Journal of Telemedicine

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and Telecare

Online orthodontic advice: a protocol for a pilot teledentistry system

J Cook, C Mullings, R Vowles, R Ireland and C Stephens
J Telemed Telecare 2001 7: 324
DOI: 10.1258/1357633011936958

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Original article
......................................................................................................................................................

" Online orthodontic advice: a protocol

for a pilot teledentistry system
J Cook*, C Mullings*, R Vowles{, R Ireland{ and C Stephens{
*Institute of Learning and Research Technology, University of Bristol; {Department of Oral and Dental Science,
University of Bristol Dental School; {Department of Primary Dental Care, Liverpool University Dental School, UK

Summary
A prototype teledentistry service was established that incorporated a PC-based expert system designed
to assist in orthodontic cases. It guided the general dental practitioner (GDP) through the assessment of
a patient’s malocclusion and helped ensure that all relevant clinical observations were made and details
recorded. The resulting data file, containing radiographic images and clinical data, was then transferred via
the Internet to a dental specialist. The specialist’s recommendations were returned by the same route or,
where appropriate, a realtime videoconference was conducted. During an eight-month trial, six GDPs referred
158 cases through the teledentistry system; another 24 cases were referred directly to a local consultant. The
protocol used during the trial worked satisfactorily. The GDPs found that it was straightforward and covered all
aspects of the cases they submitted.

Introduction themselves and, for the same reason, fail to seek

...............................................................................
Because of an uneven distribution of orthodontic
specialists in the UK, many general dental practitioners
(GDPs) are under pressure to provide orthodontic
treatment for their child patients. The result is that
40% of National Health Service (NHS) orthodontic
treatment in England and Wales is undertaken by GDPs
with no formal specialist orthodontic training. In
principle, such dentists may seek advice about how
to handle these cases from their local NHS orthodontic
consultant. However, long consultant waiting lists
deter many GDPs from using this service1 . In 1991
there was a mean waiting time of 32 weeks to see an
orthodontic consultant in the UK and in 1988 only
12% of orthodontic cases treated by GDPs had been
the subject of such advice2. Perhaps not surprisingly,
the outcome of orthodontic treatment carried out in
primary dental care is frequently unsatisfactory2,3.
This and other evidence suggests that GDPs often
lack the knowledge and experience to select those
straightforward cases which they can safely treat
Accepted 31 August 2001
Correspondence: Professor C Stephens, University of Bristol Dental School,
Lower Maudlin Street, Bristol BS1 2LY, UK (Fax: +44 117 929 9898;
Email: c.d.stephens@bristol.ac.uk)
treatment planning advice when this is necessary4.
Those dentists who have access to a specialist service
can simply refer all their child patients of orthodontic
age to it. Since only two-thirds of children are generally
considered to have a malocclusion serious enough to
warrant treatment5, this is very wasteful of specialist
time. Furthermore, UK dentists are increasingly adopting
a ‘better safe than sorry’ approach, and between 19%
and 50% of the referrals to orthodontic consultants
are judged to be inappropriate6–10.
We have investigated a teledentistry system, TeleDent,
which was designed to make treatment planning and
diagnostic advice easily and immediately available to
GDPs, and thus reduce the proportion of patients who
need to visit a hospital department for advice11. The
system and protocols adopted for its use are described
under separate headings, below. A pilot study of the
system is then described.
Expert system
The expert system (Jeremiah12) could be installed on
a PC at a surgery. It was designed to guide the GDP
through the assessment of a patient’s malocclusion and
to ensure that all relevant clinical observations were
made and details recorded. On completion of this
assessment, the program provided either:

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 J Cook et al. Online orthodontic advice

(1) a treatment plan for those simple cases that could
be treated by a GDP using removable orthodontic
appliances12,13 ;
(2) advice that the case should be a referred to a
specialist, in which case the system also identified
those clinical parameters which made the referral
necessary.
Whiteboard
In cases where the expert system recommended referral
to a specialist, the GDP could create an electronic
whiteboard file, export the details of the examination
to it, and send this with images of the clinical records
to the consultant for advice. The whiteboard also
allowed the consultant or GDP to add sketches to the
clinical images in order to clarify questions or answers.
File transmission
The method for sending the whiteboard files between
the GDPs and the consultant was FTP (File Transfer
Protocol), an international standard for transmitting
electronic files between computers across the Internet.
Using FTP, files were transferred to or from a remote
computer (an FTP server). Once the GDP had sent the
case to the FTP server, he or she then sent an email
notifying the consultant that there was a file awaiting
his attention.
On completion, the GDP requested the system’s
assessment of the case and recommendations for
treatment. Because the expert system was intended for
use by dentists with limited knowledge of orthodontics,
the software gave a treatment plan only for very
straightforward cases. For all other cases the system
advised the GDP to refer the case to a specialist. In either
case the dentist could print out the clinical findings on
the form required for payment by the Dental Practice
Board. Where the system recommended referral, the
results from the expert system could also be exported
directly to the whiteboard, ready for transmission as
described above.
Format of the whiteboard
It was considered desirable for all the GDPs to use
a standard whiteboard format to ensure that the
consultant spent a minimum of time retrieving and
checking the information required to provide advice
(see Table 1). The clinical images required were:
(1) five standardized views of the plaster casts of the
patient’s dentition, which have been found to
be satisfactory for experienced clinicians when
monitoring treatment progress14 (Fig 1);
Table 1 The template for the whiteboard

Videoconferencing Page Contents

Where the advice received by the GDP in the form of 1 Patient details (name, age)
the consultant’s text and diagrams was not sufficient, GDP’s name and address
Patient’s medical and dental history
the GDP and consultant could conduct a videocon- Patient’s complaint
ference to discuss the whiteboard file. In our study a 2–4 Output from the expert system, containing clinical information
PC-based (or ‘desktop’) system was used (PictureTel 5–7 Views of the plaster casts
8 Images of the radiographs
Live 200, PictureTel(UK), Slough) connected by ISDN
9 GDP’s questions
at 128 kbit/s. 10 Consultant’s opinion

Procedure
For the purpose of the pilot study, any child whose
treatment generated a payment from the NHS Dental
Practice Board for orthodontic care could be referred
through the teledentistry system. All details regarding
cases needing advice were to be entered via the expert
system. The procedure prompted by the software
followed the typical clinical examination: patient
history, charting, and then extra-oral, intra-oral and
radiographic examinations. For the majority of the
entries in the clinical examination the dentist was
required only to pick from a list of choices or to select
the best match from a series of images displayed on
the computer screen. Fig 1 Views of the plaster models of the dental occlusion.

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J Cook et al. Online orthodontic advice
Fig 2 Extra-oral and intra-oral radiographs.
(2) extra-oral orthodontic radiographs of the
developing dentition (Fig 2);
(3) where appropriate, additional intra-oral radiographs
to confirm the condition and location of specific
teeth.
The only means of image capture supplied to the
GDPs was the camera that came with the desktop
videoconferencing system. Still images were created
with this using the snapshot function of the desktop
videoconferencing system. In order to minimize camera
shake, a simple stand was developed that held the
camera in position.
One of the advantages of the system’s camera was
that it produced relatively small image files (about
100 kByte per image). In order to control the size of
the resulting whiteboard files (for the sake of Internet
connection times and general manageability), it was
suggested that the number of images should be limited
to no more than eight and the size of each to no
more than 120 kByte. The GDPs were shown how to
limit the file size by using a graphics program
(PaintShop Pro 5) to crop any redundant parts of the
image and reduce the colour depth of the images to
8 bits (256 colours).
Because the whiteboard software used for this project
(PictureTel LiveShare 1.6) limited file names to eight
characters, it was necessary to adopt a complex and rigid
naming convention. However, even with software that
does not suffer from this limitation it is recommended
that the file name should contain at least the following:
an identifier for the dentist; an identifier for the patient;
the date the file was created. The date is necessary
because FTP servers will record the date the file arrived
on the server rather than the date it was created on the
GDP’s machine. When a file was sent through the
system more than once, a code letter was added to
the file name to indicate this.
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Sending Ž les
The FTP server on which all whiteboard files were
stored was divided into separate password-protected
areas for each dentist. The area for each dentist
contained three directories: an ‘in’ directory, where
the dentist put all new files for the attention of the
consultant; an ‘out’ directory, where the consultant put
the modified file once he had looked at the case and
added his advice; and an archive, which was invisible
to the GDPs, in which the consultant placed the final
files of cases that had been dealt with. This approach
provided a simple way for the dentist and consultant to
check whether a case had been looked at or not and
ensured that different versions of the file did not
overwrite each other. Cases in the ‘in’ and ‘out’
directories were periodically deleted as the directories
filled up.
For easy connection to the appropriate area of the
FTP site, each dentist’s FTP client software could be
set up with a range of automatic connection profiles.
FTP has a number of advantages over email for this
purpose:
(1) Many of the whiteboard files were quite large,
because they contained several clinical images. The
mean file size in the present study was 2.4 Mbyte,
with a range of 1.0–5.4 MByte. Email attachments
of this size are likely to overload mail servers and
also may exceed the limit imposed by many
Internet service providers for email attachments
(typically 1 MByte). No such limits apply to FTP.
(2) The FTP server provided an easily manageable store
of files which could be referred to at any time by
any of the participants. It also provided an easy
means of establishing a secure data store.
(3) By using an ‘in’ and an ‘out’ directory for each
dentist, it was easy for both consultant and GDPs
to keep track of files and to see whether or not they
had been processed.
Requesting and returning advice
The GDPs, after sending a file to the FTP server, sent
an email message to the consultant to notify him of its
presence. The email carried a standard subject line so
that the consultant knew immediately that it was a
teledentistry case for his attention. The email did not
contain any discussion of the case.
It was found to be helpful for the consultant to
acknowledge receipt of this immediately and give some
indication of when his advice was likely to be dispatched.
When he had completed adding his advice to the case,
the file was sent to the GDP’s ‘out’ directory on the
same FTP server. The consultant then sent an email
Journal of Telemedicine and Telecare Volume 7 Number 6 2001

message to inform the GDP that the advice was ready
for collection.
If the FTP advice was insufficient in any way, a
GDP could ask for further clarification by adding extra
questions to the whiteboard and mailing the modified
file to the FTP server in the normal way. If the further
reply failed to answer the questions or it was judged by
the consultant that the matter could not be concisely
expressed, then a videoconference was held. This could
arise where there were a number of treatment options
to discuss or where more specific details of an appliance
design were required by the GDP.
Video-links
Rather than arranging videoconferences on an ad hoc
basis, it was thought that the most efficient way of
scheduling them would be for the consultant to be
available with his videoconferencing system turned on
during set times each week. A GDP could then simply
dial through at that time if she or he had a case that
needed discussing. Since these set times were invariably
during the lunch hour or after 17:00, this did not
present a problem as the consultant was almost always
then in his office.
The GDPs were recommended to make a test call
to a commercial site immediately before a link-up, to
confirm that their equipment was working satisfactorily.
In practice this rarely happened and technical problems
wasted a great deal of time, for example when equipment
had been moved around the surgery and cables had
become disconnected.
When establishing a video-link, the protocol stated
that the consultant would open the patient’s whiteboard
file so that he could see its contents and marshal his
thoughts while the file was being transmitted to the
GDP’s computer. In fact, in most cases the GDP had the
records to hand and did not need the images on the
whiteboard, and so discussion of the case could start
almost at once. It was essential for the consultant to
add any additional advice he had given during the
conference as a typed summary in the whiteboard.
Both GDP and consultant then saved the updated file
before the link was broken. It was the consultant’s
responsibility to save the modified file to the FTP
server.
Medicolegal issues
The ethical and medicolegal issues surrounding
the provision of advice by telemedicine do not differ
significantly from advice provided in a clinic attended
by the patient in person15,16 . Before the present study
began, it was established in a clinical trial that the
orthodontic advice which consultants provided when
Journal of Telemedicine and Telecare Volume 7 Number 6
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J Cook et al. Online orthodontic advice
viewing images of case records contained in a white-
board did not differ in appropriateness from that when
handling the records conventionally17. With both these
methods of providing advice, the consultant relies on
the referring dentist to advise him appropriately about
the patient’s medical and dental history and attitude to
treatment, and to provide any additional information
of possible relevance to the treatment which might not
be obvious from the records. In this respect they share
responsibility for the provision of care. The defence
organization for the consultant perceived his involve-
ment in the trial as merely an extension of his normal
clinical duties, for which indemnity would be provided.
The GDPs were required to seek consent from the
patient or from the parent or guardian for advice to be
sought using teledentistry. It was on this understanding
that the advice was provided.
Methods
...............................................................................
Six GDPs were chosen by interview after an initial
advertisement had been placed in the national dental
press. Practitioners were chosen who:
(1) had basic information technology skills;
(2) either undertook no orthodontic treatment and
would have liked to start treating simple cases, or
treated a few simple cases and would have liked
advice to help them treat more;
(3) were prepared to put in a significant amount of
unpaid time in their own self-training and in
helping to set up the teledentistry system.
Once the participants had been selected, their local
orthodontic consultants were contacted both to inform
them of the trial and to seek their agreement to provide
help should this be required by the GDPs (e.g. to take
over the treatment of a case which proved to be beyond
their capabilities). A formal written agreement was then
entered into with each of the GDPs that clarified issues
such as responsibilities and ownership of equipment.
In the six months before the trial the GDPs recorded
their referral patterns using a pro forma for each new
orthodontic case. During this time they were supplied
with a PC-based videoconferencing system and the
necessary training to enable them to refer their cases
during the subsequent eight-month trial period.
The protocol was evaluated in the following ways:
(1) structured interviews were carried out with the
GDPs after four months of the trial and at its end;
(2) email messages to and from GDPs and whiteboard
traffic were monitored (this was achieved by every
2001 327
J Cook et al. Online orthodontic advice

message being copied to the project manager, who to hand. These dentists worked part time, which might
stored them in a database); have been be a contributing factor.
(3) an audit was undertaken of the formal and informal
training provided to the GDPs;
(4) a count was kept of the number of cases referred
Selection of cases
through the system; Four of the six GDPs put all the cases they would
(5) the consultant kept records of all communications otherwise have referred or treated without advice
with the GDPs by keeping a paper-based log of the through the teledentistry system (although this
dates and times of the videoconferences; information is based on their self-report and may not
(6) forms were completed by the GDPs for each case; be completely reliable). The remaining two dentists
(7) a count was taken of the number of cases on the interpreted the protocol rather more loosely and
FTP archive. continued to refer a substantial proportion of their
cases to their local consultant (Table 2). For Dentist B
this appears to have been a result of unresolved
technical problems with the teledentistry equipment
Results and with failed ISDN connections. For Dentist E there
...............................................................................
was a reluctance to go through the effort of preparing
The referral patterns and working practices of the six and sending a case if she was already aware from some
participating GDPs varied markedly. There were also of the presenting features that there was little
great differences in their flexibility in embracing new likelihood of her being able to treat the condition.
working practices, as well as in their ability and
willingness to sort out minor technical problems. A
further complication was that one GDP unexpectedly
The expert system
had to enter hospital for surgery and so was out of There was a wide variation in the extent to which the
the trial for some weeks. When that dentist returned, GDPs followed the protocol for the use of the expert
considerable online retraining was required. system. Table 3 shows the extent of usage by the six
dentists.
For those cases requiring electronic referral, the expert
Location of equipment system software was designed to enable the GDPs to
Two of the six GDPs said that they would have preferred export to the whiteboard by means of a single key
to have had the system at home. Both lived some stroke all the clinical data that they had been prompted
distance from their practices and felt that it would have to collect. In fact, it was only in the closing weeks of
been much easier for them to prepare cases during the the trial that this aspect of the software was available.
weekend and in the evening if the system had been This meant that the dentists had to cut and paste the

Table 2 Referral patterns of the six participating dentists (A–F) before and during the trial

A B C D E F Total

Before the trial

Number of referrals made per month 1.6 0.5 N/A N/A 5.2 N/A
Number of cases treated per month 0.0 0.0 N/A N/A 0.0 N/A

During the trial

Number of cases referred through teledentistry (as per protocol) 26 12 55 35 11 19 158
Number of referrals through teledentistry per month 3.1 1.4 6.5 4.1 1.3 2.2
Number of cases sent directly to the local consultant (counter to protocol) 0 17 0 0 7 0 24

N/A indicates that the dentist did not provide this information.

Table 3 The number and proportion of cases in which the six dentists (A–F) used the expert system to
capture clinical information before referral

A B C D E F

Number of cases referred through teledentistry 26 12 55 35 11 19

Number of cases for which expert system was used 26 1 55 26 10 13
Proportion of cases in which expert system was used (%) 100 8 100 74 91 68

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output from the software into the whiteboard. While
this was not particularly difficult or laborious, it was
another task for the dentist to do, often at the end of a
full day of clinical practice.
Apart from this, and some irritation with early minor
technical faults, the dentists found the software easy
enough to use, but were divided in their views about
its usefulness. Some appreciated the way that it guided
them through the case assessment in detail, but others
questioned its value when it gave a treatment plan for
so few cases. Two of the GDPs, including the one who
used the expert system least, also felt that they could
not trust the advice it gave, so they referred the case
regardless.
Structured interviews with the GDPs at the end of the
trial revealed that none of them had been able to print
out a claim form which they thought would be of
acceptable quality to the Dental Practice Board. They
all preferred using the conventional manual method,
and found that quicker as well.
Clinical images
Various methods were used for digitizing the required
images (Table 4). The two dentists who did not use the
system’s camera stand said that they found it difficult
to use and time consuming to mount and then unship
the camera again for videoconferencing. The remainder
said that this was not a problem. The dentist who used
a scanner hoped that it would be quicker and give
better results. However, in practice he found that,
because of the time it took for the scan heads to return
to the ‘ready’ position, it would have been quicker to
use the camera. Two of the GDPs who used the system’s
camera said that they sometimes had to get their nurse
to help by holding the radiographs or models. Dentist B
found that it took a long time to get images in focus
and had problems with reflections from radiographs,
and so was unable to get good results. Dentist E also
had problems with shadows on radiographs.
Of the dentists who used their own digital cameras or
scanner, none followed the protocol’s recommendations
about reducing image file size, which resulted in some
very large files (5 MByte and more). However, they did
not seem to mind the longer transmission times which
Table 4 The methods used by the six dentists (A–F) to obtain their clinical images
Videoconferencing system camera without stand
Videoconferencing system camera with stand
Flatbed scanner (for radiographs only)
Domestic digital camera
Dental intra-oral camera for optional additional intra-oral and facial shots
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J Cook et al. Online orthodontic advice
these required, as they would set the file to send and go
away and do something else.
The protocol made no specifications about images
of the plaster models other than prescribing the views
which were to be used. The images produced by the
dentists of the models were judged by the consultant
to be of good to excellent quality, where ‘good’ was
defined as equal to that in Figure 4.1a in the standard
text by Houston et al., and ‘excellent’ was defined as
being equal to or better than Figure 4.1d of the same
text18. The few problems that occurred were related to
lighting. For example, one of the participants forgot
that the camera aperture could be adjusted.
Radiographic images were of more variable quality,
depending on the films that the practitioner had used.
The two practices which had the necessary equipment
to produce dental tomograms always produced images
of excellent quality. Such machines are largely operator
independent for both radiographic technique and
processing. Two other practices took only intra-oral
views and, although generally deprecated on the
grounds of additional radiation, these provided images
of excellent quality. Intra-oral films were sometimes
inadequate since they provided incomplete information
about unerupted teeth. For these cases tomograms were
obtained at the request of the consultant, by sending
the patient to the local hospital. One practice used
extra-oral rotated oblique lateral films of the jaws taken
in cassettes with intensifying screens and processed
manually at the practice. This older form of extra-oral
radiography, although satisfactory for orthodontic
purposes, is very operator dependent. Initially these
films were poor. The views were distorted by incorrect
head positioning and the films lacked contrast. During
the course of the trial, significant improvements were
obtained through instructions provided during video-
conference sessions, and a number of technical and
processing errors were corrected. By the end of the trial,
although the density of the films was still not as good
as that seen in the tomograms, the images were quite
satisfactory.
Whiteboard contents
There was considerable variation in the extent to which
the GDPs followed the protocol for the structure of the
A B C D E F
Y Y
Y Y Y
Y
Y Y
Y
329
J Cook et al. Online orthodontic advice
Table 5 Aspects of the agreed whiteboard structure followed by each of the six dentists (A–F)
Used template file
Patient details
Images of models
Radiographs
(Photographs of patient — optional)
Expert system output and chart
Questions for consultant
Blank page for consultant
Items on the correct page
Items in the correct order
Only one image per page
whiteboard file. Table 5 shows which aspects of the
agreed whiteboard structure were followed by each of
the six GDPs and to what extent all the required items
were present. Note that the images of the patient, which
could be acquired with either the video-camera or a
clinical digital camera, were optional and so are shown
in parentheses in the table.
Despite these omissions, most of the whiteboard files
provided the information needed by the consultant.
Where a file did not, it was returned with a message
asking for the missing data to be added. The only real
problem in this respect was where there was no radio-
graph but it was necessary to ascertain the presence and
condition of those permanent teeth which had yet to
erupt. One of the GDPs was very reluctant to take
radiographs even when advised that these were
clinically essential. More problems were caused by
the poor quality of some of the images (see above).
Whiteboard Ž le names
Despite having written instructions and having
successfully transmitted an appropriately named file
during the training sessions, one or two mistakes and
confusions occurred at first. However, all the dentists
were soon able to transmit consistently and accurately
labelled whiteboard files. It is an indication of how well
this worked that no file was lost or incorrectly routed
during the trial. The practice of adding suffix letters
for later versions of a whiteboard also presented few
problems. Dentist A said she would have liked to
have been able to add small amendments, such as
an additional photograph to a whiteboard, without
having to renumber the file.
The standard email subject line also presented no
problems and was used correctly by all GDPs. Email
was always used in the correct way that is, only to
notify the presence of a case rather than to discuss it.
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A B C D E F
Y
Y Y Y Y Y Y
Y Y Y Y Y Y
Some Y Y Y Y
Y Y Y
Y Y Y Y Y Y
Y Y Y Y
Y Y
Y Y
Y Y Y
Y Y Y
FTP procedure
FTP alone was used for 96% of the 158 cases sent by the
six dentists in the trial. Initially Dentists B, C and E,
who were the least technically confident, had problems
using the FTP site and getting their files into the right
directories. One simple but common problem was that
they forgot that they had to be connected to the Internet
before they could send or retrieve files. However, the
directory structure made sense to the GDPs and after
the first four months all of them said that it was no
problem to send or retrieve files. There were very few
instances of them saving files to, or trying to retrieve
them from, the wrong directory. The only complaint
was from Dentist A, who was unhappy that all the files
in her ‘in’ directory were periodically deleted, because
she wanted to be able to check whether she had sent a
particular file. The problem arose because every month
the consultant archived cases which had been dealt
with and deleted these from all the GDPs’ ‘in’ and ‘out’
directories. This was done to make locating current
cases easier for all concerned, particularly for those
who were sending large numbers of cases. The archived
files for each participating dentist were still held on the
server (as well as being backed up on tape) but were
invisible to the GDPs. It was therefore a simple matter
to restore any past case to one of the GDPs’ directories
when this was requested.
Videoconferencing
The key departure from the formal protocol was that
it was necessary to talk to all the GDPs regularly, simply
to remain in contact and to encourage and be seen
to appreciate their efforts. Videoconferences were
consequently organized each week, whether or not
there was a case to discuss. It was therefore not possible
to evaluate the approach recommended in the protocol,
Journal of Telemedicine and Telecare Volume 7 Number 6 2001

Table 6 The number and proportion of cases referred for advice which each of the six dentists (A–F)
recorded as having been discussed by videoconference
Number of cases referred through teledentistry
Number of cases discussed by videoconference
Proportion of cases discussed by videoconference (%)
although video-links were still used to discuss cases
when this was requested.
There was a surprising discrepancy between the
GDPs’ perception of the number of cases discussed
using videoconferencing (43 cases out of 158 see
Table 6) and the consultant’s (only six cases). The
consultant’s count included only those where the
relevant whiteboard had been opened at the dentist’s
request before or during the videoconference and
advice had been written onto it during the session.
The dentists seem to have also counted cases where
advice had already been provided by FTP but which
were discussed again informally without the whiteboard
being opened. In the consultant’s view, such discussions
added nothing to what had already been provided by
FTP and often occurred because the dentist had not
yet got around to retrieving a recent whiteboard file. A
specific definition of a ‘videoconference session’ in the
structured interviews with GDPs might have prevented
this misconception.
During the trial, 22 videoconferences with the GDPs
were interrupted by technical failures. Perhaps 10 of
these failures could have been avoided if the GDPs
had taken the simple troubleshooting steps with the
equipment outlined in the protocol and which they
had been trained to do. This was a particular problem
with evening calls, when it was sometimes impossible
to contact the GDP by telephone because by then the
practice telephone answering machine had been
switched on. We recommend that for future link-ups
of this sort GDPs be equipped with a mobile phone.
Initially it was expected that the main value of the
videoconferences would be where GDPs decided to
treat a case themselves and so needed detailed advice.
Dentist D confirmed that it was for these cases that he
used the video-link. Dentist C believed that the video-
link was useful for only about 30% of his cases and he
doubted whether its extra cost could be justified.
Dentist A said that if the sessions had not been booked
she would probably not have used the video-link, as
she could cope by email or telephone. However,
Dentist F believed that the advice provided by video
was more personal, and Dentists A, C and E all valued
knowing that they could contact the consultant in this
way if they did have a case to discuss. The consultant’s
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J Cook et al. Online orthodontic advice
A B C D E F
26 12 55 35 11 19
9 0 14 2 9 9
35 0 25 6 82 47
opinion was that the main value of the video-link was
an educational one.
Discussion
...............................................................................
In the UK, NHS dentists are remunerated on an ‘item of
service’ basis. While examination of a patient with an
orthodontic problem carries a fee, there is no payment
for electronic referral. Sending a patient to the local
hospital for advice costs a UK dentist no more than
a postage stamp and the time taken to write a brief
referral note, but it took perhaps an additional 20 min
of the dentists’ time to compile and transmit the
clinical records of a case in the present study. Hence
the GDPs subsidized the project with their professional
time to a considerable extent. While they were warned
that this would be the case when they were recruited,
and all understood that the study depended on their
support, it nevertheless explains some of our findings.
One major issue is whether FTP is the best method of
transmitting case records, since it requires the dentist
to install and use special software for transferring files.
Email attachments may appear to be a more attractive
alternative because email is something most GDPs who
are Internet users are familiar with. We believe that FTP
is the most satisfactory method for several reasons:
(1) the system can be set up so that files are auto-
matically saved to and retrieved from a ready-made
and logically organized directory structure;
(2) such files are easily retrieved and archived and are
unlikely to be lost;
(3) an FTP server is a more neutral storage place than
either the GDP’s or consultant’s hard drive, which
means that the responsibility for monitoring
progress of the case is more readily shared between
them.
Another issue is whether GDPs should be required
to follow a whiteboard template exactly. We concluded
that this is not necessary, as different GDPs sent different
combinations of images, which worked satisfactorily in
most cases. Consistency in the format of presentation
2001 331
J Cook et al. Online orthodontic advice
may be more important when a consultant has to deal
with a large number of cases from many different
dentists.
Another matter affecting the consultant’s ability to
provide advice is the quality of the images that the
GDP sends. This is particularly true of radiographs,
as described above. There were occasions when the
consultant had to state baldly that he was not prepared
to give advice on the basis of the available radiographic
information. On these occasions either radiographs
were repeated or the images of them were recaptured.
A further issue was that even though the dentists
were provided with extensive printed documentation
on the protocol, many of them found that they had
mislaid this when they needed to refer to it. As a result,
we suggest that full documentation be set up as a series
of linked HTML pages held locally and accessible
directly through a desktop icon on the GDP’s computer.
The system for naming files used during the project
worked well; even though other software will permit
longer file names, our recommendation is that the file
name should have the following components in the
following order:
(1) the date of sending the file (since the forward and
back slash (/ and \) characters cannot be used in
Windows file names, either the YYMMDD or YY-
MM-DD format would be suitable) the date
should probably come first for ease of sorting, since
files from different GDPs would normally already
be sorted in separate folders;
(2) a unique identifier for the GDP ideally one that is
meaningful rather than a random number;
(3) a unique identifier for the patient probably first
and last name initials would be adequate for this as
they are unlikely to be repeated for the same dentist
on the same day.
A major question is whether videoconferences are
justified, considering the additional expense and the
difficulty of arranging them. Furthermore, videocon-
ference links to three practices frequently failed to
connect 15–20% of the calls made to these practices
during the trial failed to connect at the first attempt.
Error messages suggested ‘congested networks’ or ‘line
unavailable’. However, the latter occurred when both
ends of the call were connected and equipment was
operating normally, as far as could be ascertained.
These problems occurred mainly at lunchtimes and
between 17:00 and 18:00, which of course were the
times the dentists preferred, since these did not
interfere with the treatment of patients.
We believe that the main value of videoconferencing
is for the training of dentists in teledentistry techniques
and for providing continuing professional development,
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but less so for simple provision of advice. Therefore,
for a standard clinical advice system for orthodontic
treatment, we believe that videoconferencing is not
essential but could be advantageous where resources
permit.
Conclusions
The protocol used during the trial worked satisfactorily
both for the GDPs and the consultant. The dentists
found that it was straightforward and covered all aspects
of the cases they submitted. Provided it was followed,
the consultant always had the necessary information
on which to base his advice, and this could be provided
quickly and easily. From a clinical service standpoint,
videoconferencing was not an essential part of the
system. However, it played a significant part in training
and maintaining the enthusiasm of the participants,
and was extremely valuable in providing feedback. For
example, comments on the poor quality of radiographs
were made more easily and diplomatically during a
videoconference discussion than in a letter.
Most of the GDPs followed the protocol quite closely.
Where they did not, it was due to forgetfulness rather
than problems of working within its guidance. This
applied particularly to those, such as Dentist E, who sent
relatively few cases. However, most of the participants
needed reminding about some aspect of the protocol
in the early stages of the trial and this was easily
accomplished during the weekly videoconferences.
The one persistent omission was the seeming
unwillingness to use a test site before a scheduled
call, to check that the equipment was functioning
satisfactorily. This meant that on several occasions
it took some time to establish a satisfactory video-
conference with the consultant.
The system of identifying cases worked well and
no records were lost. More consistency in whiteboard
structure could have been achieved had headed pages
of the whiteboard been generated by the software as
part of the expert system output, rather than the output
just being pasted into an empty page. While there was
no reason why this could not have been incorporated,
it would have greatly reduced the scope for modifying
the whiteboard template format had this proved to be
unsatisfactory.
The main changes undertaken during the project
were refinements to the expert system software to make
entering of clinical findings more intuitive. This was
achieved by substituting diagrams for text wherever
possible. We also had not appreciated how long it
would take the GDPs to capture the clinical images.
Those who had personal digital cameras were at a
distinct advantage. It would probably have been helpful
for the remainder to have had a flatbed scanner or
Journal of Telemedicine and Telecare Volume 7 Number 6 2001

a second camera; this would have saved time in
unshipping and relocating the camera between
conference calls.
Acknowledgements: This work was supported by the
NHS National Primary Dental Care Research and
Development Programme, grant RDO/90/42.
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