Abstract
Objectives
The purpose of this study was to assess the accuracy of predicting dental treatment modalities for children seen initially by means of a live-video teledentistry consultation.
Methods
A retrospective dental record review was completed of 251 rural pediatric patients from the Finger Lakes region of New York State who had an initial teledentistry appointment with a board-certified pediatric dentist located remotely at the Eastman Institute for Oral Health in Rochester, NY. Proportions of children who were referred for specific treatment modalities and who completed treatment and proportions of children for whom the treatment recommendation was changed were calculated. Fisher’s exact test was used to assess statistical significance.
Results
The initial treatment modality was not changed for 221/251 (88%) children initially seen for a teledentistry consultation. Thirty (12%) children had the initial treatment modality changed, most frequently children who were initially suggested treatment with nitrous oxide. Based on the initial treatment modality, changes to a different treatment modality were statistically significant (Fisher’s exact test, p < 0.0001).
Conclusions
Our data suggest that the use of a live-video teledentistry consultation can be an effective way of predicting the best treatment modality for rural children with significant dental disease. A live-video teledentistry consultation can be an effective intervention to facilitate completion of complex treatment plans for children from a rural area that have extensive dental needs.
Introduction
For years, telemedicine has been used in the different medical specialties for consultations, diagnosing, and treating disease. 1 Telemedicine programs have several benefits, including increased access to care, earlier diagnosis and treatment, minimizing cost and stress of transportation, and the ability to receive specialist care. 1
Although telehealth applications in medicine have been in practice for several decades, teledentistry applications are limited and not widely used by dental practitioners. 2 While teledentistry is relatively new compared with telemedicine, its application shows the potential to be effective in improving oral health and access to care. 3 This trend is especially beneficial for rural and urban children, where teledentistry can be a cost-effective method of screening and referral for dental care for a large number of patients with dental disease.1,4 Teledentistry can also be considered in the curriculum of dental and dental hygiene education as a means of providing comprehensive care to underserved populations. 5
Many children with severe early childhood caries (S-ECC) live in rural areas that lack pediatric close-by dentistry specialists. Often, these children experience long waiting times to be seen by the pediatric dentistry specialists due to costs associated with travel, insurance barriers, or lack of dental knowledge. Teledentistry may be a simple yet effective approach to improve access to dental care for the underserved population. 6 Teledentistry has been shown to be useful as a triage for referrals. 7 Teledentistry application can also facilitate the most severe or urgent dental cases to be seen urgently or tracked using community health workers. Alternatively, teledentistry services may reduce the need for the direct specialty services if a live-video consultation serves as a platform for a visit in a specialist’s office.
At times, general dentists are not sufficiently trained in behavior management techniques compared with pediatric dentists, often necessitating a referral to a pediatric dentist. Part of the success of teledentistry appointments is to limit the travel for rural pediatric dental patients. This study aims to assess the accuracy of a live-video teleconsultation on a pediatric dentist’s ability to predict the appropriate treatment modality. Teledentistry has been used previously to triage dental referrals as an aid in scheduling. 7 However, no studies have been conducted regarding predicting dental treatment modalities based on teledentistry consultations.
Currently, the Pediatric Department of the Eastman Institute for Oral Health (EIOH) at the University of Rochester conducts teledentistry consultations of patients in rural upstate New York. The patients are first seen by a hygienist and/or a general dentist affiliated with Finger Lakes Community Health (FLCH). If the provider at FLCH determines that a pediatric patient cannot be treated on site, due to young age, behavior, and/or the severity of the dental disease, the patient is scheduled for a teledentistry examination with an attending board-certified pediatric dentist at EIOH. During the teledentistry examination, a dentist or a hygienist at the remote site uses an intraoral camera in the patient’s mouth, while the pediatric dentist at EIOH is able to examine the oral health of the patient via a computer camera and an Internet connection. The attending board-certified pediatric dentist is also able to evaluate the behavior of the patient. Additionally, this remote examination allows for real-time communication between the EIOH provider and the patient and his/her caregiver. After completion of the remote examination and evaluation of a patient, the board-certified pediatric dentist recommends a treatment modality suitable for the patient. It may include treatment in the pediatric clinic at EIOH with the use of local anesthesia, treatment in the office with administration of nitrous oxide/oxygen anxiolysis, treatment in the office using oral sedation (OS), office consultation, or treatment under general anesthesia in the operating room (OR).
The rationale for the recommended treatment modality is based on multiple factors, including the extent of restorative needs, the patient’s ability to cooperate in the outpatient setting, the health status of the patient, the number of appointments that would be needed to complete the treatment, and the distance to travel.
The purpose of this study was to evaluate the accuracy of the initial treatment modality recommendation with the actual treatment modality.
Methods
In this study, the dental records of 251 pediatric patients who participated in a live-video teledentistry pilot program established between EIOH, the University of Rochester, Rochester, NY, and FLCH were reviewed. The teledentistry program was initiated in April 2010, and it is still ongoing. During the live-video teledentistry consultation, a Tandberg 1700 HD monitor and webcam were used. All telepresenters were trained in the American Telemedicine Association (ATA) protocols.8,9 Two board-certified attending pediatric dentists made the initial treatment recommendations. Patients were seen in the EIOH pediatric dentistry clinic by first- and second-year pediatric dental residents. Details about the program are described elsewhere. 10
The clinical progress notes stored in the electronic dental record system (Axium) at EIOH of 251 patients were reviewed to determine the initial recommendation for dental treatment based on the live-video teledentistry visit and to determine the actual dental treatment provided at EIOH. The initial treatment recommendations based on a live-video teledentistry examination fell into one of five treatment modalities: treatment in the pediatric dental clinic using local anesthesia (LA), treatment using nitrous oxide anxiolysis (N2O), treatment in the pediatric dental clinic using OS, treatment in the OR with general anesthesia (GA), or tele-consultation with the EIOH provider. The initial treatment recommendation based on a live-video teledentistry examination was based upon the same guidelines used for patients seen in the pediatric dentistry clinic. Children aged six and younger with three quadrants or more of visibly evident dental decay present were recommended for GA in the OR. GA was the treatment modality of choice for patients with a reported history of obstructive sleep apnea (OSA), developmental disabilities, or complex medical histories that ruled out the use of OS in an outpatient setting. OS in the pediatric dentistry clinic utilizes midazolam at 0.5 mg/kg, along with medical immobilization protective stabilization (MIPS). N2O was employed for anxiolysis. The initial recommended treatment modality was noted in the electronic record and was available to the pediatric dental resident who attended to the patient as she/he presented to the pediatric dentistry clinic for dental treatment. There are 14 pediatric dentistry residents in the pediatric dentistry clinic. They are supervised at all times by attending pediatric dentists, who are faculty members at EIOH. All patients initially seen for a live-video teleconsultation were seen by one of the two board-certified pediatric dentists. All patients seen for initial teledentistry consultation were offered an appointment at the EIOH pediatric dentistry clinic within four weeks, where the treatment was completed by a first- or second-year pediatric dentistry resident supervised by a pediatric dentistry faculty member, or an OR date was given within eight weeks of their initial teledentistry consultation, where the treatment was completed by a pediatric dentistry faculty member or a second-year pediatric dentistry resident under the direct supervision of a pediatric dentistry faculty member. The record of each patient participating in the teledentistry examination was further reviewed to determine the actual treatment provided. The possible options included the five treatment modalities mentioned above, with another option of no treatment provided when the patient did not present for a scheduled appointment. If there was a difference between the initial recommendation for dental treatment and the actual dental treatment provided, it was noted, and the reason for the difference was determined.
Descriptive statistics included the age and sex of the children. The children’s race/ethnicity was not collected. The proportions of the children who were referred for specific treatment modalities and who completed the recommended treatment, and the proportions of the children for whom the treatment recommendation was changed were calculated. Fisher’s exact test was used to assess statistical significance, with a p-value of <0.05. All analyses were performed using SAS v9.2.
Results
Dental records of 251 children were reviewed for this study. There were 122 (49%) girls and 128 (51%) boys; the sex for one child was missing. The race/ethnicity of the patients was not recorded. For the secondary analyses of the data, children in the study were divided into two age categories: category I included children aged six or younger; category II included children who were older than six years of age. There were 207 (82.5%) children in category I, and 44 (17.5%) children in category II. The median age of the children enrolled in the study was four, and the mean was 4.77 years, with a standard deviation of 2.36 years. The rationale for the age division was based on the treatment modalities that could be offered to the children based on their age.
Initial treatment recommendation versus actual treatment for 251 children.
OR: operating room; N2O: nitrous oxide anxiolysis; LA: local anesthesia.
Distribution of changes to the initial treatment recommendation versus the actual treatment recommendation when presenting to the clinic at EIOH.
Based on Fisher’s exact test, these changes were significantly different based on the treatment modality (p < 0.0001).
Children who were initially recommended a clinic visit, consultation, or treatment in the OR were not switched to a different treatment modality. Twenty-four children who were initially recommended for treatment with nitrous oxide and six children who were recommended for treatment with OS were switched to a different treatment modality. As shown in Table 1, most of the children who were recommended a different treatment modality from that initially prescribed were switched to OR treatment with GA as a result of the possible clinical scenarios: the behavior of the child was not manageable (he/she could not tolerate the proposed treatment) and/or new information was obtained (a clinical and radiographic exam revealed additional areas of dental caries).
Of 251 children who participated in the study and were recommended a specific dental treatment modality based on the initial teledentistry examination, 192 (76.5%) completed all treatment plans. The reasons for not initiating or not completing the recommended treatment plan for the remaining 59 (23.5%) children were: the children were still in treatment, there were insurance problems, the children did not present for the scheduled appointment, or the follow-up appointment was not scheduled.
Changes in treatment recommendations for children who completed all treatment (n = 192).
Distribution of changes to the initial treatment recommendation versus the actual treatment recommendation when presenting to the clinic at EIOH for children who completed all recommended treatment (n = 192).
Based on Fisher’s-exact test, these changes were significantly different based on the treatment modality (p < 0.0001).
Initial treatment recommendations based on children aged six and younger (n = 207) and children older than six (n = 44).
Distribution of changes to the initial treatment recommendation versus the actual treatment recommendation when presenting to the clinic at EIOH for children in the younger age category who completed the recommended treatment.
Based on Fisher’s-exact test, these changes were significantly different based on the treatment modality (p < 0.0001).
Distribution of changes to the initial treatment recommendation versus the actual treatment recommendation when presenting to the clinic at EIOH for children in the older age category who completed the recommended treatment.
Based on Fisher’s-exact test, these changes were not significantly different based on the treatment modality (p > 0.05).
Discussion
Several significant observations were made in this study. Our data suggest that the live-video teledentistry consultations were quite accurate when recommending dental treatment modalities for the pediatric patients who were treated at EIOH. As presented in the Results section, overall treatment modalities were not changed for 88% of the children; treatment modalities were not changed for 86.5% of the children who completed all recommended dental treatment. The majority of the children enrolled in our study were younger than six years of age (82%). Based on the age category, the recommended treatment was not changed for 86% of the children in age category I and for 98% of the children in age category II.
Based on our findings, live-video teledentistry consultations were relatively precise when proposing dental treatment modalities for rural children with a variety of dental needs. For those children who had extensive dental needs and were of a young age, a live-video teledentistry consultation served as an excellent platform to facilitate the completion of the needed treatment. The completion rate of the treatment in the OR under GA was 93%. The lowest completion rate was for the nitrous oxide visits (56%). However, an additional 19 children in this treatment modality arm completed some portion of their recommended treatment. 10
In a few cases, the treatment modalities were changed. Most likely, they were changed not because the initial teledentistry consultation recommendation was inaccurate but rather because new information was obtained, such as a radiographic survey or experiencing an uncooperative child’s behavior during more invasive treatment. One would expect similar changes in treatment modality based on a teledentistry consultation and a dental office consultation. As our results suggest, only a small proportion of the children were switched to a different treatment modality after the initial teledentistry consultation. In our experience, it was mainly due to the extent of the intraoral disease, mainly dental caries that was not evident during the initial teledentistry consultation. For example, as the child presented to the pediatric dentistry clinic, additional radiographs were taken. Based on the clinical and radiographic examination, the severity and extent of dental caries was such that the child qualified for a treatment in the OR under GA. Usually, that involved a child who was younger than six years of age and had three or more quadrants of dental caries present.
Another possible reason for the change of the initial treatment modality could be the circumstances where the patient was initially evaluated by an attending board-certified pediatric dentist and treated by a pediatric dentistry resident, possibly with less clinical experience than the attending pediatric dentists. Nevertheless, the residents are always supervised by the attending pediatric dentists while they work in the clinic. At times, an attending pediatric dentists may be working with another resident and may be unable to intercept another appointment in which the patient’s behavior is deteriorating.
We would like to note the study limitations. It was a retrospective dental record review, and possibly there were some missing data present in the patients’ electronic records. Also, to date, we have evaluated 251 records of teledentistry consultations. The teledentistry consultations are still ongoing, and as we collect more data, the conclusions may change.
While increased access to care is important, increased access to appropriate care is more important. This study shows that teledentistry consultations can be an effective intervention to facilitate an appropriate treatment modality that will hopefully decrease the time lost for inappropriate referrals. Based on our observations during the study, providing remote teledentistry consultations facilitated high treatment completion rates, increased access to specialty dental care, decreased treatment time and cost, and most importantly improved oral health of underserved pediatric dental patients. Further research may be considered to obtain data on the increased use of teledentistry in rural pediatric and adult population and to assess if there is an improvement in the oral health of this population.
Footnotes
Acknowledgements
We would like to thank the staff at Finger Lakes Community Health, especially Ms Mary Zelazny, Ms Terry Yonker, and Dr Tony Mendicino, for their dedication, enthusiasm, and hard work to improve the dental health of rural children from the Finger Lakes region of Western New York State.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this study was partially funded by a grant from the USDA Distance and Telehealth grant.