Refining the process: Safety net dental professionals' experiences with teledentistry implementation during the first year of COVID‐19

Abstract

Objectives

Teledentistry helped dentistry adapt to pandemic‐era challenges; little is known about dental professionals' teledentistry experiences during this time. This analysis sought to understand professionals' pandemic teledentistry experiences and expectations for the modality's future.

Methods

We conducted virtual individual interviews (n = 21) via Zoom to understand how federally qualified health centers (FQHCs) delivered oral care during the first year of the pandemic, including but not limited to the use of teledentistry. We independently coded each transcript, then identified themes and sub‐themes.

Results

We identified three major themes: (1) Logistical and equity considerations shaped teledentistry's adoption; (2) Team‐based factors influenced implementation; and (3) Teledentistry's future is as‐yet undetermined.

Conclusions

Experiences with teledentistry during the first year of COVID‐19 varied substantially. Future directions should be more deliberate to counter the urgency of pandemic‐style implementation and must address appropriate use, reimbursement guidance, patient and provider challenges, and customizability to each clinic's context.

INTRODUCTION

The COVID‐19 pandemic necessitated many changes to the delivery of oral health care to enhance infection control and reduce viral spread while maintaining essential service delivery to address patients' needs. Virtual care became an appealing method of healthcare delivery early in the pandemic because of mandated health care facility closures and restrictions, virus surges, and the resulting limits on in‐person care [1]. Teledentistry, or using technology and telecommunications to provide oral health care, was used during the pandemic's first year primarily to virtually triage patients to identify urgent needs, prioritize appropriateness for in‐person care, manage dental needs remotely when possible, and reduce in‐person contact in order to limit risks of exposure and transmission [2]. While triage and urgent care are not the only use cases for teledentistry, they were common services provided using the modality as dentistry adapted to the pandemic environment. During the first 2 months of the pandemic, teledentistry use increased by 60 times and as dental offices reopened, use remained higher into August 2020 than before the pandemic [1]. As dental professionals gained experience with teledentistry, their knowledge of and confidence with the modality improved [3, 4].

The opportunities, benefits, and challenges of delivering a wide variety oral health services such as screening, evaluation, diagnosis, consultation, patient education, and remote supervision of preventive care through teledentistry have been well documented over the last decade [5]. Recently, the 2021 Oral Health in America report highlighted these learnings and reported telehealth and teledentistry care is generally equivalent to in‐person care, valid and reliable for diagnosis, satisfactory among providers and patients, and notes its impact is likely to continue beyond the pandemic. The report also discusses the potential of teledentistry to reduce health disparities among rural populations, school‐aged children, and older adults [2].

Historical challenges with uptake of teledentistry among dental providers include lack of appropriate technology or technical support, concerns with cost and virtual diagnostic quality, and inadequate policy, regulations, and reimbursement. Patient challenges included lacking technology, proper broadband access, understanding of the virtual visit process, and preference for face‐to‐face interactions [6]. These challenges were heightened early in the pandemic with use cases for triage, prioritizing urgent needs for in person services, and follow up care for services delivered in person, as dental offices had to quickly develop virtual care options under fragmented or unclear teledentistry regulatory and reimbursement policies.

Evidence confirms teledentistry utilization increased during the pandemic and dental professionals' perceptions of using the modality were positive [7], but little is known about dental professionals' experience implementing teledentistry to adapt to pandemic‐related practice changes, especially in community‐based practice settings. This Brief Communication reports findings on health center dental professionals' experience with teledentistry during the first year of the pandemic and what they envision for the future of the modality, from a larger study of safety net providers' dental service delivery during the first year of COVID‐19 [8].

METHODS

The study methodology is described in detail in a related article [8]. Interviews were conducted with dental professionals recruited from the Health Choice Network (HCN). Informed consent was obtained from participants through direct discussion prior to beginning each interview. The Western Institutional Review Board (Study Protocol #DQPHCN01) reviewed this study and determined it to be “exempt”.

The interviewers conducted individual virtual interviews between January–February 2021. All interviews, conducted in English, lasted 30–45 min. Using an original 10‐question interview guide developed by the study team, interviewers asked participants about their clinics' experiences in the early months of the pandemic. Researchers digitally recorded each interview through Zoom. Each recording was de‐identified, transcribed by a third party, assigned a unique study code, and digitally stored in a secure shared folder.

The two researchers who conducted the interviews reviewed transcripts and memos to develop initial codes and sub codes, independently hand‐coded a sub‐sample (n = 5) of transcripts using these initial codes and sub‐codes, then compared their coding and reconciled differences. The study team reviewed themes and sub‐themes before the two researchers (redacted) completed hand coding the remaining transcripts. They then merged the independently coded data to confirm saturation.

RESULTS

A total of 21 dental professionals participated in this study (n = 21), including 14 dental directors, four dentists, and two health center administrators. They represented 15 FQHCs across six states, of which four clinics had used teledentistry prior to the COVID‐19 pandemic.

Three major themes were identified regarding dental professionals' perspectives on teledentistry during the first pandemic year: (1) Logistical and equity considerations shaped adoption of teledentistry; (2) Team‐based factors influenced implementation; and (3) The future of teledentistry is as‐yet undetermined. We describe each theme in turn and provide in the Table 1 quotational evidence was selected because it reflected common sentiment or it provided unique insight. Additional quotational evidence supporting each theme may be found in the related article [8].

TABLE 1.

Interview teledentistry quotations

Theme	Quotation
Logistical considerations shaped adoption of teledentistry	How do you get reimbursed for (spending) half an hour talking to a patient–trying to figure out what their issue is when, if they could have just come to the office, you could have figured out in 5 min and then develop(ed) a narrative that an insurance company would (say) “Okay, we can pay for this?”
	It just did not seem to be adopted well by our patients. There were some issues about how we will generate income out of using teledentistry. (Patients) think they are just calling in and getting a prescription. They do not think they should be charged. Is Medicaid going to pay for it or not?
	I would try to set up a teledentistry appointment through our texting service, then people just would not dial in or click on the link. I was just sitting there waiting for them to come on and they did not come on.
	During that time, we consolidated our site. I think we only had one site that was physically open. That was the beginning of our larger move towards teledentistry.
	When COVID hit, we sure did hit the ground running and get (teledentistry) going quickly…We had an IT department who was able to support us greatly getting the telehealth platforms up. We relied heavily upon the ADA recommendations as far as billing and coding, and just hoping that the insurances would follow along suit. We have to manually input the appointments into it. It's a little bit tricky. We do video telehealth; through that, we do screenings for patients. We try to do emergency exams and we do post‐op follow‐up visits from extractions or anyone that needs a post‐op after some treatment that they had. We do that via telehealth. It does not take away from the in‐office option, but certainly during these times, it's a great option for patients who either have tested positive for COVID, who are experiencing a dental emergency and cannot get out of the house, or who do not need the extra exposure, are medically compromised.
	We started that out with just synchronous, then just thinking about our mobile health centers sitting there, not being used. We took the portable X‐ray and intraoral camera off of the mobile health center and put it in one of our brick and mortar locations that does not currently have dental services (due to COVID restrictions). We placed a hygienist there to do asynchronous telehealth.
	We had a tele‐platform in place for medical and dental. So, there was not an issue. There is a digital divide in the community that we serve.
Team member factors influenced implementation	We feel more comfortable with face‐to‐face interaction with our patients.
	I belong to the old school, so I prefer to see my patients (in person). It is totally different because sometimes the patient has a lesion on the front of the mouth and it's related to salivary gland problems, and I have to see it. It's something that I cannot see on teledentistry.
	We did not have a telehealth program developed prior to COVID hitting. We had talked about it, but nothing was really in place. We were really caught off guard, so to speak. I was happy with what we were able to do. One of our other dentists that works here, she's pretty savvy with technology and she was able to talk some things through with the dental team. We were able to implement it on a very limited basis. We do not have the equipment needed to fully implement it.
	We started our telehealth out on Zoom and on FaceTime. We actually started it as a driving process where we had tablets because we did not know how to get consent forms from people. They would have to drive into our parking lot and a (PPE‐protected) Medical Assistant or Dental Assistant would come out with consent forms on the tablet, then we would do the visit from the parking lot to the provider inside. We did that for medical and dental. We progressed and we found the platforms like Doxy and Doximity and we kept on going. We found (their model) to be very beneficial, a great new access point for our patients with the asynchronous telehealth. We plan to keep it and boost it and help it grow even after COVID. We wanted to have as many people working from home at that time as we possibly could. If I could keep one or two dentists home a day because we were not busy in the clinic doing telehealth from home, that's, again, less people in the office.
Future is uncertain	As people have gotten used to that and telemedicine and telehealth in general, I think that demand for that is only going to grow. Once you let the genie out, in other words, you are not going to get it back in the bottle; of course, it's a good tool to have in our toolbox.
	We still need some way to implement some form of teledentistry, at least in the diagnostic stages. Treatment stages you cannot. To get to that level before you run the surface to make a diagnosis, sometimes you have to go in the mouth and diagnose the caries. You have to see it. Relying on a radiograph alone is not enough. Digital X‐ray images will give us a lot of great information as the location of the disease of the cavity, in this case, caries. A lot of times, carries, the cavities, and the biting surface, which is the occlusal surface, it's not always visible on an X‐ray. You have to go there clinically and examine the patient. I still believe teledentistry can be instrumental in doing a screening, an initial assessment of the patient, where the patient does not have to come into the office necessarily until they have to. For example, a patient may have after I speak to them, interview them and assess their situation, I can decide, “Well, you should come in so we can see you.” Or “No, you do not need to come in. Well, you need to see a dentist, we can refer you to an office that can manage you or that is open and has the equipment to handle your situation,” and we will refer them out.
	I wish at some point we were able to do it and do it consistently like it is for a medical, but that stuff like that is above my pay grade. That's more political stuff that we have to get in place for that to work out. I think the government is going to actually move towards that.
	We've just tried to refine our processes and make it better and better. We still have issues with getting the consents. Now we use a service called GetWell, where when a patient with us who automatically schedule their appointment, they get forms emailed to them. And they have to sign the consent and do the forms and the medical history via email, and that comes directly back to us. As I'm sure you are aware, there's always technological challenges. Anytime you send anybody a form or an email that they have to complete, if we do not get the consent, then we have to reschedule the visit. It becomes a little difficult. We're still working through those challenges, but it's getting better and better. It's definitely something that I want to refine it this year and make it better and make our patients realize the value of having this access to care.
	There might be some ways in which we are not utilizing it in a way that we need to that I'm not aware of.
	Some other states use teledentistry for patient education… I attended a webinar, and they were trying to have the parents actually apply varnish from the video while the provider is watching how they do it. Hopefully, this whole pandemic is over soon, but given that we are going to still limit some of these visits, or some people are not willing to come in, at least having this teledentistry expanded a little bit in terms of prevention dentistry, where we can do a brushing technique, flossing technique, fluoride application, all of these things that we can do with hygiene involved. I think that'll be a great way for us to maintain oral care.

Logistical and equity considerations shaped experiences with teledentistry

Participants described how their logistical and equity considerations informed their experiences with teledentistry. Logistical considerations included reimbursement concerns, physical space, and information technology (IT). Many participants attributed success to leveraging existing infrastructure, such as IT departments experienced in troubleshooting telehealth software idiosyncrasies. Participants' perspectives also suggest there are paradoxes in equity considerations for teledentistry. Some patients' exclusions from technological capabilities including newer mobile devices, high‐speed internet or software literacy, also known as the “digital divide,” could render telehealth out of their reach; similarly, teledentistry reimbursement restrictions by Medicaid administrators could also prove an equity barrier to care. Conversely, for patients who were more susceptible to severe COVID‐19 consequences due to pre‐existing health concerns, teledentistry offered protective effects.

Team member factors influenced implementation

Participants explained how individual team member characteristics influenced how quickly and extensively teledentistry was implemented. Some participants described providers' preference for, comfort with, and need for face‐to‐face patient treatment, particularly in diagnosing certain conditions, which limited or prevented the introduction of teledentistry. Other participants explained they were compelled by how teledentistry supported safety and staffing continuity by limiting the number of team members on site. Several clinics used a team‐approach to implement teledentistry, facilitated by staff members who, regardless their specific role, were comfortable with rapidly trying new technology to provide virtual care.

The future of teledentistry is as‐yet undetermined

When describing the future of teledentistry, perspectives among the participants were mixed. Some participants expressed skepticism of teledentistry's adequacy to address certain diagnostic capabilities and treatment options, while acknowledging the utility of teledentistry for screening and triaging patients' needs and facilitating preventive services (e.g., home hygiene education, topical fluoride instruction). Many participants anticipated demand for teledentistry will grow over time, as patients become more accustomed to receiving medical and dental care through virtual means. Finally, participants emphasized the need to strengthen policy guidance in order to implement teledentistry in a robust and stable manner.

DISCUSSION

During the first year of the COVID‐19 pandemic, dental professionals quickly encountered the opportunities and challenges of utilizing teledentistry to support the delivery of necessary care to patients, maintain a revenue stream, and minimize transmission risk and prioritize the safety of patients, providers, and providers' families. During initial restrictions on in‐person services, providers who adopted the modality primarily contacted patients by phone or using existing videoconferencing software in order to triage them and assess urgency of in‐person services, manage pain and infection by prescribing medications, and complete follow‐up care after completing procedures. As clinics increasingly reopened for patient care, some also incorporated more robust telehealth software already in use in their medical clinic to complete these services. One additional approach was mentioned: remoting dentists into synchronous visits with patients who were on site at the clinic, facilitated by on‐site dental assistants or hygienists. This approach permitted clinics to reduce staff risks of exposure and maintain staffing and revenue continuity. While none of these uses reflects the full potential of teledentistry, for example to conduct cancer screenings via high quality photography, connect multidisciplinary specialists with general practitioners, or provide behavioral coaching to patients, this expansion does indicate how some clinics developed more robust teledentistry programs throughout the first year of the pandemic. At the same time, other clinics' use of teledentistry remained limited for reasons described in existing literature including provider reluctance, patient barriers, and technology challenges.

While the variation that characterized teledentistry implementation among study participants reflected that found in other studies [1, 3, 9] our study offers three novel observations. First, dental professionals feel a general sense of inevitability of teledentistry regardless of their preference for it and seek to see guidance strengthened with regard to appropriate use and reimbursement. Next, teledentistry implementation must account for the unique contexts of each clinic, whether the repurposing of available physical and technological resources or the time investment needed to routinize practices among patients and dental professionals. Finally, given the epidemiologic likelihood of future pandemics, the importance of planning for future teledentistry use to avoid the exigent decision‐making that occurred during the first year of the COVID‐19 pandemic must be part of a broader strategy of dental public health emergency preparedness. As demonstrated by this study, the vitality and variety of dental professionals' perspectives should guide future developments in teledentistry, under pandemic circumstances certainly but also under regularized service delivery.

FUNDING STATEMENT

This study was funded by CareQuest Institute for Oral Health.

McLeod CD, Heaton LJ, Chung‐Bridges K, Raskin SE. Refining the process: Safety net dental professionals' experiences with teledentistry implementation during the first year of COVID‐19. J Public Health Dent. 2022. 10.1111/jphd.12547