Teledentistry Amid a Pandemic and Beyond

Teledentistry is the delivery of dental services through interactive audio, video or other electronic media for the purpose of diagnosis, consultation, treatment, and/or transfer of dental information to enhance care and education delivery.^1–10 This technology provides the means for patients to receive dental services at a distance — when the patient is in one physical location and the dentist or other healthcare provider overseeing the delivery of services is in another.^1–12 In 2015, the first book on teledentistry was published and it asked: Are the dental and medical professions prepared for a natural disaster that could affect the medical and dental records of millions of Americans?¹ No one could have predicted that five years later the world would be immobilized by the widespread onset of the novel coronavirus pandemic known as COVID-19. Henceforth, due to the onset of COVID-19, the use of teledentistry in private dental offices, hospitals and public health settings has increased significantly.

Within teledentistry, communication can take place synchronously via live video consultation, asynchronously (store-and-forward — which may include the remote sharing of patient information and diagnosing), remote patient monitoring, in which patient data is transmitted to a provider in a different location, and mobile health (mHealth) care supported by mobile communication devices, such as cell phones, tablets and personal digital assistants (PDAs).^1–6,13,14 With the advent of the coronavirus pandemic and stay-at-home mandates, thousands of dental practices have resorted to establishing virtual office hours for patients (with the exception of in-office dental emergencies that cannot be treated virtually).^2,5,7–14 Virtual dental office hours can consist of the initial triage, consultation and diagnosis, as well as patient education, treatment planning, electronic prescription dispatch, and specialist referral.^{2–5,8,11–14} The concept of teledentistry was first applied in Alaska, California and Minnesota in the 1990s,¹ and is likely to continue to be implemented by providers in other states well into the future. Teledentistry can be utilized in various ways by dentists, dental therapists and dental hygienists who have embraced the “new normal” way of dental practice amid the pandemic.

RULES AND REGULATIONS

In 2015, the American Dental Association (ADA) adopted a policy on teledentistry that encompassed patients’ rights, quality of care, licensure requirements, insurance reimbursement, the supervision of allied personnel, and technical considerations.⁴ In 2018, the ADA published its Code on Dental Procedures and Nomenclature codes for the use of synchronous (D9995) and asynchronous (D9996) teledentistry for submission to insurance companies for reimbursement for services provided.^{2–4,6,13,14} By January 2020, the coronavirus pandemic rendered most dental practices unable to provide routine services in the office. As a result, in May 2020, the ADA published interim guidance for COVID-19 coding and billing for virtual dental visits.^2,3,14 This guidance defined guidelines for billing and coding, as well as Health Insurance Portability and Accountability Act (HIPAA) compliance and informed consent; it also offered tips for conducting virtual evaluations.^2,3,14 Remote dental consultations and/or evaluations can be performed via Zoom, FaceTime, Skype, Google Hangouts or through secure, commercially available applications that can be used with cell phones, tablets and PDAs.^2,14 However, public-facing technologies — such as Facebook Live, Twitch and TikTok — cannot be used because they are not permitted by the federal government for this purpose.^2,14

COMPLIANT SOFTWARE

Many types of HIPAA-compliant dental apps and encrypted software are available for teledentistry. One example is a communication platform that functions comparably to a virtual office that seamlessly integrates into practice workflows and enables quick follow-up consultation or patient triage for those who require immediate care.^2,15 A different type of technology enables patient data, clinical information, intraoral images and videos to be shared live, or recorded and stored for later review. It also incorporates provider-to-specialist referrals, visual treatment plans, and multipractice data management.^5,6,16 An open-source dental practice management software provides on-premise electronic charting, billing, practice management and imaging applications.^5,17

A database provides patients with access to prescreened, certified dentists online and enables patients to easily search, access and communicate in real time with local or national dentists or specialists for the purposes of consultation, introductory meetings, appointment booking, and information and/or file sharing to meet their immediate dental needs — including emergency care.^5,18 A cloud-based platform incorporates synchronous and asynchronous telecommunications that can be used for virtual scheduling, remote case presentations, referrals and multiprovider conferencing.^6,12,19 Also available is software endorsed by the American Association of Orthodontists for conducting virtual consultations and visits.²⁰ Clinicians can similarly choose software that allows patients to upload a selfie to the platform and have a dentist review and record a video consult, which the patient views before making an appointment.²¹

MOBILE APPLICATIONS

Mobile applications include a nationwide dental directory accessible for appointments, care reports, dental advice and education.^5,22,23 Another type offers teledentistry communication tools that let dentists collect photos and videos from patients in order to perform triage. This app allows for the paperless intake of forms and outgoing appointment reminders; it also provides the ability for patients to chat with the dentist via text messages.^5,24 There is also an app-based service where patients have access to dentists located throughout the United States, and dentists can reach out to patients remotely.^25,26 Another app offers remote consultations by combining artificial intelligence via smartphones to allow providers to screen patients’ oral conditions and provide treatment recommendations and appointment scheduling.²⁷ Finally, there is a database that allows patients to search for a doctor or dentist remotely while managing health information, medications and lab work through a computer or smartphone app.²⁸

DENTISTS AND TELEDENTISTRY

Many dentists have forged alliances with dental groups to enable the full deployment of teledentistry. One such platform enables patients to access a panel of dental providers using video technology.²⁹ Patients have virtual access to general and specialty dentists in the greater New York and Florida areas using teledentistry.²⁹ In South Florida, Kansas, Minnesota, Missouri, Pennsylvania and Texas, dentists are using teledentistry to provide consultation, care coordination and triage during the COVID-19 pandemic.^{8,10–12,30,31} Patients can schedule online consultations 24 hours a day with a dentist, video-call a dentist, or make payments electronically in advance of the virtual appointment.^{8,10–12,30,31} In addition, patients can complete forms online, upload images, receive prescriptions, and schedule an in-person appointment — and the office can send appointment reminders via text or email.^{8,10–12,30,31}

DENTAL HYGIENISTS AND TELEDENTISTRY

Teledentistry can utilize off-site dental hygienists, advanced dental practice hygienists, dental therapists, and affiliated practice dental hygienists to triage patients via oral screening and provide a medical history review.^1,5,6,10,32 The results of the screenings are transferred to a dentist to diagnose and plan/coordinate treatment through electronic communication technologies.^1,5,6,10,32 This modality encourages collaboration among professionals, facilitates interaction between patients and providers, enables specialty consultations, and allows for real-time diagnostic examinations.^1,5,6,10,32 In Arizona, California, Colorado, Kansas, Minnesota, Missouri, Pennsylvania, Texas and Wisconsin, dental hygienists, advanced dental practice hygienists, and affiliated practice hygienists are dispatched to Head Start schools, community centers, assisted living facilities and elementary schools to use laptops and intraoral cameras to take patient still images or capture video.^5,6,10,32 These images and videos can be used to construct clinical data and assessments into a consultation and treatment plan for the dentist to devise.^5,6,10,32

Also available are virtual reality glasses that, when coupled with teledentistry, offer an immersive, mixed reality experience. This headset is a self-contained computer with Wi-Fi connectivity that allows the user to see holograms, read text, view three-dimensional images, and use voice commands simultaneously.³³ This remote capability permits dental hygienists to communicate with dentists and/or specialists in remote locations, bringing critical information into full view for all. Virtual reality glasses reduce costs because they create a holographic dental office with the dentist or specialist, who is capable of diagnosing and treatment planning in real time — and without the need for a laptop or intraoral camera for the transfer or storage of intraoral photos, radiographs or patient files.

TELEDENTISTRY IN USE

As examples of teledentistry in use, the Dental Hygiene Department at Northern Arizona University (NAU) in Flagstaff collaborated with the Flagstaff Medical Center to provide preventive dental care using teledentistry technology during an interprofessional education rotation. In November 2019, the lead faculty dental hygienist and dental hygiene students conducted an oral screening of a 63-year-old Native American male who presented with dental pain. His medical history revealed type 2 diabetes, and he was in the hospital step-down unit due to cardiovascular concerns. After performing an intraoral screening and taking photographs of the tooth in question (Figure 1), it was determined that tooth #14 presented with American Academy of Periodontology Stage III, Grade C status, with Class III mobility and furcation involvement. An intraoral photograph taken with a cellular phone was texted to the NAU faculty dentist. The dentist recommended surgical extraction of tooth #14 and, since the patient lived on the Indian reservation, he was referred to Indian Health Services for comprehensive care.

Due to COVID-19, dental hygienists have had minimal contact with Head Start schools, community centers, assisted living facilities and elementary schools. However, the Dental Hygiene Department at NAU has collaborated with a company that produced hardware and software which permits the dental team to conduct virtual dental visits with residents of assisted living facilities and patients of Flagstaff Medical Center during the pandemic. Five intraoral cameras and laptops programmed with cloud-based software were distributed to the directors of five assisted living centers. Additionally, an intraoral camera and laptop were distributed to the  Flagstaff Medical Center director. These individuals will secure a private, quiet room for the residents/patients and use the intraoral camera to virtually submit medical histories, dental assessments, intraoral pictures/video, and any required forms to the NAU Dental Hygiene dental faculty for consultation, referral and appointment scheduling.

WHAT THE FUTURE HOLDS

The birthplace of teledentistry can be linked to a 1994 U.S. Army project that sought to improve patient care, refine patient dental education, and facilitate communication between dentists and specialists.^1,9 Teledentistry is not a new concept and, due to the increased risk of COVID-19 transmission associated with in-office care, it will continue to increase in latitude and utilization during the pandemic and for years to come. Patient surveys conducted by the American Teledentistry Association in 2013 found that 70% of patients were comfortable communicating with their providers via text, email or video in lieu of meeting them in person.^5,7 A 2019 DentaVox survey found that 78% of patients would use virtual dental care, and believed teledentistry had the potential to promote healthy behaviors and educate individuals about the prevention of oral disease.³⁴ By 2019, eight states had policies specific to insurance reimbursement and teledentistry; however, only Alaska, Arizona, California, Colorado, Minnesota and Missouri have policies specific to improving patient health through the use of virtual dental care.^6,9,35 Virtual dentistry gained momentum after COVID-19 spread across the nation and stay-at-home mandates were declared. Consequently, patients in rural areas benefit from the use of teledentistry, as do those who live in inner cities.

As a result of the onset and duration of COVID-19, many states have taken action to remove policy barriers to telehealth utilization and insurance reimbursement to address the pandemic on an emergency basis.^35–39 Due to patient convenience, affordability, high compliance, acceptance of virtual dentistry, and improved access to dental care, many states have enacted legislation related to adopting defined requirements for use of teledentistry.^{6,7,12,35–38,40} As of May 2020, 22 states had published statements promoting the use of teledentistry to expand access and maintain continuity of oral health services, with reimbursement through Medicaid programs.^38,40 In June 2020, 340 organizations sent a letter to Congress requesting the temporary flexibility reforms regarding telehealth provided to states as defined by the Coronavirus Preparedness and Response Supplemental Appropriations Act and the Coronavirus Aid, Relief, and Economic Security Act continue after the pandemic is deemed under control.^41–43 By August 4, 2020, 37 states, as well as the District of Columbia, had approved Medicaid expansion during the COVID-19 pandemic. Moreover, the White House issued an executive order on improving rural health and telehealth access, indicating that the expansion of telehealth services is likely to be a more permanent feature of the healthcare delivery system.^44,45

CONCLUSIONS

The advantages of teledentistry range from reduced fees and wait times to convenience and improved healthcare access for patients in rural and urban areas. It provides patients with a gateway to a vast array of dental providers and specialists who are readily available. There are many types of HIPAA-compliant apps and encrypted software available to dental professionals for teledentistry in traditional and nontraditional settings. As more and more states enact laws regarding teledentistry, changes will occur. For example, as more insurance companies reimburse providers for teledentistry care, an increase in licensure portability across states for all providers may be necessary. In addition, the various modalities of teledentistry have applicability in dental offices, hospitals, assisted living facilities, public health settings and educational institutions. Ultimately, teledentistry will become more common as its use is embraced worldwide.

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From Decisions in Dentistry. September 2020;6(8):26-28, 31.