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1. Dental Health Care Services Discussion
Dental Health Care Services DiscussionORDER HERE FOR ORIGINAL, PLAGIARISM-FREE
PAPERS ON Dental Health Care Services DiscussionWHAT ARE THE BENEFITS OF DIRECT
ACCESS PROVIDERS?WHICH STATE DO YOU THINK HAS THE BEST DIRECT ACCESS AND
WHY?WHAT ARE YOUR THOUGHTS ON TELEDENTISTRY EXPANDING CARE? IS THIS A
GOOD THING OR A BAD THING?IS TELEDENTISTRY USEFUL TO HYGIENISTS? WHY OR
WHY NOT?https://www.adha.org/direct-accesshttps://www.adha.org/resources-
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Discussionattachment_1attachment_2attachment_3Unformatted Attachment
PreviewTELEDENTISTRY: A KEY COMPONENT IN ACCESS TO CARE Susan J. Daniel, RDH,
PhD,a and Sajeesh Kumar, PhDb ABSTRACT SORT SCORE A B C NA SORT, Strength of
Recommendation Taxonomy. LEVEL OF EVIDENCE 1 2 3 See page A8 for complete details
regarding SORT and LEVEL OF EVIDENCE grading system Teledentistry has the potential to
address the oral care needs of those who have limited access to care. More research is
needed to establish the evidence base to support teledentistry practice. Background and
Purpose Enormous potential exists to improve oral health services throughout the world by
using information and communication technologies, such as teledentistry to expand access
to primary, secondary and tertiary care. Comparison of teledentistry procedures with
standard clinical procedures can demonstrate the relative effectiveness and cost of each
approach. However, due to insufficient evidence, it is unclear how these strategies compare
for improving and maintaining oral health, quality of life, and reducing health care costs.
This review discusses the merits of teledentistry for the delivery of oral care. Methods This
article summarizes the available literature related to the efficacy and effectiveness of
teledentistry and presents possible barriers to its broader adoption. Conclusions
Teledentistry seems to be a promising path for providing oral health services where there is
a shortage of oral health care providers. a Gene W. Hirschfeld School of Dental Hygiene,
College of Health Sciences, Old Dominion University, Norfolk, VA, USA. b Department of
Health Informatics & Information Management, College of Allied Health, University of
Tennessee Health Science Center, Memphis, TN, USA Corresponding author. E-mail:
sjdaniel@odu. edu J Evid Base Dent Pract 2014;14S: [201-208] 1532-3382/$36.00 ª 2014
Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jebdp.2014.02.008 Key words:
teledentistry, telehealth, health information technology, dental telecommunication, access
to care INTRODUCTION T eledentistry is the use of health information technology and
telecommunications for oral care, consultation, education, and public awareness with the

2. broad goal of improving oral health. As with many branches of telemedicine, teledentistry
applications have been steadily increasing. Future applications of teledentistry have the
possibility of increasing utilization of oral care services, decreasing financial and human
costs and improving health outcomes. TELEHEALTH DEFINED Telehealth is the delivery of
health care and the exchange of health care information across distances. The prefix ‘tele’
derives from the Greek for ‘at a distance.’ Telehealth encompasses the whole range of
medical activities including diagnosis, treatment, monitoring and prevention of disease,
continuing education of health care providers and consumers, and research and evaluation.
Dental Health Care Services DiscussionTelehealth is designed to assist with case
management and monitoring to improve both management of diseases and access to care. A
fundamental goal of the Affordable Care Act (ACA) is to achieve the greatest value for the
health care resources spent with lasting improvements in health. Telehealth can contribute
to achieving this goal, yet widespread adoption is greatly 201 June 2014 JOURNAL OF
EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL
HYGIENE Figure 1. Orthodontic screening using iPhone 4S. hindered by both policy and
practice barriers. Correction of a number of misconceptions regarding this technology is
required to achieve this goal. Telehealth has progressed beyond the live videoconference.
The field is rich with a range of electronic communication technologies such as remotely
monitored biometric data and the storing and forwarding of digitized data, pictures and
video for non-real-time consultation. One of the fastest growing areas in this field is mobile
health, which makes full use of smart phones, tablets and personal health monitoring
devices for the timely collection and transmission of personal health data for diagnostic,
monitoring and educational purposes. Mobile health is depicted by the letter ‘m’ followed by
the specific health discipline, and is referred to as m-teledentistry and m-optometry. Figure
1 depicts the transmission of clinical information that can be obtained remotely and viewed
in realtime or obtained for review at a later date. families. Several states have employed
teledentistry for screening and referrals in Head Start centers, local schools, nursing homes
and group homes. Teledentistry also has a presence in the delivery of care by mid-level
providers. Dental therapists and advanced dental therapists are able to provide quality care
in collaboration with health care providers and specialists for consultation, referral, care
and evaluation of care. WHAT IS TELEDENTISTRY? Teledentistry is the use of information
technology and telecommunications for oral care, consultation, education, and public
awareness in the same manner as telehealth. Likewise, m-teledentistry is the use of mobile
devices like smart phones, electronic health records and portable radiography for the same
purposes. Teledentistry is used in generalist and specialty practices, e.g. orthodontics,
endodontics, oral surgery, periodontics and dental public health. The greatest value of
teledentistry is the potential to reduce health care inequalities, providing greater access to
specialists and timely oral care.1–6 Another early program that impacted access to care
through teledentistry technologies is on-going in Alaska. The Alaskan Native Tribal Health
Consortium (ANTHC), which developed the Dental Health Aid Therapist (DHAT) concept,
utilizes teledentistry for treatment consultation, diagnosis and referral. Modeled after the
New Zealand school-based program for dental therapists, the DHAT is a collaborative
program between the Alaska Native Tribal Health Center and the University of

3. Washington.2 The program, referred to as DENTEX, was established in 2007 to provide
distance education to students enrolled in the dental therapist program in Anchorage. The
supervising dentists and dental therapists consult using teledentistry. Digital images,
radiographs and other health information are transmitted between DHATs and dentists to
assist in these consultations. SCOPE OF TELEDENTISTRY Access to care in remote, rural and
underserved areas in the United States is being addressed by the development and
implementation of workforce models and new educational programs.1 Social determinants,
changing demographics, multiculturalism, geographical location, lack of insurance, and lack
of uniform regulations and policies inhibit reliable access to proper screening and
treatment of oral disease (See Garcia and Cadoret, Health Disparities and the Multicultural
Imperative, this publication). These factors have led to a quest for new programs and
models for the delivery of oral health care.4 Teledentistry has a primary role in the
implementation of these models and educational programs. In 2005, prior to the
development of the ANTHC, 3 groups of DHATs returned from 2 years of education in New
Zealand, completed a clinical preceptorship and began serving Alaska Natives. Alaska now
has 24 federally certified DHATs who provide preventive and advanced therapeutic care in
10 rural Alaskan clinics. The DHAT team is comprised of 1–2 additional oral care
professionals delivering services to 830 patients during 1200 visits annually. Of these
services, 700 were preventive and 500 were for restorative care. As a result of the advanced
practitioners in Alaska, as many as 35,000 people now have access to oral care.3 First used
by the Army in 1994 as the Total Dental Access Project, teledentistry soon after was
employed by the University of Southern California’s Mobile Dental Clinic in conjunction
with the Children’s Hospital Los Angeles Teledentistry Project to serve children in remote
rural areas. In 2004, the University of Minnesota, in partnership with Hibbing Community
College, incorporated teledentistry for consultations and referrals to provide care to
underserved Volume 14, Supplement 1 202 JOURNAL OF EVIDENCE-BASED DENTAL
PRACTICE SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE Figure 2. Orthodontic
screening using iPhone 4S. Figure 3. Screening for speech issues and orthodontic concerns
using iPhone 4S. In 2011, the Institute of Medicine issued a report targeting increased
access to oral care for underserved and vulnerable populations. Dental Health Care Services
DiscussionOne section of the report focused on innovations in health care settings with a
description of telehealth technologies and placement of dental hygienists in alternative
settings: school-based care, collaborations with women, infant, and children agencies (WIC)
and Head Start; all are prime settings in which dental hygienists can deliver care.4 Patients
have direct access to care provided by dental hygienists in 36 states. Yet in other states, the
dental hygiene practice act requires a dentist to evaluate all patients and to provide direct
supervision by being present in the office when the dental hygienist provides patient care.
Between these two supervision extremes, general supervision has several operational
definitions (See Naughton, Direct Access Care: The Impact on Oral Health, this publication)
Teledentistry can increase access to care regardless of the type of supervision. Five dental
hygienists recently joined Colorado pediatric medical practices to provide oral care services
to children from low income families.5 The result of this feasibility study was increased
health literacy of caregivers, reduced oral disease among children and convenience of

4. receiving preventive oral care concurrently with medical care. While these dental hygienists
were providing only educational and preventive services, teledentistry was used for referral
and consultation.5 These alternative settings demonstrate the potential for teledentistry in
interdisciplinary collaborative health care. Teledentistry and m-health are being used in
education, delivery of oral care and research activities.2 Literature documentation of
teledentistry use has steadily increased from an early publication in 1990, to 27
publications between the years of 2005 and 2010. Another 13 papers have been published
since 2010.10,11 Teledentistry use has been documented in 2 recent systematic reviews
published in 2013.10,11 One study synthesized available research but excluded studies
focused on patient and provider opinions and attitudes concerning teledentistry,
commentaries, legal issues and non-oral health studies; this analysis resulted in the
inclusion of 59 papers. This review reported studies in 15 countries with the greatest
number from the U.S.; most studies were pilot projects or short term with only descriptive
results. The focus of the reviewed papers was most often to be in the education of oral
health care providers and for consultation, diagnosis and treatment of disease.10 Reduced
costs or better resource utilization is often cited as one of the main goals of teledentistry.6
Costs associated with prolonged delays in diagnosis for certain oral lesions results in
increased morbidity and mortality.7,8 An oral disease screening tool is a promising use of
teledentistry to document prevalence of disease and treatment needs, and to obtain
consultations from specialists. Teledentistry screening for oral lesions, both traumatic and
non-traumatic, can reduce long wait periods for a specialist, reduce pain and suffering and
decrease patient financial costs.6,9 Dental hygienists can utilize teledentistry to screen,
provide care and prevent the progression of an oral disease beyond repair or recovery in
underserved areas. Figures 1–6 are examples of images obtained using m-teledentistry to
screen for orthodontic, speech and soft tissue lesions in young children. Dental Health Care
Services DiscussionThe second systematic review focused on clinical outcomes, utilization
and costs associated with teledentistry. Based on inclusion and exclusion criteria, 19 papers
were reviewed.11 describing teledentistry used for orthodontic consultation, referral,
treatment, oral disease prevention, screening and treatment. The use of teledentistry for
screening dental 203 June 2014 JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE
SPECIAL ISSUE—ANNUAL REPORT ON DENTAL HYGIENE Figure 4. Oral trauma from finger
sucking habit 4S. Figure 5. Dental caries screening using iPhone 4S. caries was deemed to be
feasible and valid, yielding a moderate to high level of sensitivity and specificity.12 intraoral
cameras to obtain photographic images of the teeth. At the end of the course, students were
re-assessed using the same instrument as the pre-test. In all categories except one, there
was a significant increase in confidence and knowledge. Student attitudes that teledentistry
increases access to care were already high on the pre-test and were only slightly higher on
the post-test; therefore the difference was not statistically significant.13 No consistent
research methodology has been used to determine efficiency, satisfaction, utilization and
costs. Standardization of methodologies and sound research are necessary to produce
evidence concerning the efficiency, satisfaction of patient and provider, prevalence of
utilization, costs (financial and non-monetary costs), and efficacy of teledentistry.
Intervention comparisons between teledentistry and traditional care delivery are needed.

5. In an effort to meet oral care needs in Arizona, the dental hygiene department at Northern
Arizona University developed a teledentistry-assisted, affiliated practice model for a mid-
level provider to be linked to the oral health care team. Using digital radiographs,
photographs and electronic health records, the mid-level provider linked directly to a
dentist in either real time or as ‘store and send’ for future review and consultation. Portable
digital equipment included handheld radiographic equipment, intraoral cameras, electronic
health records and laptops. Students received training on equipment use and the practice
model. No significant differences were found in the quality of radiographs taken using the
portable or stationary radiographic equipment. Students learned the processes for
obtaining data that were effective for diagnostic purposes while providing care to an
underserved population.1 EDUCATION OF PROVIDERS Technology has made it possible to
obtain and then send patient information within seconds, improving access to consultation
and care. With this same technology, students and professionals in dental and allied dental
programs are learning and developing new methodologies for access and delivery of care in
the office, community settings, schools, long-term care facilities and homes. Students can be
taught to use smart phones or tablets for photography and electronic health records. Patient
data can be collected in essentially any setting and sent or stored electronically for access
by another care provider for consultation, treatment planning and authorization to
treat.3,7,13 Photographs captured by smart phones can be used for screening, diagnosis
consultation, referral, documentation of disease and treatment provided.14,15
TECHNOLOGY USED IN TELEDENTISTRY A commonality of all teledentistry applications is
that a client (e.g. patient, provider or educator) contacts someone with greater expertise in
a relevant field, when the parties are separated in space, in time or both. Teledentistry
exchanges may be classified based on the type of interaction between the client and the
expert, information being transmitted, or communication medium. One dental hygiene
educational program reported assessing knowledge, attitudes and confidence of dental
hygiene students concerning teledentistry. Dental Health Care Services DiscussionStudents
enrolled in a onecredit hour course for 15 weeks on the use of teledentistry. Prior to
instruction, a pre-test was administered. Instruction on use of the intraoral camera to
obtain quality photographs for storage and retrieval was delivered. Senior students
participated in teledentistry screens of children ages 3–5 using Volume 14, Supplement 1
The type of interaction is usually classified as either prerecorded (also called store-and-
forward or asynchronous) or real-time (also called synchronous). In the former,
information 204 JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE SPECIAL ISSUE—
ANNUAL REPORT ON DENTAL HYGIENE Figure 6. Dental caries image using iPhone 4S.
Figure 7. m-Teledentistry equipment. health information vary, but regardless of the
equipment, clear radiographic and photographic images with sharp contrast and all desired
information are a fundamental necessity. is acquired and stored in a particular format,
before being appropriately sent for expert interpretation at some later time. E-mail is a
common method of store-and-forward interaction. In contrast, with real time interactions
there is no appreciable delay between the information being collected, transmitted and
displayed. Interactive communication between individuals at the sites is therefore possible.
Videoconferencing is a common method of real time interaction. Smart phone camera

6. technology has improved significantly, and has been used to obtain and transmit images for
screening of dental caries.14,15 Screening for carious lesions using teledentistry is not as
definitive as a clinical examination, but is effective in identifying children who are in need of
restorative care.7,14 Figures 5 and 6 convey images of dental caries captured with smart
phone technology. Intraoral digital wand cameras work well to capture a single surface or
one tooth in a single image however camera wands are ineffective for capturing several
teeth, a sextant or a quadrant in a single image. While 35 mm digital cameras with lens
provide excellent images, they are often large, bulky and can be intimidating to young
children; conversely, smart phones are smaller, readily available and do not intimidate
children who are familiar with the smart phone camera. The portability and accessibility
makes this technology an asset in obtaining both extraoral and intraoral photographic
images. The smart phone also has a zoom and flash feature, and requires little training to
use. Figure 7 shows a smart phone and other items for intraoral photography. Another
storage option is the ‘cloud’ or storage on an offsite server. Cloud storage and computing is
convenient with retrieval through a password protected system. Cloud technology has not
been readily embraced by oral health professionals. This is especially true among smaller
practices, which comprise the vast majority of settings in the U.S. Tablets, smart phones, and
mobile electronic health records (EHRs) have gained ground, but cloud computing and
videoconferencing lag. With adoption rates for tablets increasing rapidly, some smaller
dental settings may be unaware of all the various security vulnerabilities associated with
mobile devices such as unencrypted data, mobile malware, transmitting data via an open
Wi-Fi hotspot, and the need for remote data wiping capabilities. The most pressing
challenges regarding tablets center around security, integrating workflow, and optimizing
older software applications to run on the devices. Intraoral photography requires the use of
cheek retractors or some form of retraction for visibility, and use of photographic intraoral
mirrors to capture certain anatomical structures. Training for intraoral photography using a
smart phone involves instruction in retraction, use of mirrors and best means of defogging
mirrors when necessary. Also, 2 individuals are needed so that one can retract and defog
while the other captures the images. The information transmitted between two sites can
take many forms, including data and text, audio, still i …Dental Health Care Services
Discussion