Hi,

I think teledentistry is a great, just like telemedicine.

In my opinion, It is useful anywhere, but is particularly useful in India, Brazil and many other developing countries where the access to the health/dare care is limited and the Government is willing to fund primary care tele-dental clinics.

Although tele-dentistry is utilized in many countries, systematic studies on teledentistry come from predominantly USA. In these studies clinical outcomes were generally improved following a teledentistry intervention and satisfaction with teledentistry was consistently high. The literature is also consistent the teledentistry increases efficiency, and decreases cost. Care (Marina and Ghanim, 2013).A recent review of literature by Daniel and Kumar (2014), finds that teledentistry actually improves oral health and is a promising path forward for areas that are especially short of healthcare providers.

Lakshmanan Suresh

Selected References:

Daniel SJ, Kumar S.Teledentistry: a key component in access to care. Evid Based Dent Pract. 2014 Jun;14 Suppl:201-8. doi: 10.1016/j.jebdp.2014.02.008. Epub 2014 Mar 5.

Mariño R, Ghanim A. Teledentistry: a systematic review of the literature. J Telemed Telecare. 2013 Jun;19(4):179-83. doi: 10.1177/1357633X13479704. Epub 2013 May 23.

Hi,

I am an Oral Pathologist and I feel that Telepathology is very good and should be promoted everywhere. Now some colleges in India have started it discussing cases between Post graduate departments . This will help in sharing knowledge, and also to get help when cases are complicated. 

Thank you.

maya

Teledentistry is very valuable for patients in rural areas that don't have a dentist nearby.  Dental Hygienists (DH) and Dental Therapists (DT) under a collaborative agreement with dentists can reach these patients.  Using teledentistry, the dentist and collaborative practice DH or DT can diagnose the dental issue. If the issue can be treated within the scope of practice of the DH or DT the patient does not need to travel to the nearest dental office to be treated.  Teledentistry increases access to care.

Despite the fact that teledentristry, as well as telemedicine, represents an important tool in the helth services, we should take into consideration that the relationship between the professional and his patients should never be considered secondary. On the other hand, we have to consider the vast uses of this tecnology in Dentistry, and the rich instrument that this can be, in the hands of the patients. The exchanges of experiences among professionals around the world tend to become easier from now on, and not only this, people can be more empowered by this tecnology.    

The idea of being able to gain insight from distant sources towards diagnosis and treatment is, in my opinion, quite beneficial.  One huge advantage is the dialogue that is established in that such dialogue works towards an adult learning method which results in greater maintenance of knowledge.  When tele dentistry is used in a collegial way where there is give and take by all concerned parties this can be a tremendous way to improve treatment for patients with complicated needs.

There are many facets and phases in Healthcare services.  While the diagnosis and decision making can be accomplished with remote access evaluation, the actual performance of the treatment is highly dependent on an experienced provider since dentistry is a largely surgical discipline.  This may be great for Oral Medicine, examination and prescription of oral health preventive measures, etc, actual investigations with digital palpation, testing of lesions, etc TeleDentistry is still limited in what it can do.  Granted with better technology like CAD-CAM dentistry, we may one day be able to have an assistant facilitate much of what can be done, possibly even with something like Robotic dental surgery, there is a long way from what Tele-Medicine can do.  I still remember the days when medicine was internal medicine and surgery as 2 dichotomous approaches to health.

Dear Mary,

Great question. To keep it simple, if it is for decision making this technology could absolutely be vital in situation like where population to dentist, population to specialist, rare cases, evidence based decision making. However, the teledentistry what cannot offer is treatment which is the key element in providing care to patients unlike medicine. Please have a look at my article published last year. Hopefully this year I plan publishing another article on similar topic. Stay in touch !

http://online.liebertpub.com/doi/abs/10.1089/tmj.2012.0200?journalCode=tmj

Great answers! I loved each of your contribution! In Brazil the consultation need to be face-to-face by law. Despite of it we have experience with dental hygienists on control of periodontal patients with success!

Ssad: I will read and comment later, OK? Thank you!

The treatment decisions remain those of the treating dentist and his patient. An advising remote dentist may face liability if there is a poor outcome. While tele-dental would probably increase the quality of care there needs to be a sorting of exposure. Is there a difference between a treating dentist consulting a journal or a book versus a consulting dentist in a remote locale. 

Of course Tele Dentistry like Tele Medicine is coming up well in some parts of the world. Especially it plays an important role in Diagnosis of various oral diseases at the initial stages. for example sharing of knowledge like sharing CT scans, radiographs, MRI, Histo Pathology reports helps to diagnose any soft and hard tissue problems both in inital and terminal stages and helps to share the treatment modalities.  Histopathologically specimens can be studied and certain problems like oral cancers can be detetced at the earilier stages.  for these we should have chain of experts in the link.

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.

Definitely a new, positive direction in dentistry. Imagine being able to call in the world's leading experts to evaluate a clinical situation!

Very essential for promoting and advancing the profession of dentistry, it also opens new horizons for learning and for international collaboration among dentists. The recent advances in robotics technology is paving the path to remote teledentistry ; a virgin,  promising area which will change the future of dentistry .

Both teledentistry and remote teledentistry raise legal questions and have not been regulated yet.

Teldentistry can  be used to assist general dentists with specialty work, Rsearchgate is one of this,  and improve services to populations such as in rural or less developed areas now we looking for global conference in teledentistry.

I have been reading with considerable interest the responses that you have received regarding the question of teledentistry. They seem to fall into two groups: one that advocates its use more or less without reservations and the other one that points to its limitations.

In the first group you find those who basically depend on two-dimensional information like CT scans, radiographs, MRI, histopathology and clinical photographs for their diagnostic evaluations. However, unless the symptoms and information presented are relatively unequivocal and typical such evaluations cannot always be made with sufficient degree of reliability without also examining the patient.

In the second group the responders have focussed on the fact that teledentistry has quite limited usefulness when it comes to dental treatment – and most of the time in a dental practice is after all used in treating patients with all their diverse problems and unique characteristics. As Dr. Góes wisely states, teledentistry cannot take into account the relationship that exists between dentist and patient and, may I add, the dialogue between the two, which is essential for optimal treatment. Furthermore, optimal treatment depends, as Dr. Lee and Dr. Flanagan state, on the experience of the treating dentist.

As a prosthodontist I would like to add: how can teledentistry offer reliable advice in the absence of 3-dimensional casts mounted in an articulator together with detailed information regarding the status of the supporting tissues of a planned prosthetic reconstruction, and in compromised cases, the extent to which these tissues respond to treatment over time? Also, how can an external expert evaluate the patient’s motivation, his or her financial possibilities (or lack thereof), or if the patient has the manual dexterity to perform an adequate oral hygiene regime, which is a sine qua non for a good prognosis?

I do not mean to be altogether negative towards teledentistry. Undoubtedly it has its merits as long as both the external expert and the recipient of advice are fully aware of its limitation – where it may be of use and where it should not be depended on.

This idea  re-surfaces every few years for the last ten years .

We have tried this aproach in the past with very limited success.

Getting a really clear reproducible  picture of the colour and health of soft tissues of strategic abutment  teeth  is a big problem.

The old adage that it is history,clinical examination and only then special tests applies even more stronglywith this teledentistry  

.In other words failure to disclose what might seem to some to be obscure bits of  relevant history can be dangerous.Leaving out subtle bits of history about the patient's motivation for seeking treatment at that time and their expectations can alter decision making .

Who takes legal or ethical responsibility for these issues ?

Cooperation and patient expectations cannot be assessed  in advance for that patient and that dentist.

Sadly,What works with one patient often does not work with another with a seemingly similar problem.

Dentists vary in their  clinical skills,experience  and peopleor problem management .

Overall  my view is that extreme caution is advised  with this sort of  developing technology and ,overall,I am largely in agreement with Einer Berg's comments above  . 

Martin Kelleher

Thank you for the greta collaboration!

I think that teledentistry can answer much of the negative visions and limitations when implemented considering these aspects, but allowing research, improving education continues too, during the implementation process and encouragement for their own use.

We have a lot of issues to answer about this use:

1. responsability: in Brazil the professional that is in direct contact with the patient has the responsability for the attending, because he can ask support, but he will do the choice;

2. for the maintainance of oral hygiene, it can be done using technological tools, by patterns of results expected, which will be a guide for patients and professionals;

3. we share informations and it is an important channel of education in service, decreasing significantly the number of unknowledge situations, even for extreme cases;

...and so on.

We need to see the universe of possibilities and we have to take a look with research eyes always: there are not responses when we determine failure .... we need to continue to generate questions that bring to light new ways of safe application.

As noted above (Dr. Kelleher) this concept is not a panacea; accurate and complete diagnosis and treatment are provided by the treating clinician. However teledentistry adds a dimension to assist in patient care that when used to its full extent, it is an adjunct to and improvement of the delivery of optimum treatment. 

Dr Kelleher is correct about the past of teledentistry BUT today we have high-quality, affordable chairside video scanners(cameras) and low cost  and virtually instantaneous transmission of data throughout the world. This is the paradigm shift that is propelling teledentistry forward.

Great question.  I'd say "it depends."  In addition to dentist-OMFS interaction, there may be value in remote settings where dental emergencies may be managed by a primary care or emergency provider, or paramedic.  Dental teleconsult might be particularly helpful if imaging were also available - both to direct care as well as to determine need for evac.

Best to All,

Bob

I am thinking more of mainstream teledentistry for use in remote specialist diagnosis, real-time teaching and evaluation, and eventually, remote-control robotic treatment.

I would be very sceptical of this concept. So much in dentistry depends upon the operator to patient contact that i would find it very difficult to diagnose a problem in a remote manner with any degree of accuracy. Actual patient contact is imperative in many cases to assess both the patient and the problem. The actual level of response to tests can only be measured through patient to operator contact.

Dear Graham

We can think about diagnose support, connecting the operator with a specialist, maybe a professor. This model is working well in Brazil: the operator can send the test results and the expert can argue by asynchronous or synchronous communication.

What do you think about?

Hi Graham. While the personal touch is paramount TODAY, we know that complex, technique-sensitive REMOTE medical surgery is currently being performed. What prevents this modaliity from entering the dental realm? The dentist-patient "contact" is still present, albeit at a distance.

Certainly useful in  reasonable limits.Usually the treatment of dental patients need immediate intervention of the doctor. Teledentistry can be used for consultations between other doctors.

Greetings George. We agree that the personal touch is paramount today in dentistry and frankly i would prefer it if i were to require surgery today. MAYBE there will be sufficient progress in the future to circumnavigate this requirement but i feel strongly that it will remain difficult to obviate it in the future. There is nothing like "hands-on" for a proper diagnosis right now and i shudder to think of the implications for the future when we rely on indirect diagnosis for dental problems via "robots" or similar.

I think it is a very good option. I agree that  so much in dentistry depends upon the operator to patient contact that i would find it very difficult to diagnose a problem in a remote manner with any degree of accuracy but if the case is properly discussed by panel of dentists, better treatment can be given to patient and this will help in overall growth of dentist as well.

Rhe goal of teledentistry program must be to provide access to quality healthcare when barriers to service such as geography or distance exist. The centre aims at supplying the healthcare industry with viable and sustainable technologies that will promote global oral health , wellness and disease management by facilitating teghnological advances in the collection, processing and sharing of dental information. These will generate new products and services within teledentistry and e-health.Definitely teledentistry support decision making in dentistry

NKN (National knowledge network ) a server used by major universities in India, for educational purposes is also being used to share patient photographs along with video chat amongst specialists of two different institutions to discuss special cases and reach a consensus for diagnosis of case and treatment planning. I think it is a very innovative idea to use technology for patient care. Although actual treatment in dentistry requires a rapport between patient n doctor.

The danger in uploaded photographs is that photo parameter constancy is very dificult to assure, and photoshop is very easy to use.

I agree with you Dr George. In fact photo- editing and manipulations is another topic of interest of mine.  But there are ways and means of detecting manipulations, and attaching metadata to images would be one option. But these are more relevant in context of publication. In case two experts are discussing their cases for diagnosis and treatment planning over NKN or any other similar network, using their original photographs would be in the best of their interest.

Acceptable limits of image manipulations have been discussed in a very recent article of mine. In case it interests you:

Kapoor P. Photo- editing in orthodontics: How much is too much?. Int J Orthod 2015: 26(3);17-23.

Really nice question!

For me at least Teledentistry is a tool that in correct hands can help a lot of people !

Teledentistry today, just a few years after our original comments, can be looked at not only for educational purposes, but for remote treatment as well.

In Japan, telemedicine has been included in national health insurance from this year. So it is ongoing...now.

Teledentistry in education is fast becoming the mainstream learning environment.