patients. The most common diagnoses were; Periapical abscess (53%), irreversible pulpitis (15%), periodontal abscess (8%), Localized gingivitis (7.7%), Acute necrotizing ulcerative gingivitis (8%), and Reversible pulpitis (8%).
Table 2:
Interrater reliability between Tele-dentists and ED providers in comparison with the treating dentist for four patients
| Qualitative variables | Tele-dental Vs Dentist | 2nd Tele-dental Vs Dentist | ED Vs Dentist | |||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Observed Agreement | Sensitivity value | Specificity value | Observed Agreement | Sensitivity value | Specificity value | Observed Agreement | Sensitivity value | Specificity value | ||
| Tooth # | 100% | 100% | 0% | 100% | 100% | 0% | 0% | 0% | 0% | |
| Soft tissue involvement | 100% | 100% | 100% | 100% | 100% | 100% | 75% | 0% | 100% | |
| Hard tissue involvement | 100% | 100% | 100% | 100% | 100% | 100% | 75% | 100% | 50% | |
| Dental Infection | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | |
| Definitive Diagnosis | 100% | * | * | 100% | * | * | 25% | * | * | |
| Antibiotic Rx | 75% | 100% | 0% | 75% | 67% | 100% | 75% | 100% | 0% | |
| Narcotics Rx | 100% | 100% | 100% | 75% | 100% | 67% | 100% | 100% | 100% | |
| TeleDentist Gold Standard | Mean | 96% | 100% | 67% | 93% | 95% | 78% | 64% | 67% | 58% |
| Standard Deviation | 9 | 0 | 52 | 12 | 13 | 40 | 38 | 52 | 49 | |
Unable to calculate the Sensitivity and the Specificity (too many variables)
Sensitivity was defined as: The ability to accurately detect presence/describe/recommend a qualitative variable
Specificity was defined as: The ability to accurately exclude presence/not recommend a qualitative variable
b. waiting time findings
The mean waiting time for patient to provider-interaction was 40 min, mean time spent by dental patient inside ED room was 46 min.
4. Discussion
Implementation of Telehealth in settings will be beneficial in dental health professional shortage areas, this statement was validated by two recent studies by McLaren S et al17,18.
The first study concluded that tele-dentistry can be used as an accurate method to create a reliable treatment plan for rural children with significant dental disease. This conclusion supports our preliminary finding that tele-dentistry can be used as an accurate method to establish a diagnosis. Even more compelling is what the authors revealed in the second article about the high compliance rate (56% to 100%) of completed comprehensive dental treatment, this finding is immensely important goal of managing NTDC. Another example, of a successful usage of tele-dental approach was applied by Glassman et al, who utilized Tele-dentistry to provide dental care to underserved communities in California21. ADA recently approved incorporation of two Current Dental Terminology (CDT) Tele-dentistry codes (D9995) Tele-dentistry– synchronous and (D9996) Tele-dentistry– asynchronous to facilitate its use in clinical applications26. Although several studies have confirmed the efficacy of tele-dentistry19,20,27 to the best of our knowledge, no studies have addressed tele-dentistry as an approach for managing NTDCs at the ED.
The aim of this exploratory study was to evaluate the feasibility of managing NTDC visits to the EDs using tele-dentistry as an alternative approach to the costly ineffective current standard of care. Feasibility of establishing such an intervention was tested to collect preliminary data and inform a scaled multi-site study.
One study found tele-dentistry to be an accurate tool to obtain a solid diagnosis; Bradley et al; suggested that tele-dentistry provides an reliable method to remote recognition of root canals by experienced dentists28, furthermore a recent systemic review concluded that tele-dentistry could be used as valid replacement to face-to-face dental exam29. Our findings are in agreement with the previous conclusions, as it is shown in the high interrater agreement, sensitivity and specificity between; the tele-dental reviewer, tele-dental examiner and treating dentist (Table 1 and 2). On the other hand the overall agreement, sensitivity and specificity between the ED provider and the tele-dentists/MCHS dentist were low, which highlights the reported limited dental training that provided to medical providers9,25. Moreover, when the ED provider managements were the gold standard; the tele-dental examiner and tele-dental reviewer recommended managements were with high agreement, sensitivity and specificity with that of the ED providers, which indicates the promising ability of the tele-dentists to adequately triage dental patients that presents to ED within their scope of practice30.
Dental patients usually have a low level of emergency, consequently; they tend to wait longer than other patients with higher emergency level, which negatively impacts those patients. Okunseri et al. suggests that NTDC visits to the ED may increases the ED waiting time for other patients with medical conditions2. Based on our findings; we believe tele-dental approach may divert NTDCs away from the busy ED, and thus may reduce the waiting time for other patients who attended the ED for other reasons31. Additionally; treating NTDCs at the ED generates a significant cost on the patients and the payer, while the EDs charges are high, the final results are not fruitful7–10, our limited cost saving analysis projected a possible reduction in the cost for dental patients/payers (74%±10).
Several limitations need to be acknowledged. These limitations include: small sample size, inability to recruit patients after business hours and during the weekends due to staffing limitations, patients were included based on their dental complaint visit to ED and inclusion of only two ED sites of the MCHS and limited ability to access the dental records for the patients who were not patients of MCHS dental clinics.
5. Conclusions
Our study established that tele-dental approach to evaluate NTDC visits to the ED remotely, using the live video telecommunication and intraoral camera is feasible. Tele-dentistry also appears to be an accurate approach in obtaining accurate diagnosis for dental emergencies, with a potential cost saving. However larger scale study is needed to confirm these findings.
Clinical Significance.
Using tele-dentistry to triage non-traumatic dental visits to the emergency room may be a promising approach. Once this approach is validated through a larger study, tele-dental outreach could help in directing non-traumatic dental emergency patients to the appropriate dental setting to provide treatment for the patients.
Acknowledgments
This study was supported by an NLM training grant to the Computation and Informatics in Biology and Medicine Training Program (NLM5T15LM007359) and by Family Health Center of Marshfield.Inc and Marshfield Clinic Research Institute (MCRI). The authors would like to acknowledge the work of Dixie Schroeder, M.B.A. from Center for Oral and Systemic Health (COSH), MCRI, Ingrid Glurich, Ph.D. COSH, MCRI, Yakub Ellias MD from Urgent Care, Marshfield Medical Center, Patrick Wolf DO from Emergency Medicine Rice Like Marshfield Medical Center, Urgent Care staff and Emergency Department staff at the Marshfield Clinic Health System, Christopher L Meyer, Director of Virtual Health and Virtual Health staff. The authors would also like to acknowledge work of Elizabeth C Armagost and Diane Kohnhorst from Marshfield Medical Center and Aloksagar Panny, B.D.S., M.S from COSH, MCRI.
Footnotes
Disclosure
The authors report no conflicts of interest in this work.
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