|
By Terry Wheeler
[PHOTO -
UNC]
Dentistry has faced the same access issues that have
spurred telemedicine development in other fields. However, until recently
dentistry has lagged behind in adopting telemedicine. The findings of the
Association of Telemedicine Service Provider’s (ATSP; www.atsp.org) 1998
Report on US Telemedicine Activity, done collaboratively with Telemedicine
Today Magazine, are instructive. Out of nearly 32,000 teleconsults among 139
U.S. programs performed in 1st quarter 1998, only 200 were dental
teleconsults–and all of these were done by one program. Although that
figure represents a significant increase over the 4 dental teleconsults
reported in 1997, teledentistry has a long way to go. The first steps are now
being taken.
At the schools of dentistry at the University of
California at Los Angeles and the University of Bristol in Bristol, England,
two different approaches to teledentistry are being actively explored.
Telemedicine Today spoke with lead researchers at each school to discuss these
programs.
UCLA School of Dentistry
Dr. Glenn Clark is Professor of Diagnostic Sciences
and Orofacial Pain at the UCLA School of Dentistry and Director of the UCLA
Orofacial Pain and Oral Medicine Faculty Group Dental Practice. The group
practice specializes in diagnosing and treating chronic head and neck pain, jaw
joint disorders, salivary dysfunction, tooth-grinding, oral infections and oral
tissue lesions. These ailments affect about 15 percent of the population,
according to Dr. Clark.
"One of the big problems right now is that
general-practice dentists often have very little knowledge or experience with
problems like chronic facial pain," said Dr. Clark. "Consequently, they
don’t always know who is the most appropriate specialist to whom to refer
a patient. And who the specialist is often determines the treatment. An
orthodontist will prescribe an orthodontic treatment plan, while an oral
surgeon will suggest surgery. Dentists need to be able to contact a pain
specialist who can look at the problem more generally. So, about a year ago we
applied for and received an experimental program grant offered by the
chancellor at UCLA to set up a consultative service for dentists." The decision
was made to use store-and-forward technology using telephone lines and
customized software developed by Houston, TX-based PhysiTel, Inc.
(www.physitel.com).
The TeleDiagnosis teledentistry software is based on
PhysiTel’s ChartMailer software. It allows local dentists to encrypt
intraoral camera images, x-rays, voice mail, onscreen notations and paper-based
records, and send them via ordinary phone lines to the UCLA clinic’s
website. Clinic doctors then write a report and send it back to the local
dentist. The program’s goal is a three-day maximum turnaround.
"We’ve used TeleDiagnosis in a pilot program in
our clinic with about 40 patients, and we already have requests from dentists
who want it," said Dr. Clark. "Right now, we’re only going to be offering
it to dentists in California. We’re not sure what the law is about
crossing state lines. So, until our lawyers say it’s ok, we’re going
to stay in California. Anyway, there are 30,000 dentists in California, and
only one or two facial pain clinics, so we expect the program to get a lot of
use. We anticipate that we can handle about 40 cases a week for each of our
three full-time faculty members, but we really don’t know what the
response will be."
The TeleDiagnosis software will be sent this month to
about 10,000 dentists in local communities to use on a trial basis, according
to Dr. Clark. Initially, the service will be free. After the trial period, an
hourly consultation fee will be charged. "One thing we hope to discover through
our research during this trial period is what the minimum dataset is–that
is, how much information do I really need to make a diagnosis? We want to hone
the questions so that a local dentist doesn’t have to spend hours filling
out a form. We’re targeting two areas: chronic facial pain and oral lumps
and lesions," explained Dr. Clark. "With chronic facial pain, there’s
usually nothing to see that will help to make the diagnosis. It’s very
subjective. So we’re going to try to help local dentists diagnose and
treat this kind of pain. In the other area–the lumps, bumps, patches and
ulcers that show up in the mouth–there is something to see, so the local
dentist using our service would send images of the lesion along with a
description to our group. The program will have an educational component, too,"
said Dr. Clark. The program will also have an educational component, offering
distance learning via the Internet where students are given a case to analyze,
and answers are posted on the Web.
When asked what he sees in the future for
teledentistry, Dr. Clark was noncommittal. "It could fall on its face, or fall
only to be reborn at a later time. Who knows? But I think it has a future. In
fact, the California Dental Association Journal is planning to do an entire
issue on teledentistry in February 2000. I’m the guest editor for that
issue. We plan to present our data and explain why we have gone with
store-and-forward technology rather than interactive videoconferencing."
University of Bristol Department of Oral and Dental
Science
Dr. Chris Stephens is Professor of Child Dental Health
(Orthodontics) in the Division of Child Health at the University of Bristol
(UK) Department of Oral and Dental Science. The school has completed a two-year
trial using interactive dataconferencing and videoconferencing for dentistry,
and has now commenced the second phase of the study, a two-year program funded
by England’s National Health Service (NHS). Dr. Stephens relates that in
the first phase of the study five general dental practitioners participated in
the University’s TeleDent clinical trials. At a cost of £1.50
(US$2.46) for a ten-minute call, the dentists were able to transmit full-color
images directly from their offices to a consultant at the University using
PictureTel (www.pictel.com) videoconferencing and dataconferencing systems and
an ISDN telephone network. The images included x-rays and views of dental
moulds, as well as live digital images transmitted from an intra-oral camera.
In addition to the clinical component, 20 dentists received education and
training through courses transmitted from the University of Bristol to two
medical postgraduate centers in the southwest of England using the PictureTel
equipment.
Dr. Stephens emphasized the extent of the unmet need
for orthodontic consultations. "There are 26,000 dentists in the UK and only
200 orthodontic consultants," he explained. "Each consultant provides support
to dentists in a defined geographical region. So, on average, there is one
orthodontist for every 130 dentists. Typically, a patient is referred to a
consultant in the event of a non-standard dental problem, but studies have
shown that up to 40% of patients waiting to be seen by an orthodontic
consultant either don’t need to be seen at all, or have been referred at
the wrong time."
On the other hand, there are a larger number of
patients who don’t get the advice they need at all, according to Stephens.
"Some practices ‘don’t see a problem,’ so they don’t refer.
And, because so many orthodontic problems are treated by non-specialists, up to
half of all orthodontic treatment plans adopted are not optimal. They may work,
but they’re not quite right. Dentists think they’re doing the best
thing, even when they’re not. Videoconferencing is a way to get them on
board. The advice comes to them; they don’t have to ask for it. We think
this will help to ensure that all patients get appropriate care."
The first phase of the program has emphasized more
effective delivery of distance education and clinical support services. The
old-fashioned ways were inefficient. For example, the school provided service
to an area of southwest England that is 270 miles long–a long, tiresome,
expensive way to transport personnel or patients. Videoconferencing got around
these inefficiencies very neatly.
While the educational component that provided the
program’s initial focus, it soon expanded to clinical support. "The
Institute for Learning and Research Technology at the University acquired the
equipment and we linked up with them. Then, while we had the equipment, we
thought we’d do clinical support as well. It worked very well. This
combination of patient consulting and problem-based teaching is very
productive. It educates dentists while it provides treatment plans for
patients," maintains Stephens.
In the initial phase of the program, clinical
teleconsultations were done one morning each month for two hours. Case images
were collected, pasted into a whiteboard, and sent to the University site.
There the case was discussed and a final opinion was recorded and sent back.
The interactive ability of the whiteboard was an essential element, according
to Stephens, noting that the only real problem has been the download time. "At
ISDN speeds – 128 Kbps – it takes a while to transmit a lot of color
images. The download time seems like a real waste of time for the dentist and
the consultant." As a result, researchers are looking at ways of getting around
that problem in the next phase of the study, without having to make huge
investments in bandwidth.
The approach they plan to take is quite similar to
that used by UCLA–with a twist. It includes computer-based expert
knowledge systems that have been available on PCs for quite a while. The
problem in orthodontics is that the field is too complex. "Coding has been
developed that covers simple, garden-variety stuff, but local dentists have
been disappointed in the result, because 75% of the time the program would say
to consult an expert," explains Stephens. "Three years ago, the wait to see a
specialist was 86 weeks. Today, it’s 23 weeks. That’s an improvement
but still a long time. Dentists want to short-circuit the wait, so they put
people on the list before they’re sure they need it. That creates more
problems."
The problem appears to be solved by a pilot program
now in place, that ties the videoconferencing system into the PC expert
program. The local dentist can fire up the expert program, answer the
questions, match images, and after a few minutes of entering data can have a
treatment plan for most things. If a referral is indicated, the local dentist
can dial up a videoconference for immediate advice.
Dr. Stephens believes that videoconferencing and
dataconferencing will play major roles in professional dental education and
clinical support for general practitioners. "General practitioners can’t
be experts in everything. For 50 years, dentists have been going to consultants
with photos and models to get advice. Videoconferencing is a way for them to do
this without leaving the office. Once we let it be known that this exists,
we’ll be inundated."
Contact information:
Dr. Glenn Clark
UCLA Oral Medicine Faculty
www.ddsdetective.dent.ucla.edu
glennc@dent.ucla.edu
Dr. Chris Stephens
Bristol Dental Hospital
www.dent.bris.ac.uk/cdh/cdhhome.htm
c.d.stephens@bristol.ac.uk |
