Teledentistry in Georgia
can Increase Access to Care
Dental hygienists in Georgia working in safety-net settings defined under HB 154 and in rural areas of the state can increase access to care for underserved Georgian's and enhance the Georgia Dental Association’s Action for Dental Health objective of promoting quality attainable dental care for the uninsured and underserved and mitigate potential barriers to a dental home.
According to the Journal of the American Telemedicine Association, teledentistry is defined as the remote provision of dental care, advice, or treatment through the medium of information technology, rather than through direct personal contact with any patient(s) involved. (1)
In November 2015, the American Dental Association (ADA) adopted a comprehensive policy statement on teledentistry and defined it as “a combination of telecommunications and dentistry involving the exchange of clinical information and images over remote distances for dental consultation and treatment planning”. The policy also addresses the methodology by which these services may be delivered. (2)
Telemedicine has been practiced in Georgia for the past 20 years and has become one of the most widely accepted solutions for increasing access to care across the state. (3) The Southeast District Health Department (SEHD) began providing telemedicine services in 1993 and in 2009, a school-based pilot teledentistry clinic was established to provide services to children who may not otherwise receive dental care. (3)
The Augusta University (AU) School of Dentistry has supported SEHD since the inception of the pilot program. Board-certified pediatric dentists from the school oversee the work of several dental hygienists using state-of-the-art interactive video consultation. (4)
Dental hygienists working in the pilot program have provided prophylaxis, application of fluoride, radiographs, and dental education to thousands of children.(4) Outcomes from the program indicate that many rural areas in Georgia could benefit from teledentistry. However, state law only allows public health dental hygienists to practice teledental services under the remote supervision of a dentist. (4)
Currently, 19 states have passed some policy related to teledentistry. The information may be shared through dentist to dentist, dentist to dental hygienist and dentist to physician interactions. Some sites where teledentistry may originate include dental offices, physician offices, school-based programs, community settings and nursing facilities. (5)
A few states have designed teledentistry-specific legislation around existing programs, such as California’s Virtual Dental Home (VDH). (6) This model of care provides preventive and simple therapeutic services to underserved populations such as children in Head Start Centers and elementary schools to disabled adults in residential care settings or nursing homes. The VDH links practitioners in the community with dentists at remote office sites.
The model relies on community-based practice of specially trained dental hygienists and assistants who collect dental records and provide preventive care. Information is sent through a
secure telehealth system to a dentist at a clinic or dental office who establishes a diagnosis and creates a dental treatment plan. (6)
In addition to preventive procedures, the hygienist or assistant, if directed to do so by the dentist, may provide a type of small protective filling called an "interim therapeutic restoration" (ITR), that stabilizes the tooth until the dentist determines what further treatment is required. Patients who require more complex treatment that only a dentist can provide are referred and receive assistance securing a dental appointment. (6)
Services provided in the VDH community locations include:
Health promotion and prevention education
Dental disease risk assessment
Preventive procedures such as application of fluoride varnish, dental sealants and for dental hygienists, dental prophylaxis and periodontal scaling
Placing carious teeth in a holding pattern using interim therapeutic restorations (ITR) to stabilize patients until they can be seen by a dentist for definitive care.
Tracking and supporting the individual's need for and compliance with recommendations for additional and follow-up dental services.
The six-year demonstration project for the VDH by the Pacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry (Pacific), indicated that approximately two-thirds of the patients seen in a VDH were able to receive the care they needed at the community site. This is care they most likely would not have received otherwise or would have had great difficulty getting. (6)
Preventable dental diseases are a major health concern affecting almost every person in Georgia… particularly the uninsured and underserved. The main objective of the Georgia Dental Association’s (GDA) Action for Dental Health is to promote quality attainable dental care for the uninsured and underserved and mitigate potential barriers to a dental home. (7)
The 2017 final report of Georgia’s Health Care Reform Task Force (January 2018), declared the state needs new models of health care delivery, which are more flexible, less capital-intensive, and take advantage of new technologies to deliver care in a timely and efficient manner. (8) The expansion of teledentistry provides one solution toward achieving that goal.
The ADA resolution on teledentistry suggests that this model of delivery of care can expand the traditional dental practice to provide patients a virtual dental home instead of a physical one and provide easier access to dental care for nursing home residents or those who live in rural areas without a dentist. (2)
According to the ADA Policy on Teledentistry, Teledentistry may take several forms;
Synchronous teledentistry. This is where delivery of patient care and education is live, two-way interaction between a person or persons (e.g., patient; dental, medical or health caregiver) at one physical location, and an overseeing supervising or consulting dentist or dental provider at another location. The communication is real-time and continuous between all participants who are working together as a group. Use of audiovisual telecommunications technology means that all involved persons are able to see what is happening and talk about it in a natural manner.
Asynchronous teledentistry is different from synchronous teledentistry, in that there is no real-time, live, continuous interaction with anyone who is not at the same physical location as the patient. This is also known as “store-and-forward”. Asynchronous teledentistry involves transmission of recorded health information (e.g., radiographs, photographs, video, digital impressions and photomicrographs of patients) through a secure electronic communications system to another practitioner for use at a later time.
Remote patient monitoring is where personal health and medical information is collected from an individual in one location and then transmitted electronically to a provider in a different location for use in care. This could be used in a nursing home setting or in an educational program.
Mobile health involves health care and public health practice and education supported by mobile communication devices such as cell phones, tablet computers or personal digital assistants (PDA). This could include apps that monitor patient brushing or other home care. (9)
In 2018 the CDT Code Maintenance Committee added teledentistry codes to the code-set for the first time. The two full CDT Code entries are:
D9995 teledentistry – synchronous; real-time encounter
Reported in addition to other procedures (e.g., diagnostic) delivered to the patient
on the date of service.
D9996 teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review
Reported in addition to other procedures (e.g., diagnostic) delivered to the patient
on the date of service. (9)
Although advances in technology, communication and data management have resulted in new approaches to delivery of oral health care services, these new practice forms require oversight and regulation.
Teledentistry guidelines may include general principles that are technologically neutral rather than focusing on the use of any specific current technologies (10) or may be specific to existing statutes governing the practice of dentistry and dental hygiene within the state.
As with most policies governing the practice of dentistry, teledentistry may include definitions for the technology used, providers, the patient-dentist relationship and define guidelines for appropriate use. (10)
Some guidelines for use may include:
Standard of Care
Allowable Treatment Parameters
An example of this may be found at the WA State Department of Health on Appropriate Use of Teledentistry. (10) https://www.doh.wa.gov/Portals/1/Documents/2300/2017/Teledentistry.pdf
Adjunct Dental Technology and Teledentistry:
Almost every modern dental office can support some form of teledentistry. Most dental offices provide computerized patient registry, electronic invoicing, digital radiography, intraoral cameras and digital cameras.
With the passage of HB 154, authorizing licensed Georgia dentists to supervise dental hygienists under general supervision in safety-net settings, the combination of teledentistry and adjunctive dental technology supports the cornerstone of GDA’s Action for Dental Health by enhancing dental prevention, early diagnosis and treatment and referral of patients requiring more therapy.
According to the American Cancer Society (ACS) more than half of all oral cancer patients are 65 years of age and older. However, tobacco use, second hand smoke, frequent and heavy consumption of alcohol, infection with the HPV virus, gender, poor oral hygiene and poor diet and nutrition are also risk factors for oropharyngeal cancer. (11)
“The Burden of Oral Health in Georgia” (12) report states that although Georgia has made great strides in achieving some of the Healthy People 2010 (HP2010) objectives, we still lag behind in preventing and treating childhood caries and providing early detection of oral and pharyngeal cancers.
Although dental hygienists providing services in nursing homes, long-term care facilities and other safety-net settings under HB 154 may provide a thorough head and neck examination and evaluate oral mucosa by means of visual inspection and palpation, pathologies typically are only observed once a lesion has advanced from its earliest stage.
Noninvasive, adjunctive screening devices using fluorescence technology allow clinicians to identify abnormal lesions at an earlier stage. One such device is OralID (Forward Science).
Oral ID uses visible blue laser light at 435–460 nm that is shined directly into the oral cavity. When the blue light shines on healthy oral tissue, it fluoresces green, but when it shines on abnormal tissue it appears dark, due to a lack of fluorescence. (13)
Oral ID comes with a yellow adapter for a smartphone camera, so a photo may be taken of a suspected pathology and forwarded to the supervising dentist for evaluation. Dental hygienists working under general supervision using adjunctive fluorescence technology will allow our dental teams to provide earlier interventions for possible oral and pharyngeal abnormalities.
In 2017 the ADA provided updated information on caries risk assessment and management and suggests that preventing the caries process from resulting in cavitated lesions requires careful and systematic methods for documenting and monitoring disease at early stages and intervening prior to the development of advanced lesions. (14)
Carious lesions may be detected via a visual clinical evaluation, tactile methods and adjunctive radiographs. However, although radiographs are used to detect interproximal caries, occlusal decay can only be observed radiographically after it has reached the dentinoenamel junction. (15) As a result, radiographs are not the ideal method to detect incipient carious lesions. Further, radiographs are not an authorized delegated duty for dental hygienists working in safety net settings under HB 154.
Adjunctive caries detection devices are now available that can help clinicians quantify, monitor, and record changes in the structure of enamel, dentin, and cementum. These devices include laser fluorescence, transillumination or a combination of noncontacting modulated laser luminescence and photothermal radiometry. (14)
Caries detection devices have been used to evaluate enamel structure prior to sealant placement, and some caries detection devices can also be used to check sealant margins over time. (16) Although it is the dentist who makes the dental caries diagnosis, dental hygienists can perform a thorough assessment of the individual's oral health (17) and relay information back to the supervising dentist for treatment decisions.
Dental hygiene assessment includes evaluation of hard tissue for the presence of demineralization, caries, enamel defects, and the condition of existing restorations and sealants. (17) The adjunct use of caries detection devices by dental hygienists in safety-net settings such as Title 1 Schools will aid our supervising dentists in treatment planning while determining the individual needs of the patient.
Another mode of information transmission is the use of the intraoral camera. TeleDent™ (MouthWatch) is a recent teledentistry and remote monitoring solution that can connect our supervising dentists with their hygienists working in safety-net settings defined in HB154. TeleDent offers Synchronous live streaming videoconferencing, screen sharing and intraoral camera integration. The asynchronous technology provides clinical document storage, image and file sharing and store and forward evaluations. (18)
Soprolife (Acteon Imaging, La Ciotat, France www.acteangroup.com) is another intraoral camera system is that acts as both a caries detection device and high magnification intraoral camera. It uses two types of LEDs to illuminate the tooth structure and evaluate changes in mineral density. (19) As a caries detecting device, Soprolife uses fluorescence technology to detect occlusal or interproximal decay.
Soprolife uses a color-coding system. Green fluorescence is considered an indicator of healthy tissues whereas the red fluorescence indicates a carious lesion thus allowing our supervising dentist to differentiate healthy tooth structure from infected tissue and so they may treatment plan accordingly.
With the use of Teledentistry, light and laser fluorescence, transillumination and intra oral cameras, dental hygienists working under the general supervision of their doctors in safety net settings defined under HB 154 will allow our dental teams to reinforce GDA’s Action for Dental Health objective of promoting quality attainable dental care for the uninsured and underserved and mitigate potential barriers to a dental home.
The GA Board of Dentistry has not yet addressed whether dental hygienists in GA may be practice teledental services under the remote supervision of their dentist.
Telemed J E Health. 2013 Jul;19(7):565-7. doi: 10.1089/tmj.2012.0200. Epub 2013 May 14.
Teledentistry in practice: literature review. Khan SA1, Omar H.
ADA News. House passes guidelines on teledentistry. December 07, 2015 https://www.ada.org/en/publications/ada-news/2015-archive/december/house-passes-guidelines-on-teledentist
Tara E. Schafer, DMD, MS and Bruce Riggs, DMD. Augusta University Dental College of Georgia, Department of Pediatric Dentistry J Ga Public Health Assoc (2017), Vol. 6, No. 3 Use of a teledentistry partnership program to reach a rural pediatric population. https://www.gapha.org/wp-content/uploads/2017/05/6.311-jGPHA.pdf
Georgia Dental Association’s Action for Dental Health. http://www.gadental.org/docs/librariesprovider16/default-document-library/dental-health-action-plan-final-10142015.pdf?sfvrsn=6
D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events. D9995 and D9996 ADA Guide – Version 1 – July 17, 2017 – Page 1 of 10. ©2017 American Dental Association (ADA).
WA State Department of Health Systems Quality Assurance. Appropriate Use of Teledentistry https://www.doh.wa.gov/Portals/1/Documents/2300/2017/Teledentistry.pdf
Cancer.Net Editorial Board, 09/2017 Oral and Oropharyngeal Cancer: Risk Factors and Prevention 2005-2018 American Society of Clinical Oncology (ASCO) https://www.cancer.net/cancer-types/oral-and-oropharyngeal-cancer/risk-factors-and-prevention
GA Burden of Oral Health Report_061914 NEWEST.pdf Georgia Oral Health Program. Office of MCH Epidemiology. Maternal and Child Health Section. https://dph.georgia.gov/sites/dph.georgia.gov/files/MCH/OralH/GA%20Burden%20of%20Oral%20Health%20Report_061914%20NEWEST.pdf
2018 Forward Science Oral ID. https://forwardscience.com/oralid/
2017, ADA Caries Risk Assessment and Management https://www.ada.org/en/member-center/oral-health-topics/caries-risk-assessment-and-management
Anil Govindrao Ghom Textbook of Oral Radiology - E-Book. Chapter 45, Dental Caries. Page 621
Marsh L. Advances in caries detection. Dimensions of Dental Hygiene. 2014;12(5):42-44 Karlsson L. Caries detection methods based on changes in optical properties between healthy and carious tissue. Int J Dent. 2010;2010:270729.
2015, American Dental Hygienists Association Standards of Clinical Practice. www.adha.org/resources-docs/7261_Standards_Clinical_Practice.pdf
MouthWatch, TeleDent™ https://www.mymouthwatch.com/teledentistry.php
Tassery H, Levallois B, Terrer E, et al. Use of new minimum intervention dentistry technologies in caries management. Aust Dent J. 2013;58(Suppl1):40-59.