Teledentistry and
its use in dental
education
JUNG-WEI CHEN, D.D.S., M.S.; MARTIN H. HOB-DELL, B.D.S., M.A., Ph.D.; KIM DUNN, M.D., Ph.D.; KATHY A. JOHNSON, Ph.D.; JIAJIE ZHANG, Ph.D.
W
ithin the past decade, significantchanges have occurred in information technology and telecommunication technology in health care fields that have had a positive impact on practice style. This new technology makes access to health care easier and faster. New terms like “telemedicine,” “tele-dentistry” and “telepharmacy” have caught the public’s
attention. Although many disciplines exist within the health care field, they all share an important common denomi-nator: the use of telecommunication technology as an important role in health care practice. In the same way, teledentistry provides new opportuni-ties for education and delivery of care that offer much potential and chal-lenges. In this article we review the development of teledentistry, its use in dental education, its limitations and its future role.
DEFINITION OF TELEDENTISTRY
Teledentistry’s roots lie in telemedicine. Telemedicine has been practiced since the late 1950s,1and a substan-tial amount of money has been spent on research and demonstrations. However, telemedicine still has no uni-versally accepted, all-inclusive definition. One of the best definitions of telemedicine is that expressed by the Association of American Medical Colleges, or AAMC: “Telemedicine is the use of telecommunications tech-nology to send data, graphics, audio, and video images between participants who are physically separated (i.e., at a distance from one another) for the purpose of clin-ical care.”2 This definition is more inclusive than many
Background.Teledentistry is a rela-tively new field that combines telecommu-nication technology and dental care. Most dentists and dental educators are unaware that teledentistry can be used not only for increased access to dental care, but also for advanced dental education.
Type of Studies Reviewed.The authors describe teledentistry as it is applied worldwide, as well as its uses in education. Teledentistry in education can be divided into two main categories: self-instruction and interactive videoconfer-encing. Both of these methods have been used in several studies and countries.
Results.The type of network connectivity used greatly affects the feasibility of tele-dentistry education. Furthermore, no optimal type exists, but health care profes-sionals should choose the mode based on budget, geography and technical support available. Of the two main categories of teledentistry in education, the interactive videoconferencing method has had better results because of its ability to provide immediate feedback.
Clinical Implications.Teledentistry can extend care to underserved patient pop-ulations, such as those in rural areas, at a reasonable cost. Teledentistry provides an opportunity to supplement traditional teaching methods in dental education, and will provide new opportunities for dental students and dentists.
and provides an overview of the breadth and depth of existing practice. We can amend this definition slightly to include oral health care and education.
The initial concept of teledentistry developed as part of the blueprint for dental informatics (a new domain com-bining computer and information sci-ence, engineering and technology in all areas of oral health3(pp3-17)), which was drafted at a 1989 conference funded by the Westinghouse Electronics Systems Group in Baltimore.3(pp53-64)Three groups of workshop participants addressed Teledentistry provides an opportunity to supplement traditional teaching methods in dental education.
issues relating to dental informatics and telecom-munications used in dentistry. Only the first of these is relevant to teledentistry, and its focus was a discussion of how to apply dental infor-matics in dental practice to directly affect the delivery of oral health care.
The term “teledentistry” was used in 1997, when Cook defined it as “… the practice of using video-conferencing technologies to diagnose and provide advice about treatment over a distance.”4 The state of California considers telemedicine to be “the practice of health care delivery, diagnosis, consultation, treatment and education using interactive audio, video, or data communica-tions.”5The federal government, in its 1997 Telemedicine Report to Congress, defined it as “the use of electronic communication and infor-mation technologies to provide or support clinical care at a distance.”6
HISTORY OF TELEDENTISTRY
The Internet and broadband high-speed connections.Teledentistry often has been nar-rowly defined as only the videoconference mode of dental care. As discussed above, however, tele-dentistry is not confined to that narrow scope. It also includes data exchange through telephone lines and fax machines, as well as exchange of computer-based documents. When this broader definition is included, we find that teledentistry has a long history.7,8Changes within the past decade in the speed and method of data transfer have prompted clinicians and information tech-nology experts to re-evaluate teledentistry as a highly valuable health care tool. The corner-stones of modern teledentistry are the deploy-ment of the Internet and broadband high-speed connections, which have helped teledentistry enter a new era.
U.S. Army Project.The U.S. Army’s Total Dental Access Project is seen as being at the fron-tier of teledentistry.9 Begun in 1994, this project initially used a traditional plain old telephone system, or POTS, with two different communica-tion methods: real-time and store-and-forward.9 The real-time method transfers the information immediately, whereas the store-and-forward method allows data to be stored in a local database to be forwarded as needed. POTS goes through the telephone company with low-speed and unreliable connections. Higher volumes of phone use worsen this situation. As a result, video and audio signals can be severely delayed,
and quality sometimes is sacrificed to increase the speed.
Nevertheless, patients have remarked that they received better care than that received from the traditional referral process when this system was available.9POTS still is used frequently in teledentistry because of its low maintenance and technical support costs. In 1995, Rocca and col-legues9conducted a pilot study in Haiti to connect a general dentist to a dental specialist in Wash-ington, D.C., via a low-bit-rate satellite system. The results showed that the video quality of the teleconsultation (consisting of intraoral photo-graphs and dental radiophoto-graphs) was insufficient for accurately diagnosing most pathological conditions.9
Integrated Services Digital Network.Two years later, Integrated Services Digital Network, or ISDN–based teledentistry was tested in Ger-many, Belgium and Italy.10ISDN provides a higher speed, and information can travel in both directions simultaneously, which increases acces-sibility to and reliability in teledentistry. Because setting up an ISDN network is very expensive (a major determinant of cost is distance in feet), it is not the ideal infrastructure for the U.S. Army’s dental practice. Army dental practice must be positioned worldwide, and in the event of an emergency, the support of specialists may be needed. Building an international ISDN network is too expensive and impractical. Even though the network speed of ISDN is very good and the system provides good-quality images, it is more suitable to city or suburban clinics, such as those in Germany, Belgium and Italy.10
Studies also have been conducted in Scotland, Japan, England and Taiwan to examine ISDN-based teledentistry.11-14The next generation of teledentistry practice uses a combination of the World Wide Web for videoconferencing and POTS for sending patient records. The Web is popular and available in most cities. Web-based teleden-tistry, unlike the ISDN, does not require a special network and, hence, is more cost-effective. How-ever, the Web-based network poses privacy and security concerns because of hackers (that is, people who are proficient with computers but do no malicious damage) and crackers (people who use various tools and techniques to gain illegal access to computer platforms and networks). (An ISDN network, on the other hand, is connected from one point to another with no network sharing.) Studies conducted in Australia15and at
the University of California, Los Angeles16 men-tioned that privacy was one of the major concerns for Web-based teledentistry.
TELEDENTISTRY IN DENTAL EDUCATION
Web-based self-instruction.Formal online edu-cation can be divided into two main categories: Web-based self-instruction and interactive video-conferencing. The Web-based self-instruction edu-cational system contains information that has been developed and stored before the user accesses the program.17The advantage of Web-based self-instruction is that the user can control the pace of learning and can review the material as many times as he or she wishes. Johnson and Schleyer18studied Web-based dental continuing education, or CE, courses and evaluated them on the basis of a set of well-designed guidelines using the Design of Educational Software (developed by the American National Standards Institute Standards Committee for Dental Informatics).
Disadvantages of Web-based self-instruction also have been noted in areas of satisfaction and accuracy. In 2001, Spallek and colleagues19 con-ducted a survey of participants in several Web-based dental CE courses (38.8 percent response rate). The researchers found that the lack of face-to-face communication with peers and instructors was one of the main reasons for dissatisfaction. A study of electronic mail–based oral medicine con-sultations16found that face-to-face patient exami-nations are more accurate in establishing a cor-rect diagnosis for oral mucosal pathoses than are transmitted descriptive patient data alone.
Interactive videoconferencing.Interactive videoconferencing (conducted via POTS, satellite, ISDN, Internet or Intranet) includes both a live interactive videoconference (with at least one camera set up where the patient’s information is transmitted; however, cameras at both locations are ideal) and supportive information (such as patient’s medical history, radiographs) that can be sent before or at the same time (for example, via fax) as the videoconference (with or without the patient present). The advantage of this educa-tional style is that the user (typically the patient’s health care provider) can receive immediate feedback.
Positive feedback.According to a 1999 U.S. Army study, teledentistry can be a very good tool for teaching postgraduate students and even for providing continuing education for
den-tists. Although a complete evaluation of interac-tive videoconferencing has not been performed, studies have shown positive reactions from both the educator and student.20In interactive video-conferencing, patient information is evaluated first (with or without the patient present), which allows for interaction and feedback between the educator and students. Patient cases can be reviewed thoroughly and at the students’ pace.
Cook and colleagues13studied a pilot teleden-tistry system (videoconferencing) for offering orthodontic advice and found very good results. They received positive feedback from the partic-ipating general dentists, patients and patients’ parents. The authors stated, “From a clinical service standpoint, videoconferencing has not been an essential part of the system. However, it has played a significant role in training and maintaining the enthusiasm of participants, in addition to providing valuable feedback.”21The general dentists participating in the pilot study stated that teledentistry taught them when to refer a patient and how to treat more compli-cated cases, which changed their practice style and gave them more choices in treating
patients.
In Japan, the staff of the Rural Health Center in Hokkaido12participated in videoconferencing for more than one year (1998 to 1999). The study’s results showed that teledentistry signifi-cantly elevated health care knowledge and computer skills.
The U.S. Army has been using teledentistry in its postgraduate dental residency programs for several years.20In its experience, orthodontics and periodontics are especially well-suited to tele-dentistry because much of the hands-on care can be rendered by dental assistants and hygienists. Dental radiology and imaging is another specialty area that is well-suited to teledentistry in educa-tion.22In all of these specialties, the cases can be discussed after all the clinical data have been col-lected and transmitted, without the patient being present at the scheduled meeting. According to our literature review, interactive videoconfer-encing is more effective than Web-based self-instruction because of the ability to generate immediate feedback, which enhances students’ enthusiasm for learning.11-13,16,19-23
Dental chat rooms.In addition, teledentistry is used widely and less formally at the grass-roots level. Dental chat rooms are available through
numerous dental organizations and study clubs, as well as through individual practitioners who exchange information on a variety of topics.
HOW TO USE TELEDENTISTRY IN DENTAL EDUCATION
Although teledentistry looks promising within the realm of dental education, users need to under-stand its limitations and certain critical factors. Legal issues exist, including licensure, malprac-tice, privacy, security and ethics. Educational technique issues relate to protocol design, sus-tainability, standards, uniform charting, use of diagnostic codes and selection of instructors.
Potential problems.Just as every state has its own licensing and dental requirements for the practice of dentistry, telemedicine and teleden-tistry licensure requirements also vary from state to state.24One of the advantages of teledentistry is its ability to increase access to dental care, but users must be careful when providing consulta-tions across state lines. If technical problems occur during data transmission that cause a mis-diagnosis or medical error, issues of responsibility and malpractice need to be considered. In addi-tion, privacy and security are important issues in cyberspace.24,25If patient data are lost or stolen during the process of transmission, the entire pro-ject may need to be discontinued, especially once the Health Insurance Portability and Account-ability Act becomes law.26
Maintaining teledentistry courses.In additon to the need for speed and cost-effective-ness, sufficient efforts are required to maintain and sustain a course. The educational team must continually update the course material and schedule consultations between the consultant and the patient.27A clear, nationwide teleden-tistry protocol is needed (covering, for example,
forms, equip-ment recom-mendations, pri-vacy and security require-ments), which would enable organizers to control the prob-lems caused by different stand-ards and result in a more objective program evaluation.
A standardized recording system would make the data-collecting process much easier and decrease the learning curve.28Diagnostic codes pose another problem. Because no universal dental diagnostic coding system exists that would enable users to maintain uniform records (the Code on Dental Procedures and Nomenclature, as printed in the Current Dental Terminology 4 manual, is for clinical procedures only), confu-sion over various systems might ensue.
Need for experienced instructors.In addi-tion, more is required of instructors for teleden-tistry education courses because they need to have both teaching experience and computer knowledge.19Educational courses should be guided by instructors who are experienced in leading online communication, able to promote discussion and familiar with the use of computer technology. Because of the diverse nature of CE courses, participants’ ages and computer skills can be varied. Instructors should recognize this problem and have the ability to assist most participants.
Furthermore, before any teledentistry video-conference begins, it is necessary to test all of the connections.7,13A backup communication system and technical support group (for example, made up of network technicians, computer hardware and software technicians and security experts) also are needed. Reimbursement for CE courses is another issue that needs to be addressed. Cur-rently, no insurance company has a particular reimbursement scheme for teledentistry. Without reimbursement from insurance companies, the financial support for these projects is limited to grants and other limited resources.19Sustaining such high-maintenance projects after the grant period ends can be a serious problem. Finally, most of the teledentistry-based education pro-grams are in English. Since the Internet is a
Dr. Chen is a clinical assistant professor, Department of Pediatric Dentistry, University of Texas–Houston Health Science Center, Dental Branch, 6516 MD Anderson Blvd., Room 357, Houston, Texas 77030, e-mail “chen27@hotmail. com”. Address reprint requests to Dr. Chen.
Dr. Hobdell is a pro-fessor and chair, Dental Public Health and Hygiene, University of Texas–Houston Health Science Center, Dental Branch.
Dr. Dunn is an assistant professor, Health Infor-matics, School of Health Information Science, University of Texas–Houston Health Science Center.
Dr. Johnson is an assist-ant professor, Health Informatics, School of Health Information Science, University of Texas–Houston Health Science Center. Dr. Zhang is an asso-ciate professor, Health Informatics, School of Health Information Sci-ence, University of Texas–Houston Health Science Center.
worldwide tool, future goals should include con-sideration of more multilingual programs. SUMMARY
We have reviewed the definitions, history and use of teledentistry in clinical oral health care and education. In rural areas, where there is a shortage of specialists, the lack of comprehensive and sophisticated health care is a problem.29 Pri-mary health care professionals in rural areas must treat a large number of low-income patients, while earning less money than they otherwise would.30Teledentistry can extend care to addi-tional patient populations at a reasonable cost, as well as ease the problem of a shortage of special-ized dental consultants and professional isolation in rural areas. Choosing the right type of network connection depends on the characteristics of the practice (for example, budget, geography, mainte-nance requirements and available technical support).
Teledentistry clearly can be a valuable tool for long-distance CE programs. The interactive video-conferencing system is more effective than the Web-based system because of its ability to provide immediate and adequate feedback. Teledentistry in dental education can provide primary care pro-fessionals with easy access to efficient consulta-tion and case-based CE opportunities.
Some barriers still exist for teledentistry prac-tice, including legal, educational and insurance issues. Most important, an experienced instructor is required for designing protocols, instructing students and providing necessary technical sup-port. A well-designed teledentistry practice needs to consider all of these issues. With thorough planning, however, teledentistry has a bright future.
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