Caring at a Distance: The Current State of Teledentistry
How virtual dental care is evolving and what it means for patient access.
Dentistry is a very hands-on field, but, in this increasingly digital world, teledentistry services are finding more of a role in everyday practice.
Teledentistry services are provided remotely via audio and visual digital communication tools.1 These services can be synchronous (in real time) or asynchronous (the patient leaves a message or sends information that the dentist reviews later, also known as “store-and-forward”). Dentists can also participate in teledentistry via remote patient monitoring, in which patient data is electronically sent to a provider for supportive care.2 Examples of this include monitoring saliva pH levels as well as patient use of mandibular advancement devices in treating obstructive sleep apnea. Digitally connecting with patients can help dentists make diagnoses, reassure patients, determine how much chair time is necessary and make any appropriate referrals.
While telehealth is more established in medicine, it is relatively nascent in dentistry. As some dentists are embracing teledentistry during the COVID-19 pandemic to increase access to care, they are figuring out answers to many questions. How can dentists address their own concerns and the concerns of patients using these technologies? What regulations must be considered? How are dentists reimbursed for their services? How can dentists effectively integrate teledentistry services into their practices?
The Pros and Cons of Teledentistry
Teledentistry can expand access to care. Patients who cannot immediately access in-person dental services can use a teledentistry service to speak with a licensed dentist for initial evaluation. Over the phone, the patient can describe their dental problem; in a video chat, the patient can give the dentist a visual. HIPAA-compliant platforms designed for teledentistry allow dentists and their patients to communicate and exchange information in a secure, compliant environment.
This kind of access opens the door to dental care for patients who live in rural areas far from a dentist’s office. Additionally, patients who have dental concerns can get answers that do not necessarily require in-person care.
“A simple phone call would be more cost-effective for the patient and would not take up chair time for something that really could be a verbal answer,” said Stephanie H. McGann, DMD, FAGD, owner of Rainbow Valley Dental in Coatesville, Pennsylvania.
Expanding access to care is undeniably advantageous, but teledentistry does not come without concerns — namely, a reduction in the scope of issues that can be addressed.
“Medicine is the perfect place for telehealth because it’s 90% diagnostic, whereas dentistry is about 5% diagnostic,” said Wayne C. Radwanski, DDS, FAGD.
Dentists can provide an initial diagnosis and advice via teledentistry, but, in most cases, the patient will still need to come into the office to undergo treatment. Additionally, when evaluating a patient remotely, dentists don’t have access to their usual in-office tools.
“It’s hard for a patient to take a good photo of something happening in the upper backside of their mouth using an iPhone. It’s not really reasonable to expect a clinical-quality photo,” said McGann.
While virtual care has limitations in dentistry, it is a relatively simple service for both providers and patients to navigate. Various platforms are available and offer a secure way for dentists and patients to connect with a few clicks.
Practicing Teledentistry
As each state creates its own legislation regarding the practice of teledentistry, this has led to varying definitions of teledentistry and its allowable scope.3 Currently, 23 states specifically outline regulation and reimbursement, while the remainder do not explicitly regulate it.4 Though legislation varies across states, there are common threads. Typically, the dentist providing the service must be licensed in the state where the patient is located.
Practicing teledentistry rarely requires any form of special training for dental staff. Platforms are designed to be user friendly, and, as teledentistry becomes more mainstream, the process will likely become even easier. McGann foresees dental practice management software adding telemedicine features that will allow for patient record upload during virtual consultations.
Reimbursement is also an important consideration for any dental practice potentially adding teledentistry services. Two codes in the American Dental Association’s Code on Dental Procedures and Nomenclature (CDT Code) specifically apply to teledentistry: D9995 applies to synchronous teledentistry; D9996 applies to asynchronous teledentistry services.5 Additional CDT codes covering the services provided — such as oral evaluation, reevaluation, postoperative visit and care coordination — can also be used to document a teledentistry encounter.6 Many third-party payers accept these codes, but reimbursement for teledentistry services depends on each insurance company’s specific policies. Dental offices also have the option to offer teledentistry visits on a fee-for-service basis.
The Future of Teledentistry
Teledentistry is a useful tool for dentists to connect with established patients, but it also offers the possibility of expanding care to vulnerable populations that do not have regular access to oral care. Guy E. Acheson, DDS, MAGD, was one of several dentists to sit on a panel observing the pilot version of the University of the Pacific Arthur A. Dugoni School of Dentistry’s Virtual Dental Home program in California. The program involves registered dental hygienists in alternative practice (RDHAPs), registered dental hygienists working in public health programs (RDH) and registered dental assistants in extended functions (RDAEF) conducting work in the field under the remote supervision of licensed dentists. If a patient needs more complex treatment, such as a pulpotomy, root canal or definitive restoration, a licensed dentist will perform the procedure.
In the program, the RDHAPs, RDHs and RDAEFs travel to underserved areas to conduct oral examinations with digital equipment. Patient information, such as radiographs and photographs, are sent back to the supervising dentist for diagnosis and a care plan going forward. Over the course of his two years of involvement, Acheson made several site visits to places such as public schools to observe the program in action.
“It was transformational for me, in that it really showed what the problem of access to care is,” he said.
The scope of practice is one of the main concerns dentists have when dental hygienists are out in the field. Are hygienists pushing the boundaries of care they are qualified to provide?
“You need credibility and confidence that you have control and are providing a good service for patients,” said Acheson. “The hygienist working remotely and in direct contact with the supervising dentist, using the internet, was really part of the dental team. That alleviated all of my concerns about whether an inappropriate level of unsupervised care was being provided out in the field.”
This type of program sheds light on just how many people could benefit from teledentistry services provided by dentists and allied health professionals. People who lack reliable transportation, people with disabilities, people with chronic pain, the elderly and people who do not live near a dental office all face barriers to accessing traditional dental care. Teledentistry could help people who live in areas designated dental health professional shortage areas (HPSAs) gain access to oral healthcare.7 There are more than 59 million people living in dental HPSAs in the United States.8
“I think teledentistry provides a growth opportunity. There are so many people who have mobility issues,” said Acheson.
The same tools that have proved effective for in-person care, such as digital photography, are also useful in teledentistry programs. As patient access challenges become more widely recognized, the opportunities for dentists and allied health professionals to use these tools, work together and provide teledentistry will grow.
“I think dentists should always be looking for ways to expand their scope of services and expand their patient population. There is a huge number of people who are looking for alternative ways to accept dental care,” said Acheson. “With the electronic means we have — radiographs, photographs, electronic records — we have a very credible and powerful way of doing that.”
The Role of Teledentistry During the COVID-19 Pandemic
The COVID-19 pandemic has disrupted nearly every aspect of daily life, and dentists have had to navigate rapidly changing regulations throughout the crisis. Statewide shutdowns and stay-at-home orders dramatically reduced patient access to oral care. In response to the situation, many dentists looked to teledentistry as a way to stay connected to their patients.
Adrian J. Cummins, DDS, FAGD, of Cummins Dental Group in Silver Spring, Maryland, began offering teledentistry services to his patients to reduce the number of in-office and emergency room visits. For example, he saw a patient via teledentistry for a toothache she was concerned couldn’t wait until her regular dentist, whose office was shut down entirely because of the pandemic, was available.
Cummins reviewed her medical history and intake paperwork, sent ahead of the virtual consultation, and asked the patient a series of diagnostic questions. “Once I determined it was not an airway issue and her submandibular area appeared normal, I felt comfortable managing her virtually rather than referring her to a surgeon or emergency room immediately,” he said. He helped to manage the patient’s condition, which appeared to be consistent with an irreversible pulp infection, with over-the-counter painkillers, antibiotics (should her condition worsen) and a referral to a specialist.
While teledentistry existed before COVID-19, the pandemic has pushed it to the forefront of the dental industry. “Dentistry is going to have to change how we see patients, how we treat patients and how we can ensure everyone’s safety. One of the things that we can do through teledentistry is be more prepared for in-person appointments,” said Cummins.
Teledentistry can be an effective patient screening tool to ensure the safety of patients and staff. Before coming into the office, patients can undergo a series of questions related to COVID-19 and to assess their risk factors.
As patients and dentists become more accustomed to using teledentistry, it will likely become a part of dentistry that remains after the pandemic subsides. “The systems in place are going to become more robust. Insurance carriers and employers are going to recognize the value of it, and it will become an adjunct to the traditional delivery systems,” said McGann.
Teledentistry in General Dentistry
Read more about teledentistry in the May/June 2020 issue of General Dentistry. “Teledentistry: Remote Observation of Patients with Special Needs” outlines the benefits of new technology in the evaluation of all patients but particularly the more complex population that has been diagnosed with a disability. Three case examples illustrate the value of technology in remote patient observation and offer ideas for use and further research.
Carrie Pallardy is a freelance writer and editor based in Chicago. To comment on this article, email impact@agd.org.
References
1. “Facts About Teledentistry.” American TeleDentistry Association, americanteledentistry.org/facts-about-teledentistry/. Accessed 30 April 2020.
2. “ADA Policy on Teledentistry.” American Dental Association, ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-teledentistry. Accessed 30 April 2020.
3. State Telehealth Laws & Reimbursement Policies. Center for Connected Health Policy, 2019.
4. “Oral Health Providers Overview.” Scope of Practice Policy, scopeofpracticepolicy.org/practitioners/oral-health-providers/. Accessed 30 April 2020.
5. “D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events.” American Dental Association, 27 March 2020, ada.org/~/media/ADA/Publications/Files/CDT_D9995D9996-GuideTo_v1_2017Jul17.pdf?la=en. Accessed 30 April 2020.
6. “COVID-19 Coding and Billing Interim Guidance.” American Dental Association, 14 April 2020, success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf. Accessed 30 April 2020.
7. Bersell, Catherine H. “Critical Issues in Dental Hygiene.” Journal of Dental Hygiene, vol. 91, no. 1, Feb. 2017, pp. 6-14.
8. Bureau of Health Workforce, Health Resources and Services Administration, U.S. Department of Health & Human Services. Designated Health Professional Shortage Areas Statistics: Second Quarter of Fiscal Year 2020 Designated HPSA Quarterly Summary. U.S. Department of Health & Human Services, 31 March 2020.
Dentistry is a very hands-on field, but, in this increasingly digital world, teledentistry services are finding more of a role in everyday practice.
Teledentistry services are provided remotely via audio and visual digital communication tools.1 These services can be synchronous (in real time) or asynchronous (the patient leaves a message or sends information that the dentist reviews later, also known as “store-and-forward”). Dentists can also participate in teledentistry via remote patient monitoring, in which patient data is electronically sent to a provider for supportive care.2 Examples of this include monitoring saliva pH levels as well as patient use of mandibular advancement devices in treating obstructive sleep apnea. Digitally connecting with patients can help dentists make diagnoses, reassure patients, determine how much chair time is necessary and make any appropriate referrals.
While telehealth is more established in medicine, it is relatively nascent in dentistry. As some dentists are embracing teledentistry during the COVID-19 pandemic to increase access to care, they are figuring out answers to many questions. How can dentists address their own concerns and the concerns of patients using these technologies? What regulations must be considered? How are dentists reimbursed for their services? How can dentists effectively integrate teledentistry services into their practices?
The Pros and Cons of Teledentistry
Teledentistry can expand access to care. Patients who cannot immediately access in-person dental services can use a teledentistry service to speak with a licensed dentist for initial evaluation. Over the phone, the patient can describe their dental problem; in a video chat, the patient can give the dentist a visual. HIPAA-compliant platforms designed for teledentistry allow dentists and their patients to communicate and exchange information in a secure, compliant environment.
This kind of access opens the door to dental care for patients who live in rural areas far from a dentist’s office. Additionally, patients who have dental concerns can get answers that do not necessarily require in-person care.
“A simple phone call would be more cost-effective for the patient and would not take up chair time for something that really could be a verbal answer,” said Stephanie H. McGann, DMD, FAGD, owner of Rainbow Valley Dental in Coatesville, Pennsylvania.
Expanding access to care is undeniably advantageous, but teledentistry does not come without concerns — namely, a reduction in the scope of issues that can be addressed.
“Medicine is the perfect place for telehealth because it’s 90% diagnostic, whereas dentistry is about 5% diagnostic,” said Wayne C. Radwanski, DDS, FAGD.
Dentists can provide an initial diagnosis and advice via teledentistry, but, in most cases, the patient will still need to come into the office to undergo treatment. Additionally, when evaluating a patient remotely, dentists don’t have access to their usual in-office tools.
“It’s hard for a patient to take a good photo of something happening in the upper backside of their mouth using an iPhone. It’s not really reasonable to expect a clinical-quality photo,” said McGann.
While virtual care has limitations in dentistry, it is a relatively simple service for both providers and patients to navigate. Various platforms are available and offer a secure way for dentists and patients to connect with a few clicks.
Practicing Teledentistry
As each state creates its own legislation regarding the practice of teledentistry, this has led to varying definitions of teledentistry and its allowable scope.3 Currently, 23 states specifically outline regulation and reimbursement, while the remainder do not explicitly regulate it.4 Though legislation varies across states, there are common threads. Typically, the dentist providing the service must be licensed in the state where the patient is located.
Practicing teledentistry rarely requires any form of special training for dental staff. Platforms are designed to be user friendly, and, as teledentistry becomes more mainstream, the process will likely become even easier. McGann foresees dental practice management software adding telemedicine features that will allow for patient record upload during virtual consultations.
Reimbursement is also an important consideration for any dental practice potentially adding teledentistry services. Two codes in the American Dental Association’s Code on Dental Procedures and Nomenclature (CDT Code) specifically apply to teledentistry: D9995 applies to synchronous teledentistry; D9996 applies to asynchronous teledentistry services.5 Additional CDT codes covering the services provided — such as oral evaluation, reevaluation, postoperative visit and care coordination — can also be used to document a teledentistry encounter.6 Many third-party payers accept these codes, but reimbursement for teledentistry services depends on each insurance company’s specific policies. Dental offices also have the option to offer teledentistry visits on a fee-for-service basis.
The Future of Teledentistry
Teledentistry is a useful tool for dentists to connect with established patients, but it also offers the possibility of expanding care to vulnerable populations that do not have regular access to oral care. Guy E. Acheson, DDS, MAGD, was one of several dentists to sit on a panel observing the pilot version of the University of the Pacific Arthur A. Dugoni School of Dentistry’s Virtual Dental Home program in California. The program involves registered dental hygienists in alternative practice (RDHAPs), registered dental hygienists working in public health programs (RDH) and registered dental assistants in extended functions (RDAEF) conducting work in the field under the remote supervision of licensed dentists. If a patient needs more complex treatment, such as a pulpotomy, root canal or definitive restoration, a licensed dentist will perform the procedure.
In the program, the RDHAPs, RDHs and RDAEFs travel to underserved areas to conduct oral examinations with digital equipment. Patient information, such as radiographs and photographs, are sent back to the supervising dentist for diagnosis and a care plan going forward. Over the course of his two years of involvement, Acheson made several site visits to places such as public schools to observe the program in action.
“It was transformational for me, in that it really showed what the problem of access to care is,” he said.
The scope of practice is one of the main concerns dentists have when dental hygienists are out in the field. Are hygienists pushing the boundaries of care they are qualified to provide?
“You need credibility and confidence that you have control and are providing a good service for patients,” said Acheson. “The hygienist working remotely and in direct contact with the supervising dentist, using the internet, was really part of the dental team. That alleviated all of my concerns about whether an inappropriate level of unsupervised care was being provided out in the field.”
This type of program sheds light on just how many people could benefit from teledentistry services provided by dentists and allied health professionals. People who lack reliable transportation, people with disabilities, people with chronic pain, the elderly and people who do not live near a dental office all face barriers to accessing traditional dental care. Teledentistry could help people who live in areas designated dental health professional shortage areas (HPSAs) gain access to oral healthcare.7 There are more than 59 million people living in dental HPSAs in the United States.8
“I think teledentistry provides a growth opportunity. There are so many people who have mobility issues,” said Acheson.
The same tools that have proved effective for in-person care, such as digital photography, are also useful in teledentistry programs. As patient access challenges become more widely recognized, the opportunities for dentists and allied health professionals to use these tools, work together and provide teledentistry will grow.
“I think dentists should always be looking for ways to expand their scope of services and expand their patient population. There is a huge number of people who are looking for alternative ways to accept dental care,” said Acheson. “With the electronic means we have — radiographs, photographs, electronic records — we have a very credible and powerful way of doing that.”
The Role of Teledentistry During the COVID-19 Pandemic
The COVID-19 pandemic has disrupted nearly every aspect of daily life, and dentists have had to navigate rapidly changing regulations throughout the crisis. Statewide shutdowns and stay-at-home orders dramatically reduced patient access to oral care. In response to the situation, many dentists looked to teledentistry as a way to stay connected to their patients.
Adrian J. Cummins, DDS, FAGD, of Cummins Dental Group in Silver Spring, Maryland, began offering teledentistry services to his patients to reduce the number of in-office and emergency room visits. For example, he saw a patient via teledentistry for a toothache she was concerned couldn’t wait until her regular dentist, whose office was shut down entirely because of the pandemic, was available.
Cummins reviewed her medical history and intake paperwork, sent ahead of the virtual consultation, and asked the patient a series of diagnostic questions. “Once I determined it was not an airway issue and her submandibular area appeared normal, I felt comfortable managing her virtually rather than referring her to a surgeon or emergency room immediately,” he said. He helped to manage the patient’s condition, which appeared to be consistent with an irreversible pulp infection, with over-the-counter painkillers, antibiotics (should her condition worsen) and a referral to a specialist.
While teledentistry existed before COVID-19, the pandemic has pushed it to the forefront of the dental industry. “Dentistry is going to have to change how we see patients, how we treat patients and how we can ensure everyone’s safety. One of the things that we can do through teledentistry is be more prepared for in-person appointments,” said Cummins.
Teledentistry can be an effective patient screening tool to ensure the safety of patients and staff. Before coming into the office, patients can undergo a series of questions related to COVID-19 and to assess their risk factors.
As patients and dentists become more accustomed to using teledentistry, it will likely become a part of dentistry that remains after the pandemic subsides. “The systems in place are going to become more robust. Insurance carriers and employers are going to recognize the value of it, and it will become an adjunct to the traditional delivery systems,” said McGann.
Teledentistry in General Dentistry
Read more about teledentistry in the May/June 2020 issue of General Dentistry. “Teledentistry: Remote Observation of Patients with Special Needs” outlines the benefits of new technology in the evaluation of all patients but particularly the more complex population that has been diagnosed with a disability. Three case examples illustrate the value of technology in remote patient observation and offer ideas for use and further research.
Carrie Pallardy is a freelance writer and editor based in Chicago. To comment on this article, email impact@agd.org.
References
1. “Facts About Teledentistry.” American TeleDentistry Association, americanteledentistry.org/facts-about-teledentistry/. Accessed 30 April 2020.
2. “ADA Policy on Teledentistry.” American Dental Association, ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-teledentistry. Accessed 30 April 2020.
3. State Telehealth Laws & Reimbursement Policies. Center for Connected Health Policy, 2019.
4. “Oral Health Providers Overview.” Scope of Practice Policy, scopeofpracticepolicy.org/practitioners/oral-health-providers/. Accessed 30 April 2020.
5. “D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events.” American Dental Association, 27 March 2020, ada.org/~/media/ADA/Publications/Files/CDT_D9995D9996-GuideTo_v1_2017Jul17.pdf?la=en. Accessed 30 April 2020.
6. “COVID-19 Coding and Billing Interim Guidance.” American Dental Association, 14 April 2020, success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf. Accessed 30 April 2020.
7. Bersell, Catherine H. “Critical Issues in Dental Hygiene.” Journal of Dental Hygiene, vol. 91, no. 1, Feb. 2017, pp. 6-14.
8. Bureau of Health Workforce, Health Resources and Services Administration, U.S. Department of Health & Human Services. Designated Health Professional Shortage Areas Statistics: Second Quarter of Fiscal Year 2020 Designated HPSA Quarterly Summary. U.S. Department of Health & Human Services, 31 March 2020.