Teledentistry: What Is It Now, and What Will It Be Tomorrow?

A few years ago, teledentistry involved calling an expert on the telephone for advice. Now it involves consulting experts using the Internet. This article explains the basic ideas underlying teledentistry. It involves the local dentist digitizing and electronically transmitting drawings, diagrams, photographs, and X-rays to a specialist. Along with these data, the dentist will most likely need to fill out a standard consult form from the specialist’s Web site. In return, the specialist will develop and return a confidential consultation report to the dentist or physician requesting help. For this service, a time-based fee will be paid to the expert. Unfortunately, it is likely that some doctors will use the Internet to set up and seek direct patient contact, thus becoming "cyberdentists." In most cases, cyberdentistry will not be in the best interests of the public. However, teledentistry should not only be a practice builder for the local dentist but also has the potential for helping dentists better serve their patients while increasing their own knowledge.

To some dentists, teledentistry means searching the Web for information that might help a patient. To others, it is partaking of online continuing education courses. These two activities are actually Web surfing and distance learning. Teledentistry, on the other hand, is using the Internet to consult with an expert. This consultation could be direct (between the patient and the expert) or indirect (between the patient’s doctor and the expert). The former has made the news recently in the form of cautionary stories to the public about the dangers of using "cyberdocs" for health care. Cyberdocs will be discussed further in this article. For the present, the discussion will focus on the primary care dentist’s need to consult with an expert about a specific patient’s problem.

Only a few years ago, teledentistry was performed by calling an expert on the telephone and asking for advice. In the past few years, however, dentists and physicians have been able to consult with acclaimed and acknowledged experts at any location by using the Internet. The doctor who desires a teleconsult will have to fax or electronically transmit scanned chart notes or fill out a standard consult form obtained from the particular specialist’s Web site. Along with these text-based data, some consults will require the doctor to digitize and transmit drawings, diagrams, photographs, or X-rays. Technology also allows doctors to transmit questions via audio recordings rather than text. The doctor who has this capability will be able to attach these digital audio messages to the other information sent. In return, the specialist, based on the data received, will develop and return a confidential consultation report or a request for more information to the dentist or physician requesting help, usually within 48 hours. For this service, a time-based fee will be paid to the expert. The information provided to the requesting doctor will enable him or her to better treat the patient in question. In medicine, this service is active and growing in a rapid fashion, but in dentistry the process is just beginning.¹ Specifically, data derived from the Association of Telemedicine Service Provider’s (ATSP: www.atsp.org) 1998 Report on U.S. Telemedicine Activity, done collaboratively with Telemedicine Today magazine, indicates there were more than 40,000 teleconsults among 139 U.S. programs performed in 1997. In contrast, there were only 200 dental teleconsultations reported. Probably the largest teledentistry undertaking in the world is being performed by the U.S. military to service their troops and their dependents around the world. For information about the military system, access its Web site at http://tdent.tatrc.org.

Reasons for Teleconsulting

The reason dental teleconsulting is going to be increasingly necessary is that modern dentists must differentiate and manage well more than 200 oral diseases (Table 1), and medical and dental knowledge is rapidly changing. As recently as 25 years ago, HIV/AIDS did not exist. Antibiotic-resistant infections were also virtually non-existent, and our life span was substantially shorter. For some, there is the inaccurate perception that training dentists is less important than it once was; but this perception is wrong. $50.6 billion was spent on dental care in the United States in 1997² and 21 million work days are lost every year because of dental disease.³ Each year, more than 30,000 new cases of oral or throat cancer are diagnosed, and 9,000 U.S. citizens die from this disease (more than ovarian or cervical cancer).⁴ Chronic pain costs society $100 billion each year, and 20 percent to 25 percent of all chronic pain is orofacial in origin.⁵ Dentistry is continuing to grow and flourish as it creates new treatment and diagnostic methods for the myriad of oral diseases and conditions in its purview.

Table 1 General Categories of Orofacial Disease (partial listing)

· Intrabony jaw cysts, infections,neoplasia, and deformities · Genetic craniofacial/dental deformities · Acquired craniofacial/dental deformities (including trauma and malocclusions) · Oral-pharyngeal infections (viral, fungal and bacterial, including caries and periodontal · Intraoral mucosal and gingival tissue diseases (including neoplasias) · Extraoral tissue/gland disease (neoplastic disease; white, red, and blue lesions; ulcers and bullous lesions; allergic reactions; autoimmune reactions; dry mouth; burning mouth; systemic disease effects; and salivary and lymphatic disease) · Temporomandibular disorders (myalgia, arthritis, derangements) · Mandibular mobility disorders (ankylosis, contracture, hypermobility) · Neuropathic orofacial pains and trigeminal sensory deficits (phantom tooth pains, trigeminal sensory disorders, c-fiber sensitization, neuritis, neuromas, neuralgia and neuropathies associated with systemic disease and toxicity) · Headache disorders (migraine, tension, cluster, chronic daily, rebound, ice-pick, cervicogenic) · Orofacial motor disorders (bruxism, dyskinesia, dystonia, tics, tremors, spasm)

When a patient presents to a dentist’s office with a difficult diagnostic dilemma, the dentist will typically do one of three things:

* Ignore the problem and hope it goes away;

* Try to do something that has a substantial chance of being the wrong treatment;

* Refer to a another doctor in the area (possibly a dental specialist) who also may not have the knowledge to diagnosis the problem and who might also try an incorrect treatment approach.

In a large urban area, the chances of having a wide range of specialists to choose from is much higher, and the chances of getting the correct diagnosis and treatment are far higher than in a rural area where the pool of experts is smaller. It is now possible to add a fourth option to the above list -- seek an electronic consultation from an expert. As mentioned, the old form of the teleconsult was to make a phone call to an expert. While this is commonly done, the degree of information imparted over the telephone is minimal. These telephone consults have overwhelmingly been free, and the level of service may have reflected this informality. With the digital revolution, these limitations can now be eliminated. Since large amounts of information can be transmitted quickly and the process is both more documentable and formal, a fee can be set and agreed upon a priori.

Previous Obstacles

As little as 10 years ago, the Internet was operational at only a few university sites; and the World Wide Web was conceptualized only by science fiction writers and futurists. As the technology has developed, it has become apparent that low-cost teleconsulting will be as available to private medical and dental practitioners as word processing is now. All of these changes are producing a very rapid change in society that futurists have termed the digital revolution. In the arena of telehealth, the main reason it has not been more readily available is that the laws governing telehealth across federal boundaries have not yet been established. In addition, an easily managed system for connecting local medical practitioners with experts (and not disenfranchising them from patient care) does not yet exist. Also, most individuals who have conceptualized the telemedicine process have visualized it as needing expensive and logistically difficult to achieve live-teleconsults as the core of the service. With the advent of the Web, some not-too-expensive hardware, a good organizing store-and-forward software program, telemedicine and teledentistry are possible. These methods will open the door to a new way of providing quality health care to individuals in regions of the world where this care is not as readily available. Restrictive laws not withstanding, telemedicine will essentially eliminate geographic obstacles, thereby letting experts provide their knowledge to all that will partake of it.

Growth of Medical Web Sites

A recent article in Fortune magazine described the massive growth of Web sites on the Internet.⁶ It reported that in the past three years, hundreds of new health-related Web sites have popped up. The need to consult an expert is becoming more and more necessary each year as the medical knowledge explosion continues to gain pace. More than 360,000 articles are published in medical journals every year. In fact, it has been estimated that medicine accounts for perhaps 10 percent of the information on the Internet. It is clear that no single general practitioner could keep current on this new information. Recently, a survey conducted by PSL Consulting, Inc., demonstrated that 44 percent of physicians and dentists around the world access the Web for health-care related purposes. The survey also reported that this number was expected to rise to 64 percent by the spring of 1999, and to 78 percent shortly thereafter.⁷ These findings give a powerful pointer to the fact that health care can and will be provided over the Internet. The two-part survey was a telephone survey of 1,103 physicians in 11 countries, and the second was a questionnaire answered by 2,532 physicians in 105 countries who were experienced Internet users. The study found that of their time on the Internet, physicians spend 47 percent accessing medical or health-related information. The heaviest use of the Internet was in the United States, Canada, and the United Kingdom, where almost 75 percent of physicians claimed to access the Internet on a daily or weekly basis. In other countries, the rate of daily or weekly access ranged from 55 to 65 percent. According to the survey, doctors used the Internet most frequently to access information on diseases (95 percent). Seventy percent of doctors surveyed said they use the Internet to consult with colleagues in their own country, while 45 percent used it to consult with colleagues in other countries.

Store and Forward

Until recently, the idea that a teleconsult had to be done live using point-to-point expensive dedicated teleconferencing equipment was commonplace. With the advent of E-mail, it is clear that it is possible to collect the necessary information and then when ready, forward it to an expert for comments. This store-and-forward method eliminates time zone and schedule logistics and makes the teleconsult readily available to most doctors with a computer and an Internet connection. Certainly, acute medical crises exist, and they need immediate attention. Live conferencing is better suited for these emergency situations, but most complex diagnostic medical and dental dilemmas are not acute problems and do not need the live teleconference.

One area of society where telehealth consulting is both needed and most advanced is the U.S. military. In fact, the military medical units face the challenge of delivering the latest medical knowledge and advances to remote areas of the world. A recent study⁸ described the utilization patterns of the tertiary care telemedicine consultation group at the Walter Reed Army Medical Center. Using a satellite-based system, within a three-year period, 240 consults were received from 12 remote telemedicine sites supporting military medical missions. The consults used a combination of store-and-forward technologies and interactive video conferencing systems. The distribution of consults included medicine (40 percent), surgery (36 percent), radiology (21 percent), and dentistry (3 percent). The most frequently consulted medical subspecialty was dermatology (29 percent), followed by orthopedic surgery (16 percent). Most consults were routine (88 percent) and were completed within the predefined telemedicine response criteria (24 hours for routine consults and three hours for emergencies). They concluded that a responsive telemedicine service at a tertiary facility provided valuable support to the various medical missions ongoing in the military.

The Need to Teleconsult

Any physician or dentist who has a modern desktop computer, one of several software programs to facilitate teleconsulting, a modem connection to the Internet, a digital camera, a radiograph/text scanner, and a minimum amount of training will be able to access a teleconsultant. This individual can send appropriate patient history and examination findings and high quality images to the expert teleconsultant. It is anticipated that complete patient records can be transmitted in just minutes. The addition of high resolution digital photos; audio and video clips; and MRI, CT or standard radiographs that have been digitized will require some additional transmission time, depending on the size and number of images to be sent (however, the transmission time is not always critical since most teleconsults are not real-time events). For the largest imaging files (e.g., MRI), regular telephone service will not be adequate because transmission time is far too long. In these instances, cable and satellite transmission methodologies will need to be used.

A report out of the University of North Carolina Dental Radiology Department evaluated the accuracy of Internet-transmitted tomograms of the temporomandibular joint using three different digital formats.⁹ Three series of TMJ images were transmitted by telephone, and transmission times were measured. The original radiographs, the digitized images (seen on a computer monitor), the transmitted images and the transmitted-and-printed images were presented to 10 observers, who were asked to rate image quality. No difference in image quality was found between the initial digitized and the transmitted images. However, transmitted and transmitted-and-printed images were of significantly lower quality than the original radiographs or the digitized images viewed on a computer monitor.

Practice and Knowledge Builder

Of course, if the primary care dentist does not wish to go to the trouble of getting a teleconsult for his or her patient, then the best thing to do is to refer the patient to someone else. This is certainly easier, but in the competitive world of health care, teleconsulting would not only be a practice builder, but substantial information could be gathered in the process. Moreover, in rural areas, the availability of specialists may involve an all-day trip to a bigger city. Of course, until more experience is gathered, it is only speculation, but it appears that a substantial advantage might accrue to the dentist (and the patient) who gets a teleconsult with an expert. First, teleconsulting between the expert and the local dentist (who knows the patient, ultimately makes the diagnosis, and delivers the care) does not involve direct patient care. Therefore, this process could and should be considered exempt from state dental board laws that require the individual providing care to hold a license in the state. This allows the primary care dentist to seek help from experts who might not reside in the local jurisdiction. Of course, until the state board rules on this issue formally, it is subject to interpretation by lawyers. The second advantage is that the teleconsultation does not disenfranchise the local dentist or physician but, instead, involves them in the care (unless the recommendation requires a specific set of skills that cannot be provided by the local doctor). This means that the more the primary care dentist partakes of expert advice, the more he or she will become adept at the diagnosis and treatment of such cases. Not only will the doctor benefit, but the next patient who has a similar problem will get earlier and better local care.

Finding Experts

It can be difficult to find the best, most knowledgeable expert to consult. If the primary dentist selects an individual with excellent credentials, he or she will usually be well-served. Although not always, such individuals are usually at a major medical center in a large urban setting at a research university. It would also be wise to select a teleconsulting group that not only consults but also sees patients, to make sure the members provide practical advice.

Accuracy

It should be assumed that true diagnosis cannot be done via the Internet except for those conditions for which a visual inspection of the problem produces the definitive diagnosis (i.e., dermatologic lesions that are pathognomonic in their appearance). There are also some problems for which a careful history is definitive for the disorder. For most problems, however, the ability to arrive at a definitive diagnosis is beyond the scope of the teleconsult. This means that exact diagnoses are not likely. What can be achieved, however, is differential diagnosis advice about what should be done to get a clearer picture of the problem. Moreover, general information about what approach to take in treatment and detailed information about the latest forms of treatment for specific problems can be provided. In two or three years, individuals who engage in teleconsulting will have to conduct ongoing research on the validity of their consults.

Although no validation work on teledentistry consulting has been conducted, research in several areas of telemedicine gives some insight on this issue. Specifically, a study¹⁰ evaluated 15 elderly patients who participated in a teleconsultation with an orthopedic surgeon as well as a conventional, face-to-face consultation. The comparison between the surgeon’s ratings for both types of consultation suggested that the telemedicine consultation was satisfactory in terms of the quality of image and sound, the clinical examination, and general simplicity. The telemedicine consultations did not generate a need for any additional clinical investigations, although in two cases a face-to-face consultation was necessary to clarify clinical signs (shortening of a limb and scar tissue). The surgeon’s rating of his decision level was superior in the face-to-face situation in four cases, and for 11 patients it was equal. Similarly, the surgeon’s level of confidence in decision-making was superior in the conventional situation for five patients and equal for 10 patients. Patient attitudes toward teleconsulting were favorable. There was a high level of patient satisfaction. Teleconsulting between orthopedic surgeons and elderly patients therefore appears to be possible, provided that certain technical, clinical, and psychological considerations are addressed.

Another study,¹¹ evaluated use of real-time and store-and-forward teleconsulting methods for inpatients who presented to the New York Eye and Ear Infirmary for otolaryngology care. Forty-five patients were seen in the study. There were no significant differences between local and remote otolaryngologists when interpreting the examinations, indicating that transmission did not affect the ability of a qualified physician to make an accurate diagnosis. In the store-and-forward examinations, only 62 percent of the electronic records provided sufficient information for a confident diagnosis. Records were judged inadequate primarily due to poor selection or an insufficient number of stored images. The study demonstrates that both interactive and store-and-forward techniques can be used to provide accurate clinical consultations in nasopharyngolaryngoscopic examinations.

Public Interaction

There are many ways for physicians and dentists to interact with the public via the Internet. The two basic areas are health information-based Web sites and direct "cyberdoc" Web sites. In the former category, there are many valuable sites. One of the most famous sites in this arena is the one endorsed by former Surgeon General Dr. C. Everett Koop. This site is at http://www.drkoop.com. It does not provide direct patient-to-doctor consultations but instead provides information about health care problems, much in the same way as a good textbook. In this arena, there was a recent survey of more than 4,000 individuals conducted by the Health on the Net group (http://www.hon.ch/Survey/Apr99/). They asked "Which 3 medical /healthcare Web sites most closely meet your needs?" The results of this survey are presented in Table 2. No such top 10 list exists for dentistry’s informational Web sites.

Of course, there are doctors who provide consultations directly to the public over the Internet. These individuals have been labeled "cyberdocs." The problem with giving specific advice directly to a patient is that it might be bad advice for the right problem or good advice for the wrong problem. Both of these problems can and do occur in a direct patient-to-doctor interactions, but at least the patient has an individual to deal with face-to-face. Moreover, if something goes wrong, the patient has recourse with the local professional society peer-review boards, state boards, or the legal system. Certainly, the cyberdoctoring process is susceptible to lawsuits, but it is more difficult to conduct these suits if the individual is not in the same state or country. It is also difficult to say that the teleconsult was done improperly because there is no standard of practice for direct doctor-to-patient telemedicine or teledentistry.

Since it is likely that abuses will occur in the cyberdoc arena, dentists would be wise to keep abreast of problems. It would be valuable to periodically check several Web sites that monitor and deal with health care fraud. One is the National Council Against Health Fraud, Inc. at http://www.ncahf.org. The other is a Web site called Quackwatch (http://www.quackwatch.com/). There is a third Web site that is valuable to know about, and it is run by the Health on the Net Foundation Code of Conduct (HONcode) for medical and health Web sites (http://www.hon.ch/). This organization addresses one of the main issues of the Internet: the reliability and credibility of medical and health information. The problem is not finding information but finding good information. For example, in many cases, a Web site provides no appropriate documentation regarding the scientific design of a medical study, nor are studies made available that support given claims. The Code of Conduct for medical and health Web sites has been elaborated on by the Health on the Net Foundation to help unify and standardize the reliability of medical and health information available. The HONcode doesn’t intend to rate the quality or the information provided by a Web site. It only defines a set of rules designed to make sure the reader always knows the source and purpose of the data accessed.

Applicable Areas

The U.S. military has elected to incorporate all of the basic areas of dentistry into its teleconsultation process (e.g., restorative, periodontics, orthodontics, pediatric, oral pathology, endodontics, prosthodontics). The military has special needs that would not apply to the public sector. First, the military dentist cannot go outside of the military health care system. Second, military clinics are often in an isolated location, and military specialists are not readily available. Even if the patient is willing to travel, his or her duties may not allow it. Alternatively, military patients might be relocated so that needed follow-up care cannot be done by the doctor who performed the original procedure. In contrast, in the private dental marketplace, there are more dentists to handle the more routine aspects of dentistry. It is, therefore, unlikely that the demand for teleconsultation will be high in the more routine areas of dentistry such as restorative or periodontal care. Of course, with more difficult cases, specialized knowledge will be required, and teleconsultation is more likely. If dentistry parallels medicine, the arenas of oral medicine (mucosal lesions) and chronic facial pain will be areas in which teleconsultations will be desired. The first area is likely because there are many different oral tissue lesions, and many are recognizable from their appearance. Secondly, the areas of TMD and chronic orofacial pain are diseases that can be nearly diagnosed by a careful history. In the private medical arena where telemedicine activity is already present, the consults seem to occur in very rural settings; and dermatology, orthopedics, emergency neurosurgery, ophthalmology, pulmonology and radiology are frequent users.

Conclusions

With teledentistry, there is good news and bad news. The bad news is that it is highly likely that some doctors will set up and seek direct patient contact via the Internet, thus becoming "cyberdentists." In most cases, cyberdentistry will not be in the best interests of the public, and state dental boards should monitor cyberdentistry and punish abuses. The good news is that for many, teledentistry will produce wonderful advantages for the patients of a primary care doctor who partakes of the vast expertise available through teleconsultation. The title of this article poses two questions with regard to teledentistry. The first is, "What is it now?" Right now, except for the U.S. military and in a few places around the globe, teledentistry is not much more than an idea whose time has come. The second question is "What will it be tomorrow?" The answer to this question is yet to be written, but it is hoped that it will become an everyday event where primary care doctors can consult with experts and deliver the best care to their patients. As the digital revolution moves forward, it is only a matter of a few months or years before most dentists will gain familiarity with and have the necessary technology to make teledentistry a reality. Hopefully, the various state boards will rule that it is not a violation of the law if an out-of-state expert consults with local licensed dentists who actually provide care. Finally, the dental leadership in California should help make this hope a reality, since it would be a win-win situation for the public and the dental profession of California with very little downside.

Contributing Editor

Glenn T. Clark DDS, MS, is a professor at the University of California at Los Angeles School of Dentistry. He is also director of the Oral Medicine and Orofacial Pain Faculty Practice at UCLA.



References

1. Wheeler T, Smile for the camera: telemedicine comes to your local dentist’s office. Telemedicine Today 7(1):14-5, 42, 1999.

2. Health Care Financing Administration 1998 (http://www.hcfa.gov/stats/nhe-oact/tables/t17.htm).

3. Gift HC, Reisine ST, Larach DC, (1992) The social impact of dental problems and visits. Am J Public Health 82:1663-8.

4. American Cancer Society, Cancer facts and figures. 1992. Atlanta.

5. Bonica JJ, General considerations of chronic pain. In, Management of Pain, Vol 1. Bonica JJ, et al, eds. Lea & Febiger, Philadelphia, 1990, pp 180-96.

6. Stipp D, Health help on the net, Fortune Jan 12, 1998, 137(1):135.

7. Survey results available directly from PSL consulting Inc. and described in a Nov. 4, 1998 report on the Doctors Guide listserve at http://www.pslgroup.com/docguide.htm.

8. Gomez E, Poropatich R, et al, Tertiary telemedicine support during global military humanitarian missions. Telemedicine J 2(3):201-10, 1996.

9. Eraso FE, Scarfe WC, et al, Teledentistry: protocols for the transmission of digitized radiographs of the temporomandibular joint. J Telemedicine Telecare 2(4):217-23, 1996.

10. Couturier P, Tyrrell J, et al, Feasibility of orthopedic teleconsulting in a geriatric rehabilitation service. J Telemedicine Telecare, 4 Suppl 1:85-7, 1998.

11. Stern J, Heneghan C, et al, Telemedicine applications in otolaryngology. J Telemedicine Telecare 4 Suppl 1:74-5, 1998.



To request a printed copy of this article, please contact/Glenn T. Clark DDS, MS, 100 UCLA Medical Plaza, Suite 355, Los Angeles, CA 90095-7063.



Table 1. General Categories of Orofacial Disease (partial listing)

* Intrabony jaw cysts, infections, neoplasia, and deformities

* Genetic craniofacial/dental deformities

* Acquired craniofacial/dental deformities (including trauma and malocclusions)

* Oral-pharyngeal infections (viral, fungal and bacterial, including caries and periodontal disease).

* Intraoral mucosal and gingival tissue diseases (including neoplasias)

* Extraoral tissue/gland disease (neoplastic disease; white, red and blue lesions; ulcers and bullous lesions; allergic reactions; autoimmune reactions; dry mouth; burning mouth; systemic disease effects; and salivary and lymphatic disease)

* Temporomandibular disorders (myalgia, arthritis, derangements)

* Mandibular mobility disorders (ankylosis, contracture, hypermobility)

* Neuropathic orofacial pains and trigeminal sensory deficits (phantom tooth pains, trigeminal sensory disorders, c-fiber sensitization, neuritis, neuromas, neuralgia and neuropathies associated with systemic disease and toxicity)

* Headache disorders (migraine, tension, cluster, chronic daily, rebound, ice-pick, cervicogenic)

* Orofacial motor disorders (bruxism, dyskinesia, dystonia, tics, tremors, spasm)



Table 2. A List of the Top Informational Health Web Sites as Determined by a Survey

Organization Address

National Library of Medicine, MEDLINE, Pubmed, National Institutes of Health http://www.nih.gov/

British Medical Journal http://www.bmj.com/

http://www.medscape.com/

Intelihealth http://www.intelihealth.com/

Mayo Health System http://www.mayohealth.org/

Centers for Disease Control and Prevention http://www.cdc.gov/

HON http://www.hon.ch/

The Lancet http://www.thelancet.com/

Healthgate.com http://www.healthgate.com/