Important moments in history have a habit of forcing innovation forward. Even when humanity is at its lowest ebb, necessity not only gives way to invention but also to funding, staffing and other resources that help to bring that invention forth into the light of day.
World War II not only brought us radar and computers, but allowed our best and most learned minds to perfect such medical triumphs as blood transfusions, the invention and mass production of penicillin, and aviation medicine to inform the ability for humans to fly at high altitude without adverse effect.
So too has the continuing pandemic advanced the marriage of technology and healthcare that is telehealth and, certainly, teledentistry, with the latter becoming not just a part of our everyday industry vocabulary, but part of so many Australian dental practitioners' service offerings.
A slow burn
The practices of telehealth and teledentistry were certainly nothing new when we entered the worst of 2020's pandemic and its subsequent lockdowns. "Yes indeed, in the United States Civil War years in the 1860s, the infirmaries would use the telegraph to communicate with patients," says Professor Rodrigo Mariño, recently retired Professor of Population Oral Health who has done much research work on the subject at the University of Melbourne. "In Australia in the 1870s, the doctors used the technology when they used the telegraph to communicate between Adelaide and central Australia."
Teledentistry, as a concept, was reportedly developed at a 1989 conference funded by the Westinghouse Electronics Systems Group in Baltimore, USA, concentrating particularly on ways to apply dental informatics in practice to directly affect the delivery of oral care. (1) Like so many other technologies, it was further developed by the US military in 1994 as part of its Total Dental Access Project – a project that successfully showed that teledentistry reduced healthcare costs, increased quality of care and life for those in remote areas and offered ideas for technology advances. (2)
Even with all that background, though, it took a pandemic to convince a perhaps sluggish approvals process to accept teledentistry into more common usage. After all, without official approval and endorsement, says Prof. Mariño, dental practitioners have grounds for resisting lesser-used techniques and styles of patient care.
"In most aspects, I think a tele-consultation is very similar to a face-to-face. Of course, some things are a bit different and this can make people feel less confident and reluctant to use this new system unless they feel protected – in terms of insurance coverage and also industry policy," he says. "If there is no provision for that, dentists may feel uncertain. There were and still are legal issues and ethical issues that continue to need to be discussed and addressed."
Support and safety
Policy support came in April 2020 in the form of the ADA's release of a temporary item code (code 919: Teleconsultation) specifically to use for emergency dental consults. Its 'emergency' status meant it could not be used with any code involving physical contact with a patient (e.g. preventive, prophylactic or bleaching services within codes 100-199, and so on) but any code that covers a non-invasive service (e.g. diagnostic codes in the 000s, general services in the 900s and other preventive services in the 100s) could now be used in conjunction with 919.
In announcing the Teleconsultation code, the ADA clarified in its accompanying guidelines that "it should be noted that a service may only be provided by teledentistry where it is safe and clinically appropriate to do so. This item number is not intended to be used for offering routine assessments, advice or oral health instructions. It is a patient-led service. Ideally teledentistry services should only be offered to existing patients or those referred by another practice."
With this policy clearly in place, Australian practitioners could more confidently add this practice to their services schedule knowing they stood on firmer legal ground. However, Prof. Mariño warns that we should learn from the example of teledentistry as we move forward. "Legal issues are very slow because the process of making laws is slow," he says. "But meanwhile technology moves very fast. So the issue remains into the future that legal and policy and also funding need to catch up with technology – as a general issue, not just specific to telemedicine."
Less clear-cut, but no less important, is the ethical side of teledentistry. "Teledentistry has altered the patient practitioner relationship," says Prof. Mariño. "For example, of course you still need to obtain consent, but the process of obtaining consent is little different. Your responsibilities are different with the use of this technology."
The most obvious ethical question with technology is protection of your patients' private details and data; increased internet and data security can be necessary to protect the information you are sharing over many possible platforms, including Zoom, Skype or FaceTime. The security and limitations of the platforms you use are suddenly your business to understand and utilise in a responsible and secure manner.
Other ethical considerations involve the appropriate application of teledentistry as a service. The ADA's Policy Statement maintains that:
• 1.7. Dental treatment is best provided in a fully equipped dental surgery; and
• 1.8. Teledentistry is not suitable for procedural dental care.
Furthermore, considering there are still limitations on insurance and Medicare coverage, and industry-wide recommendation that practitioners understand the limitations of teledentistry and its applications, it is up to us to help communicate those limitations to our patients, and to consider any out-of-pocket expense to the patient when something falls outside the scope of insurance or Medicare coverage.
Into the future
With constant advances in technology, from communications and internet speed through to artificial intelligence, it seems a reasonable assumption that the leap forward telemedicine has experienced, thanks to COVID, can continue its momentum into the future.
Before the pandemic, teledentistry was already an option for patients best suited to its practice, for the following reasons:
• live in rural or remote areas;
• have limited transport options or abilities;
• are of advanced age with mobility issues; and/or
• are immuno-compromised and must stay away from public areas.
With the newfound acceptance and widespread adoption of teledentistry, along with both policy and industry culture changes that have followed, even in the event that the pandemic comes to a partial or total end in future, these cohorts look to have better choices available, and wider access to teledentistry and telehealth services across the board.
References
1 Chen JW, Hobdell MH, Dunn K, Johnson KA, Zhang J. Teledentistry and Its Use in Dental Education. J Am Dent Assoc. 2003;134:342–6.
2 Mihailovic B, Miladinovic M, Vujicic B. Telemedicine in Dentistry (Teledentistry) In: Graschew G, Roelofs TA, editors. Advances in Telemedicine: Applications in Various Medical Disciplines and Geographical Areas 2011. Rijeka (Croatia): InTech; 2011. pp. 215–30.
