The Future of Teledentistry

Teledentistry is a rapidly forming subset of telehealth, a field that already has considerable impact on the health care industry. Recent advances have created new opportunities for teledentistry, and changes in diverse technologies have created new tools for the practitioner. Technologies currently available are beginning to change the dynamics of dental care delivery. As teledentistry evolves, it will offer new opportunities to improve the level of patient care and reshape current business models.

Telehealth, both medical and dental, is a new facet of overall patient care that is rapidly increasing in popularity and value. Uses range from telehouse-call systems and monitoring patients in their homes, to globally deployable, self-contained biomedical sensing units that can link anyone from astronauts to oil rig workers with care providers. Fields as diverse as telepsychiatry, teleurology, and teledermatology are rapidly becoming established segments of traditional health care. Teledentistry will experience a similar growth as new tools become available for the practitioner and new business models are defined.

Earlier obstacles to implementing telehealth programs fell into one of two distinct areas: sociological or technological. As the technologies have become available to facilitate valuable telehealth applications, practitioners and patients have been forced to undergo a paradigm shift in the way they interact. The Orwellian image of a robotic health care provider in a sterile and impersonal environment dispensing care like a vending machine was touted by some to be just on the horizon. The reality, however, is that people who previously went without care or who received inadequate care can have access to a vastly improved level of services. Initial concerns regarding the dehumanization of health care are being quickly washed away by the overwhelming benefits that can be provided using innovative telehealth concepts to deliver care. Innovative journals and periodicals evolved such as Telemedicine & Virtual Reality and TeleHealth that specifically focus on increasing the understanding and effective utilization of telehealth in everyday applications.

As technology has advanced, patient benefits have continued to increase. Changes in the size, features, and costs of various technological components created entire new types of communications tools that facilitate telehealth in general and teledentistry in particular. The intraoral video camera, which has gained widescale popularity and general acceptance only within the past five years, is one example. This tool allows dental care providers to document and communicate their visual observations. Similarly, other solutions for storing, retrieving, managing, and communicating images and other aspects of a total patient record have also improved during this time. Practitioners now have a wide array of telehealth tools at their disposal. With technologies ranging from basic store-and-forward applications running on inexpensive laptops to real-time A/V satellite links, care can be provided to those patients that, in the past, often suffered due to economic, political, or geographic limitations. In the near future, wireless communication technologies will be available that will make Internet communication truly ubiquitous, further providing access to care in the most remote regions of the globe.

Several seemingly unrelated technologies have helped contribute to the reduced cost and increased availability of telehealth solutions. The miniaturization of charge-coupled device chips has allowed smaller, lighter, and less expensive video imaging cameras to be developed. New compression technologies have resulted in better image quality, and increases in bandwidth have made high-speed transfer of information affordable. One finite example of the convergence of discrete technologies is a new telehealth device soon to be commercially available from CyberMDx Inc. that combines a number of diverse technological advances used by NASA into a single unit that can be deployed virtually anywhere on Earth (or beyond), linking the most remote patients with care providers.

As capability has increased, the cost of technology has decreased. A 9,600 bps modem in 1989 cost more than $500. Today, a 56,000 bps modem is less than $150. That same year, a video frame grabber required a full-sized PC with two ISA slots, was extremely slow to process, and cost $2,000 or more. Installation was a day-long affair. Today, PCMCIA frame grabbers are less than $200, support near real-time conferencing, fit in a notebook, and install in less than two minutes. The increasing performance and decreasing cost of technology has not been confined to computer-related products. Other technology areas -- such as video imaging, hard copy printing, and voice recognition -- have also experienced similar evolutions and are continuing to improve.

Today’s practitioner has a wide array of telehealth solutions available. There are primarily three types of telehealth modalities: store-and-forward, real-time, and near-real-time. Each has value for specific subspecialties in specific situations. Store-and-forward solutions have the lowest cost and can often provide ample benefit for a wide range of applications. On the other end of the spectrum, true real-time solutions require expensive transmission equipment and extremely fast connections that are not usually available outside of major metropolitan areas unless a satellite is deployed. Near-real-time solutions range from low-resolution, low-frame-rate to something that looks like jittery television. For most dental applications however, store-and-forward technologies will provide excellent results without excessive costs for equipment or connectivity.

A typical store-and-forward teledentistry system might consist of an intraoral video camera, fame grabber, standard consumer-grade paper scanner, computer, color printer, 33.6 Kbps modem, and an Internet connection via regular telephone service. A second video camera and an X-ray viewer might also be used to acquire and digitize radiographs. The price for a hardware configuration such as this would be approximately $9,000; however, most practices will already have many of these components, greatly reducing the cost. For extremely cost-conscious practices and clinics, a care provider could use a Polaroid or other camera with close-up attachments and scan the resulting photograph. While this will not provide the same quality as a good video image, it eliminates the need for a video camera and frame grabber and would be a reasonable substitute for many applications.

This component configuration would allow a practitioner to create a multimedia patient chart that would include intraoral and exterior images; copies of handwritten paper-based patient records, charts, and diagrams; and virtually any other type of relevant patient data. New software that can compile all of this information into a single electronic patient chart, encrypt the chart for security, and transfer the chart via the Internet is now being introduced for teledentistry. This software streamlines and simplifies the process of gathering and securing data, as well as communicating it via the Internet.

While the issue of Internet security of health records makes good headlines, in reality a well-encrypted patient chart sent via the Internet is far more secure than an ordinary fax left sitting in the in-basket at the front office. While the media has warned of the ease of breaking encrypted files, they often fail to mention that the file broken was usually nothing more than a string of 16 numbers such as a credit card account secured with minimal encryption. This is a much simpler task than decoding a 120,000-bit image. Using a 128-bit proprietary encryption routine, a single file that contains an image of a tooth would be virtually impossible to decode.

The benefit of teledentistry, in fact in all of telehealth, lies in linking patients with care providers. The scenario of a rural practitioner coordinating the care of a patient with a subspecialist at a major teaching facility is one of the most likely uses for teledentistry. Here, a general practitioner could continue to manage a patient’s treatment while giving the patient access to specialized expertise in difficult or unusual cases. Beyond this, teledentistry will allow practitioners to link up into virtual dental health clinics. In a time of increasing consolidation and payment capitation throughout all of health care, this could create an entire new dynamic within dentistry. Imagine the impact of multiple providers creating virtual care groups to coordinate not only care, but also contracts for the delivery of services.

In the future, multiple care providers will coordinate the care of a single patient electronically, sharing a complete multimedia chart and all of the documentation therein. For instance, a reconstructive specialist in Encino might share a record with a orofacial pain specialist in Los Angeles. A dental lab in Long Beach could be linked with dentists in the surrounding area, reducing time and expenses. A university teaching center in Southern California could increase services in community outreach programs and clinics in Third World countries, helping local practitioners and technicians improve the level of care they deliver. Third-party reimbursement might also be expedited, not by electronic claims filing, but by providing secondary documentation, such as radiographs, electronically as well. This would reduce the cost of film duplication and potentially streamline the reimbursement process.

In conclusion, telehealth and teledentistry are on the verge of exciting new growth and opportunity. Care providers will soon be able to take advantage of remote resources and define new business models and patient care synergies. Alliances to provide teledentistry services are already beginning to take shape. Technologies will continue to provide practitioners benefits and savings. But above all else, it is the patient that will benefit the most from better care, more accessible care, and more affordable care.

Author

Jeffrey M. Birnbach is the executive vice president of FDV Millennium, LLC, a private investment company with interests in the development of software for telemedicine and related applications. FDV Millennium has a business relationship with CyberMDx Inc., a firm mentioned in this article.

To request a printed copy of this article, please contact: Jeffrey M. Birnbach, FDV Millennium, LLC, 523 S. Palm Ave., Villa One, Sarasota, FL 34236.