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Kristin Hohman serves as Associate Editor for DPR.
There might not be better proof of dentistry’s ability to adapt during a crisis than the rapid growth of virtual, remote dentistry.
In 1925, radio and publishing pioneer Hugo Gernsback wrote an article for his magazine, Science and Invention that predicted a device that would allow doctors to treat patients from afar.1 Gernsback called the device a teledactyl (tele for “far” and dactyl for “fingers”), a system that included a television screen and two robotic arms to view and examine patients from their homes.1
At the time, a teledactyl probably seemed closer to a fever dream than an actual tool for physicians. But over the decades, telehealth has grown from a novelty to a juggernaut with an estimated worth of $155.1 billion by 2027.2
Perhaps no area of healthcare has seen more growth during the COVID-19 pandemic than telemedicine. As it provides a no-contact approach to screen and advise patients, perhaps no moment in our history has a remote solution for doctors and patients been so necessary. This is especially true for dentistry, as many dentists have had to close their offices amidst this pandemic.
Whether you’re already a teledentistry expert or you’re exploring the technology for the first time, this facet of dentistry provides an effective approach to practicing during this crisis.
The teledentistry advantage
Teledentistry meets patients where they are, giving it an edge over traditional dentistry while social distancing is the new norm. Before the COVID-19 pandemic, the most common teledentistry workflows involved a hygienist or dental assistant traveling to the patient-whether that be a nursing home or school-and, using a portable device, images would be taken and then the hygienist/assistant would video conference with the dentist, who is able to remain in the office.
This form of teledentistry has had to change over the last several weeks, as the American Dental Association (ADA) and state dental boards have urged dentists to only see emergency cases in order to mitigate the spread of COVID-19.
However, teledentistry has proven adaptable. Instead of sending a staff member out to the patient, this technology allows dentists to screen patients from home and determine if their case constitutes an emergency, says Mike Uretz, founder of dentalsoftwareadvisor.com and author of The Teledentistry Survival Guide.
“Of course, now it's changed so much with the COVID-19 is that now, you can't really have anybody going into your home,” he says. “The cool thing about teledentistry is the sophisticated tools you can kind of screen. So, maybe a hundred percent of patients might think they need to come in for an emergency. But you might find out really it’s only 20 percent through the teledentistry software and video. It's a really good screening tool, which will cut down on the amount of time and the amount of visits for the dentists and the staff, they screen for emergencies.”
Being able to classify patients in an efficient manner is crucial to keeping these patients out of emergency rooms, says Dr. Edward Shellard, chief dental officer at Carestream Dental.
“Certainly, when dealing with COVID, it's very important being able to triage those patients,” Dr. Shellard says. “We all know that the emergency rooms and hospitals right now are inundated with COVID cases and so being able to keep those dental patients out of emergency rooms is very important because, in the grand scheme of things, these are not life and death situations for the most part. Keeping those patients away from emergency rooms so that those physicians and nurses can work on the more sick patients is important.”
Teledentistry has never been more accessible or easy to use. With the spread of COVID-19, the need for remote appointments has emerged, and many vendors have added or expanded teledentistry services.
For instance, teledentistry company MouthWatch waived setup fees for their platform TeleDent after seeing the closure of practices-and even the barring of emergency procedures in some states-all due to the Coronavirus, says founder and CEO Brant Herman.
“We saw the need kind of right out of the gate-as practices realized they needed to reduce the number of patients, and as ADA, Centers for Medicare and Medicaid (CMS), and Centers for Disease Control (CDC) recommendations all pushed toward practices closing initially for emergency only,” he says. “We responded by offering a waived setup fee, a waived 30-day implementation of TeleDent so that practices could get up and running and start allowing for remote exams communication with patients-just allowing them, even as they were being forced to close or recommended to close, to stay in touch with their patients and potentially generate some revenue through teledentistry evaluations.
“So we really just put the pedal to the metal on a lot of additional development of tools to allow patients to request consultations,” Herman continued. “Whether they were storing forward evaluations or real-time video evaluations, a lot of that just got accelerated to make that process really easy and seamless for practices.”
In addition, training and onboarding for your team is also available at no cost at this time.
MouthWatch even went so far as to organize a COVID-19 Advisory Board, which will help the company develop best practice protocols for implementing teledentistry in the new reality of urgent-only care. The team will also assist the company in creating teledentistry-focused education and training materials, including establishing oral triage protocols; implementing proper coding; coordinating dental team participation, developing virtual workflows; and conducting live consultations.
“We brought together some of our existing clinical advisors and brought in some new providers,” Herman says. “We thought that would be helpful as far as educating clients on how, not only we're responding now, but what the future landscape looks like.”
Carestream Dental will be offering dentists who use the company’s digital imaging and practice management solutions access to MouthWatch’s TeleDent platform, something which something Carestream felt would be a swift response to the COVID-19 pandemic.
“It was really important for us to get something to market quickly,” Dr. Shellard says. “We felt very strongly, certainly now with COVID, that being able to do that in a HIPAA-compliant, easy-to-use way was so important to our customers. [MouthWatch] has a functioning platform, and the infrastructure to be able to manage a large number of folks. We have thousands of people on one of our practice management software platforms. They have a scalable platform that will lend itself to a company of our size, which was really important. They have a system that they've been using for a while that was well-vetted and well-tested.”
“We're working on integrations directly from Carestream practice management suites into Teledent,” Herman adds. “But, for now, we have a lot of customers really just using it for their teledentistry consultations and then billing out through their Carestream practice management. Many additional practice management systems will be integrated with TeleDent shortly."
Software technology company Simplifeye has also joined the teledentistry field with the launch of Simplifeye Connect. The goal behind connect was to create a seamless teledentistry platform that integrates with current Simplifeye services, says Simplifeye founder and CEO, Dr. Ryan Hungate.
Simplifeye Connect is browser-based, meaning it launches right from your internet browser, eliminating the need for extra software downloads. It works on any connected device, allowing for real-time video calls with patients. Doctors can take photos and notes during the appointment, then the system will organize all of this information on the patient’s record, making billing fast and easy.
“The idea is to simplify, not complicate,” Dr. Hungate says. “A virtual practice in a box is the easiest way to think of it. It works on every single thing that's got a browser. If you can open up a website, you're good to go. You can do a phone, tablet or PC.”
Teledentistry company, The TeleDentists, is working with insurance company Cigna to provide dental virtual care in response to COVID-19. Cigna Dental Virtual Care will be available to over 16 million dental customers enrolled in Cigna’s employer-sponsored insurance plans at no cost through May 31, 2020. Through a video consultation, licensed dentists can triage urgent situations such as pain, infection, and swelling and guide the customer on the next steps. If necessary, the dentist will prescribe medications, such as antibiotics and non-narcotic pain relievers, according to Cigna.
In addition, The Teledentists have seen an uptick in the number of dentists who would like to become consultants, according to The TeleDentists co-found Dr. Maria Kunstadter.
“We opened another channel, which is called My TeleDentist, and it was for dentists to have telehealth services for their patients,” Dr. Kunstadter says. “Dentists are realizing they have no way of really, other than a telephone call, working with their patients during this crisis. So, we've had probably 30 or 40 offices sign on to that in the past two weeks. We'll get them trained up so that they can reach out to their patients.”
The TeleDentists offer 24/7 consultations for patients and have added about 70 new dentists as consultants since the beginning of the epidemic, Dr. Kunstadter says, bringing their total up to around 350 dentists from every demographic and in all 50 states and Puerto Rico.
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As with every new technology or innovation, there are bound to be some growing pains. And although teledentistry has been around for several years, the Coronavirus has shed light on some hurdles still to be jumped.
A challenge dentists face when accessing teledentistry platforms are state-by-state guidelines regarding telemedicine appointments. While states such as Maine, Maryland, and Kansas have executive orders on the books that help expand access to telehealth, it’s been harder to receive teledentistry services in states such as Texas, Dr. Kunstadter says.
“It's sort of like a showdown at the OK Corral in Texas,” she says. “They said no to teledentistry. I said, you need to define teledentistry. If you say that we can't do our teledentistry then that dentist shouldn't be able to talk on the telephone to their patients-because all we're doing is adding a video to that and helping emergency patients.”
“I know Texas right now is having some issues because their board of examiners states that you need a tactile exam for that to count as an evaluation,” Herman adds. “So, many dentists in Texas are up in arms saying, ‘We can't do anything now with our patients if we don't have that definition refined.’ So, we'd love to see people and boards and approaches where they start recognizing teledentistry is a tool.”
Groups, DSOs, and practices that are new to teledentistry will run across two main workflow models, and it's important to understand how each one fits into the virtual visit. Some teledentistry vendors have built both models within their products, according to Uretz.
The first model of teledentistry is ‘synchronous,’ meaning it happens in real-time. Dentists are viewing live video making recommendations directly to the patient. ‘Asynchronous’ means that a kind of messaging platform is being used to communicate back and forth. For instance, an image is uploaded and sent to the dentist, who then views those images, and writes back to the patient, he says.
“It just changes the workflow, because now what you're doing is you're using video, chats, or web portals to pre-screen a patient from their home. And then they may come in for a visit. So, I think the challenge is you are, number one, getting used to the workflow,” Uretz says. “You might do a synchronous video consult visit, but how do you follow up on that? How do you document the visit? Do you start an asynchronous behind the scenes communication with your patient?. So basically, the overall workflow of the virtual visit will determine its efficacy."
Another challenge is dentistry, by definition, is a very hands-on endeavour. Sure, dentists can advise and consult with patients from almost anywhere. But there’s no real replacement for old fashioned dentistry, according to Dr. Lorne Lavine, founder and president of The Digital Dentist.
“Obviously, it's not the same as sitting in the dental chair. But at least you have that one-on-one interaction with the patient so that you can discuss care, decide if something's an emergency or not if they need to be seen or not, be able to do lots of things you can do basically when you see someone on a video screen,” Dr. Lavine says.
“I think the challenge, of course, is that number one, in order to diagnose you need to be able to see inside the mouth. Webcams are perfectly fine for full-face shots or smiles and maybe you could see a tooth kind of close,” Dr. Lavine continues. “But, it's not the same as having a real macro-lens, it's in there, that can see cracks and restorations that have deteriorated. And of course, it doesn't change the fact that almost all dental treatment has to be done in a dental office.”
Maybe the most obvious challenge-as with most things done on the internet-are the security considerations that must be taken into account when practicing teledentistry. The recent hackings of Zoom meetings have highlighted the need for a secure means of video conferencing.
Cyber security checks shouldn’t be too different when working remote than the checks that are in place in a practice, according to Dr. Lavine.
“That's a challenge for a lot of offices is that they have really secure office networks, but their home networks aren't as secure,” he says. “So, a lot of it is based on common sense stuff that people aren't doing at home, for the most part. They need to make sure that if they’re using a wireless network, that it has encryption enabled in addition to a password that you have to enter into in order to access it. You need to make sure you limit access.”
Plus, any home-office computers that are used to access patient data must be secured, especially if a spouse or children could potentially see the monitor, Dr. Lavine adds. He suggests having a screensaver that turns on after 10 minutes of inactivity, then requires a username and password be reentered to log in again.
HIPAA compliance is still relevant, Uretz adds, and clinicians still need to make a good faith attempt at patient privacy and information security.
“When it gets to the records themselves, you're going to need to make sure all the things that you would normally check are there,” he says. “For example, since teledentistry systems are cloud-based, you need to make sure that the data center that hosts the software is HIPAA compliant and follows all the associated rules and regulations for security."
Dentists should run a security risk assessment and take inventory of their security practices, Uretz suggests.
Teledentistry should never take place over an unsecure platform such as Facebook Live, SnapChat, Tik Tok, Twitch, or Zoom, Dr. Lavine says. Only encrypted, HIPAA compliant platforms should be used.
The future of teledentistry
The Coronavirus pandemic has virtually transformed telemedicine in, essentially, a matter of weeks. But is it sustainable in a post-COVID world?
“Appointments, provider communications, and online collaborations-a lot of patients these days would rather do things online. So the train had left the station,” Uretz says.
Once dentists get a feel for teledentistry and see the value it can add to their practice, there’s no turning back, Dr. Shellard says.
“It may not be as common post COVID, but I do feel that once doctors start using the platform and start incorporating teledentistry in their daily lives, I think you're going to find it's going to become an important tool for them,” he says.
Teledentistry isn’t just a tool for dentists during a pandemic, Dr. Kunstadter says, but could be a tool to increase efficiency and provide excellent patient care in the future. And it will be a driver of patients into the practice.
“I think that patients are going to experience this and not be hesitant to do this-and doctors are going to experience this and not be hesitant to do this,” she says. “So, I think more doctors will be able to will provide this service for their own practices. After they try this and realize how much more streamlined it will be for their practices, I think more offices will integrate this as a regular service to their patients-and patients love it.”
Plus, patients aren’t as anxious sitting in front of a computer screen as they would be, say, sitting in a dental chair, and many patients will begin to expect some kind of teledentistry service, Dr. Kunstadter adds.
“Before COVID, 125 million people didn't see a dentist last year. So, even though offices will open back up, there are 125 million people who don't have an office to go to. The average person sees a dentist every three years now,” she says. “They are embarrassed to talk to dentists, but not embarrassed to talk to teledentists. They’re embarrassed to have a dentist sit down and chastise them-they’re so much more comfortable using the video on their phone.”
Teledentistry is providing more patients to traditional brick-and-mortar practices, not replacing the services that those practices offer, Herman says.
“It's actually going to connect more patients to dental care and see the opportunity that brings as opposed to, it's another thing that we need to pitch and kind of locked into a certain set of circumstances,” Herman says. “I think patients are looking for it and practices realize the value that it has. And if they can kind of take the ball and run with it, and not just limited to very few pandemic response-type applications, but for patient engagement and tools to connect patients to care. I think that's going to go a long way.”
1. Novak M. Telemedicine Predicted in 1925. Smithsonian.com. https://www.smithsonianmag.com/history/telemedicine-predicted-in-1925-124140942/. Published March 14, 2012.
2. Telemedicine Market Size Worth $155.1 Billion By 2027. Telemedicine Market Size Worth $155.1 Billion By 2027.