Transitioning to Teledentistry
Ready or Not, the Next Era of Hygiene Practice Starts Now
Catherine Paulhamus, MA
Throughout the nation, the work environment changed abruptly this year, fast forwarding technologic integration. Telecommuting, virtual conferences, and online purchasing became the only way to maintain businesses. Of necessity, products, services, and even patient care were categorized as "essential"-or not-as people recalibrated their priorities to control the spread of SARS-CoV-2. For dental practices, the initial economic impact was significant. A survey from the Health Policy Institute of the American Dental Association showed that, in the week of March 23, 76% of respondents stated they were closed and seeing emergency patients only, while another 19% were closed and not seeing any patients. Practices trying to stay connected with patients have been turning to teledentistry (synchronous and asynchronous), adjusting to technology and even developing new skillsets on the fly. At the same time, dental hygienists, with unique experience in patient relationships and education, are evolving into new roles to set up and manage teledentistry programs.
"The closure of offices required an immediate ability to reassure patients and conduct safe consultations" says Brant Herman, Founder and CEO of MouthWatch. "Aside from emergency procedures, teledentistry was the only path to revenue at the time. This was the catalyst for the rapid adoption of teledentistry technology by insurance carriers, practices, and providers. What's also exciting are the long-term opportunities on the hygiene side. Hygienists are fantastic at relationship building and communication whether it be in-person or virtual. They can be the heart of a practice's successful teledentistry initiative."
This change in practice is likely to be long term. Another wave of virus, with possible closings or restrictions, could occur. Hygienists in practice can be implementing it now, so that they and their patients are ready for it.
"Teledentistry is perfect to help bridge the gap," says Michelle Strange, MSDH, RDH, an educational consultant and cohost of a dental hygiene podcast. "I think it's going to open up our hygiene scope of practice to help us get patients the care they need."
"For the average practice that wants to leverage teledentistry, I would look at it from two perspectives: emergency screening and virtual consultations," says Bryan Laskin, DDS, founder of OperaDDS. "How can we use it to triage emergencies? Off hours, or during closings, we can prescreen patients, which is both more efficient and safe."
Laskin also is enthusiastic about the potential for virtual consultations. "This could be very powerful for people who have massive needs. For example, a patient who hasn't been to the dentist in 25 years and doesn't know what to expect. We can give people a safe, easy way to contact us, send us some photos and video. Then we can reach out to them and say, ‘We see people like you all the time, and we're here to help you in whatever way we can.' It becomes a way to baby step people into the practice, get them over their fear."
"The irony is that today, there's a more personal touch through a video conference follow-up, when the practitioners look like themselves again," Herman adds. "On video, they're not covered head to toe in PPE, but are face-to-face with the patient. At the same time, practitioners are avoiding potential infection touch points during the appointment, improving the patient's experience and building trust."
Videos demonstrating safety precautions at the practice are another opportunity for patient outreach, explains Kristine Berry, RDH, MSEC, founder of Getting It Done Remotely™. "While the main messages need to come from the doctor/owner, hygienists certainly have an opportunity to do their own videos showing the hygiene department, which they can send to patients prior to the appointment. The patients can see, specifically, what's being done for their safety."
Hygienists can also provide follow-up consultations and home care instruction, either synchronous (live) or asynchronous (recorded and sent to patient), depending on the patient's preference. They can answer patient questions about oral hygiene, proper brushing and flossing techniques, implant maintenance, and postoperative care. Herman suggests, "Hygienists can also record their own instructions and send them to patients to watch whenever they need to. A lot of information can get lost when a hygienist is chairside explaining something. Sometimes the patient simply forgets. Teledentistry really enables hygienists to expand their roles and shift oral care education to the home where it's convenient for the patients, and where they're more likely to adopt a behavior change."
"Behavioral change skills are definitely something hygienists can consider, because it's not simply educating," Berry adds. "We have to be able to elicit autonomous motivation and action, through open-ended questions, reflections, empathy, and rapport. We can let patients know we're there to support them, even with brushing and flossing and basic home care." For example, Berry mentions a practice might mail disclosing tablets to patients, who then take a selfie after using them that they can send to the practice, supporting a self-care or case management conversation.
Berry also sees community outreach opportunities for hygienists, promoting the integration between medical, dental, and the oral-systemic link. In addition, practices that provide nutritional counseling or sleep apnea consultations can include those services in a virtual assessment prior to the appointment.
Revitalizing Other Services
During the closures, practices were also implementing teledentistry to take advantage of the down time-for example, by preparing and presenting treatment plans to patients. Herman says, "That way, when the office opened up, not only was there a backlog of patients that had missed preventive and planned restorative treatment, but there were also new cosmetic or more complex cases. Since it's expected that there will be a series of openings, closing, and reopenings, depending on new outbreaks, it will be critical to maintain treatment planning momentum throughout this cycle."
Berry agrees, "Virtual case acceptance and enrollment has a lot of advantages, especially as we need to limit people coming into the practice. We can schedule conversations without PPE and use motivation interviewing skills with the patient, including discussing financial arrangements. And the partner can be there, too. It's more relaxed when they're in their home."
"The practice no longer needs to shut down when the doctor is out," says Strange. "If I see areas of concern, I can take an intraoral picture or video to send. Even if the doctor is on a beach somewhere, he or she can review that record and decide if we should make a referral. This way, we don't have to wait and bring the patient back for an additional exam with the doctor. It just makes so much more sense."
This workflow works within the office, too, as practices try to preserve PPE. "Rather than doctors donning PPE for the examination or evaluation component of that hygiene appointment, they're now able to do an evaluation remotely based on images and radiographs that the hygienist acquires," Herman explains. "That evening, they can review everything and then consult virtually with the patient. The ability for the dentist to virtually review and consult also gives the hygienists the additional time they now need to turn over and sanitize the operatory in between patients."
The Hygienist as the Starting Point
Strange suggests that hygienists starting to utilize teledentistry begin slowly. "Practice it in your operatory. Work out any technical issues, and lead by example. That way, when the office wants to get on board, you already know the nuances of how the technology works and how it applies to certain types of patients."
Hygienists also need to clarify the standard of clinical processes and protocols with the doctors, Berry says. "They need to have clear expectations on data collection, what is expected from a clinical standpoint, and what competencies clinically as well as with the behavioral data collection. We have to make sure we're all buttoned up. Because as teledentistry develops, quality assurance is essential."
Hygienists completely understand the need for documentation, Laskin says. "A synchronous video conference, like many are using at this time, is horrendous for documentation. Practices that use synchronous video conferencing should make sure to use a system that integrates with their practice system and is HIPAA compliant, to protect against malpractice claims."
They also want to do due diligence on their state practice acts, Berry explains. "Specifically, they need to know what their state regulations for telehealth are now in this current situation, and then monitor for any changes. The Center for Connected Health Policy and the American Teledentistry Association are good resources."
Beyond the technical and clinical skills, Berry mentions the need to learn about optimizing virtual presentations. "Building rapport through video conferencing is different than sitting down, knee-to-knee with a patient. The team has an opportunity to step up their game in communication skills, and employ new ones."
"The future is teledentistry and I very much encourage hygienists to jump onboard," Strange concludes. "Because we can utilize it to facilitate more access to care. It allows us to work smarter as a team. We can use teledentistry to move away from the disease model of treatment, and help patients before disease happens. We can finally embrace the prevention model."