Telehealth

By Dorota T. Kopycka-Kedzierawski, Sean W. McLaren, and Ronald J. Billings

doi: 10.1377/hlthaff.2018.05102

Advancement Of Teledentistry At
HEALTH AFFAIRS 37,
NO. 12 (2018): 1960–1966
©2018 Project HOPE—
The People-to-People Health
Foundation, Inc.

The University Of Rochester’s

Eastman Institute For Oral Health

Dorota T. Kopycka-
Kedzierawski (dorota_kopycka ABSTRACT Dental caries is the most prevalent infectious disease among US
kedzierawski@urmc.rochester
.edu) is an associate professor
children. National surveys have shown that poor and minority-group
in the Division of Community children are not only disproportionately affected by dental caries but also
Dentistry and Oral Disease
Prevention, Eastman Institute
have limited access to oral health care. Following successful exploratory
for Oral Health, University of applications of both synchronous and asynchronous models at the
Rochester, in New York.
Eastman Institute for Oral Health, teledentistry has been demonstrated to
Sean W. McLaren is an be a practical and cost-effective way to improve oral health care for rural
associate professor in and
chair of the Division of and disadvantaged children. These models support the role of
Pediatric Dentistry, Eastman teledentistry in reducing the costs of and barriers to accessing oral health
Institute for Oral Health,
University of Rochester. care, improving oral health outcomes, increasing use of oral health care
resources, and leading to the establishment of a dental home for
Ronald J. Billings is a
professor emeritus at the underserved children. The advancement of teledentistry underscores the
Division of Community need for its integration with local, regional, and national telehealth
Dentistry and Oral Disease
Prevention, Eastman Institute programs and the role of policy makers in establishing a balanced
for Oral Health, University of
Rochester.
framework for teledentistry within the overarching health care system.

T
elemedicine is defined as the use of
technology to deliver health care
services at a distance; telehealth
includes telemedicine and patient
and health professional education,
as well as public health and administrative activ-
ities.1 The use of telemedicine was initiated in
rural and remote communities and in federal
health programs. It is now being used in various
medical specialties and subspecialties in the US
and other parts of the world.2 The digital trans-
formation of medical health care redefined many
aspects of clinical practice and related daily busi-
ness activities, including practice management,
payment, and marketing strategies. Since the
immense explosion in computer and mobile de-
vice technology, telemedicine services can reach
large segments of the general population.1 Den-
tistry has embraced telemedicine more slowly
and on a smaller scale. Nevertheless, teledentis-
try has been demonstrated to be a practical and
cost-effective way to improve access and increase
oral health care use, especially among rural and
disadvantaged children.3,4 Teledentistry has
been shown to reduce the costs of and barriers
to accessing oral health care, improve oral health
outcomes, increase the use of oral health care
resources, and lead to the establishment of a
dental home for underserved children.
The first entity to explore teledentistry was the
US Army. Two US Army pilot projects were begun
in 1994, and they demonstrated that teledentis-
try could save patient travel and evacuations.5,6
Subsequently, teledentistry has slowly evolved
and is currently used for patient screenings, spe-
cialty consultations, referrals, education, and
emergency care in various dental specialties
(including pediatric dentistry, oral medicine,
orthodontics, and maxillofacial and oral sur-
gery).4,7–15 The first virtual dental home program
to deliver dental care to underserved and vulner-
able patients was created in California in 2010.16
The virtual dental home is an innovative model
for delivering dental care in locations where un-

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derserved and vulnerable populations receive in-
tegrated oral health and general health services
along with educational and social services. Re-
cently, six teledentistry programs operating with
varying success in Colorado, Georgia, Minne-
sota, New York, and Oregon have been described
and evaluated.17 Teledentistry can take one of
three forms: asynchronous (the transmission
of a patient’s oral images that are not used in
real time; that is, store and forward), synchro-
nous (the use of real-time interactive technolo-
gies, such as two-way interactive video), and
mobile health care services (the use of mobile
technology, such as smartphone apps and text
messages, to manage and track dental health
conditions or promote healthy behaviors).
The Centers for Disease Control and Preven-
tion reports that dental caries is the most preva-
lent infectious disease in US children.18,19 Data
further show that socially and economically dis-
advantaged US children have limited access to
oral health care.
The purpose of this article is to describe the
advancement and uses of teledentistry at the
University of Rochester’s Eastman Institute for
Oral Health (EIOH) as an integral component of
the oral health care system and its relation to the
general telemedicine initiative within the univer-
sity’s Medical Center as a whole. Additionally, we
discuss the relevant policy applications, includ-
ing the organizational changes within the facili-
ties that offer teledentistry services, and we pres-
ent the encouraging outcomes of the existing
teledentistry initiative. We describe the develop-
ment and implementation of the program in the
context of policy-based health care initiative at
the local, state, and federal levels. A few of the
policy-relevant issues addressed here are related
to personnel and administrative responsibilities.
The Teledentistry Initiative
Teledentistry at EIOH was originally envisioned
as a way to screen large numbers of children for
oral disease, mainly dental caries. Following two
small-scale feasibility studies to test the hypoth-
esis that teledentistry could reduce or eliminate
the need for a dentist or dental hygienist to per-
form a visual/tactile oral examination, a longi-
tudinal comparative-effectiveness teledentistry
study using a store-and-forward (asynchronous)
method to examine Medicaid-eligible children
ages 1–6 years for dental caries was undertak-
en.3,7 Subsequently, the success of the asynchro-
nous model led to the development and
implementation of a synchronous teledentistry
program involving EIOH and a community
health center in an underserved rural region of
New York State.
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Asynchronous Teledentistry In the spring
of 2004 EIOH conducted a pilot project to assess
the feasibility of the store-and-forward method,
using intraoral images to screen for and diag-
nose oral disease—mainly dental caries in pre-
school children.20 Each child received two dental
examinations. The first, a visual/tactile oral ex-
amination, was performed by a calibrated dental
examiner (trained systematically by a gold-stan-
dard examiner); the second, a teledentistry im-
aging examination, was performed by a trained
telehealth assistant. After a two-week washout
period, the images were assessed by the first
examiner. Each child was scored as having caries
experience or not, as a primary measure, and the
number of decayed and filled tooth surfaces due
to caries in primary tooth surfaces (dfs) was cal-
culated for each child. The diagnostic quality of
the intraoral images was assessed by comparing
the results of the traditional visual/tactile exam-
ination to the images obtained using an intraoral
camera. Sensitivity of the teledentistry examina-
tion was 100 percent, and specificity was 81 per-
cent, given that the oral visual/tactile examina-
tion was used as the gold standard. The mean dfs
scores for the teledentistry images and the visu-
al/tactile examinations were not significantly
different. The results showed no difference be-
tween asynchronous teledentistry examinations
and visual/tactile oral examinations performed
by a calibrated dental examiner, thus demon-
strating the potential for teledentistry to sup-
plant the standard visual/tactile examination
by a dentist or dental hygienist. Intraoral images
were captured using the Dr. Camscope intraoral
camera. This camera provided bright and clear
images; furthermore, various magnifications
and focus adjustments could be made as needed
during the process. Usually, six intraoral images
were completed for each dental screening, and
two anterior and four posterior images were
transmitted for distant evaluation by the dentist.
Initially, we used Second Opinion software.
However, in our next teledentistry screening
project, we transitioned to the web-based soft-
ware Teleatrics.
Our asynchronous teledentistry screening
projects complemented the existing pediatric
telehealth model that began in 2001 at the Uni-
versity of Rochester Department of Pediatrics.
The Health-e-Access telehealth program had
trained and certified employees at a child care
center as telehealth assistants. The assistants
were in charge of performing telemedicine
screenings for ill children as they presented at
the center. Before the commencement of the tele-
dentistry project, the assistants were trained to
image children’s teeth for a dental assessment.
Initially, a PowerPoint module was presented to
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Telehealth
the assistants to familiarize them with the first
signs of oral disease—predominantly early child-
hood caries. To obtain clinically acceptable in-
traoral images, the training modules included
a synthetic dental model (typodont) and adult
volunteers. The final step included imaging chil-
dren’s teeth and transmitting the images to the
dentist for assessment.
Encouraged by the results of the initial feasi-
bility project, in conjunction with the Monroe
County Department of Health, we initiated a den-
tal screening program for urban child care cen-
ters located in Rochester, New York. Almost two
hundred preschool children ages 12–60 months
who attended such child care centers were
screened in 2004–06 for the presence of dental
caries (especially early childhood caries) by
means of teledentistry. All children who partici-
pated in the screening program were eligible for
Medicaid or Child Health Plus (the state’s Chil-
dren’s Health Insurance Program). Forty-three
percent of the screened children had dental car-
ies experience (dfs > 0). Furthermore, twenty-
eight children were classified as having severe
early childhood caries. These results were espe-
cially troubling, as we observed only a minimal
indication of dental treatment. Detailed results
of this screening project have been presented
elsewhere.21
In 2007 we initiated a longitudinal study to
assess caries prevalence, incidence, and dental
utilization patterns in preschool children
ages 12–60 months who were enrolled in select-
ed child care facilities in Rochester. We screened
almost 300 preschoolers and followed them for
twelve months. At the initial screening, about
28 percent of the children had caries experience
in the primary dentition, and—based on the re-
sponses of parents or primary caregivers to a
questionnaire—almost 50 percent of the chil-
dren had never visited a dentist. Perhaps the
most important observation was that children
with dental caries who were screened by means
of teledentistry accessed and used dental care
significantly more than children screened via
visual/tactile examinations, as evidenced by
the presence of dental restorations (fillings)
for decayed teeth.3,7 We hypothesized that the
difference could be attributed to the fact that
the intraoral images served as motivational
agents when presented to the children’s parents
or primary caregivers.
Synchronous Teledentistry The success of
the asynchronous model led to the implementa-
tion in 2010 of a synchronous teledentistry pro-
gram involving EIOH and a community health
center in an underserved rural region of New
York State to diagnose, plan the treatment of,
and facilitate the care and appropriate treatment
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of Medicaid-eligible children with oral disease
(mainly dental caries) in real time—thus saving
two or more trips to Rochester for these initial
services. Concomitantly, a teleanesthesia pro-
gram was established to facilitate care in the
hospital setting for children who required treat-
ment in the operating room.
In 2010 EIOH was contacted by Finger Lakes
Community Health (FLCH), a federally qualified
health center with multiple locations that serves
people in the Finger Lakes region of New York
State. FLCH has seven dental clinics in its loca-
tions in addition to a seasonal facility based on
agriculture seasons and a school-based program.
These dental clinics serve the entire population
and are staffed by general dentists. The dentists
who provided care at the clinics often noticed
that children referred for specialized pediatric
dental services rarely had their treatment com-
pleted. An internal review of 158 records demon-
strated that approximately 15 percent of the chil-
dren who had a referral for pediatric dental care
actually completed treatment. This observation
led to a discussion with EIOH’s Division of Pedi-
atric Dentistry about establishing a teledentistry
initiative. It was decided that a live-video (syn-
chronous) teledentistry program would be
started to help facilitate oral care for the children
of the Finger Lakes region.
The planning for teledentistry services at
FLCH required significant ongoing organiza-
tional changes, including the commitment and
availability of administrative and support per-
sonnel. FLCH requires that a care coordinator
be assigned to ensure appropriate follow-up
for patients who receive teledentistry examina-
tions. An information technology position was
created to manage and maintain telehealth ap-
plications, and a scheduler was assigned to assist
the care coordinator with the large volume of
services. FLCH provides the majority of the ad-
ministrative work that is needed at the front end
of patient care, a dental home for the patient, and
follow-up services.17 FLCH’s outreach program
uses a team approach that includes care coordi-
nators, patient advocates, and community
health workers to assist patients and determine
their needs. Telehealth and teledentistry services
at FLCH are provided through portal-to-portal
connections.
Before the teledentistry initiative at FLCH was
established, the barriers to oral health specialty
care were abundant.17 They included lack of den-
tal insurance, limited or lack of transportation
options, considerable geographic distance to
specialty oral health care providers, cultural
and language differences, and the inability to
take time away from work during the day. Tele-
health services are now an integral part of FLCH,
including specialty consultations in mental
health, otolaryngology, dentistry, and diabetic
retinopathy.
Given the extensive oral health care needs of
the children served by FLCH, a synchronous
model was chosen to help facilitate the appropri-
ate scheduling of patients for definitive dental
treatment. Equipment purchased to initiate a
synchronous teledentistry program included a
Tandberg 1700 HD monitor, webcams, laptop
computers, and an Oracam ST-111 intraoral
camera.
When a child is seen in one of the FLCH clinics
and identified as having pediatric dentistry
needs that require a pediatric dentistry special-
ist, the parents or primary caregivers are in-
formed. A care coordinator meets with the family
to complete permission slips. The patient’s den-
tal records and paperwork are uploaded to the
electronic dental record. A description of the
synchronous teledentistry program is provided
to the parents or primary caregivers, and an ini-
tial teledentistry appointment is scheduled. The
care coordinator at FLCH works with the care
coordinator at EIOH to identify an appointment
time for the teleconsultation.17
On the day of the initial consultation, the par-
ent or primary caregiver signs a consent form for
teledentistry examination. An internet connec-
tion is established, and the participants are in-
troduced and their roles explained. A typical tele-
dentistry appointment would involve a pediatric
patient, their parent or primary caregiver, the
telepresenter, a community health worker as-
signed to the case, and a pediatric dentist at a
remote site. The pediatric dentist then conducts
a brief medical history review with the parent or
primary caregiver. Any questions are answered,
and the teledentistry examination begins. The
video feed is switched from the webcam to the
intraoral camera. The telepresenter systemati-
cally shows the pediatric dentist views of the
hard and soft intraoral tissues. After completion
of the intraoral examination, the video feed is
switched back to the webcam. The findings of the
examination are discussed with the parent or
primary caregiver, and treatment recommenda-
tions are discussed along with risks and benefits
of the various treatment modalities. The treat-
ment plan is recorded in the patient’s FLCH chart
by the community health worker, and a teleden-
tistry appointment note is recorded in the
e-dental record by the pediatric dentist.
Monthly meetings are scheduled between the
pediatric dentist at the remote site and the tele-
dentistry program coordinator at FLCH, to dis-
cuss the progress of treatment of every enrolled
child. If further interventions are needed to fa-
cilitate treatment completion, the community
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health workers are notified. If the community
health workers are unable to facilitate the remov-
al of treatment barriers, social workers at EIOH
are engaged.
To date, over 850 rural pediatric patients have
been seen remotely via a live-video teledentistry
module. Over 95 percent of the children
screened for oral disease had significant treat-
ment needs and could not be accommodated in
the rural community dental clinic. The recom-
mended treatment pathways (for example, treat-
ment in EIOH’s pediatric dental clinic, treatment
using nitrous oxide anxiolysis, treatment with
oral sedation, treatment in the operating room
with general anesthesia, or teleconsultation)
were identified via the live-video teledentistry
module.
An initial review of treatment progress for the
first 251 patients who were enrolled in the syn-
chronous teledentistry program was completed
in 2014.4 This review showed a treatment com-
pletion rate of approximately 93 percent for chil-
dren identified as having oral health needs and
requiring oral rehabilitation under general an-
esthesia. Almost half of the patients required
such oral rehabilitation. The remaining children
required treatment using oral sedation (this
group had a treatment completion rate of 87 per-
cent), treatment with nitrous oxide anxiolysis
(56 percent), treatment at EIOH with local anes-
thesia (100 percent), or a consultation (90 per-
cent). Our initial data review suggested that the
rates of treatment completion, irrespective of the
treatment modality, were much higher than the
original 15 percent observed in the initial record
review that was conducted before the initiation
of the synchronous teledentistry program.4,22
Additionally, our review of the program’s
initial 251 patient records showed that the
initial treatment modality as recommended in
synchronous teledentistry consultations was
not changed 88 percent of the time. The 12 per-
cent of the treatment modalities that needed to
be changed usually involved patients who were
initially scheduled for restorative treatment with
nitrous oxide anxiolysis who instead received
oral rehabilitation under general anesthesia.
Thus, live-video teledentistry consultations have
been demonstrated to be a practical and poten-
tially cost-effective way to facilitate the use of
appropriate treatment pathways and to increase
oral health care use when treating complex pe-
diatric dental cases.
Teledentistry is the most common telehealth
service provided at FLCH. Teledentistry services
are considered a great value-based activity at
FLCH, as they have established professional re-
lationships among providers, improved the qual-
ity and availability of oral health care for rural
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Telehealth
pediatric patients, and promoted the use of fol-
low-up services at local general dentistry clinics
and the establishment of a dental home at FLCH
for rural pediatric patients.
Discussion
Since its inception in 2004, the teledentistry
program at the Eastman Institute for Oral Health
has reached almost 1,500 disadvantaged urban
and rural preschool and elementary school
children in New York State. All of the children
screened in either an asynchronous or synchro-
nous teledentistry module were eligible for Med-
icaid and Child Health Plus. Many of them had
never seen a dentist and had significant untreat-
ed dental disease. Our program—especially the
synchronous module—clearly demonstrated
that teledentistry screenings assisted in estab-
lishing a dental home for disadvantaged rural
children.4,22 As described by Margaret Langelier
and coauthors, the beneficial outcomes of tele-
dentistry services at Finger Lakes Community
Health include significantly shorter waits to ob-
tain specialty consultations; higher treatment
completion rates; lower no-show rates for ap-
pointments; and improved work-flow efficien-
cies for patients, providers, and support staff.17
The teledentistry consultations help establish
patient-provider rapport. Children and parents
who present at FLCH for a teledentistry consul-
tation in the presence of a familiar dental hygien-
ist are more comfortable when they meet the
pediatric dentistry specialist in person in Ro-
chester. Parents are receptive to the convenience
of teledentistry services, as it fosters treatment
completion by accurately triaging children into
the specific treatment modality while saving
time, mileage, and resources.
As clearly demonstrated by the asynchronous
and synchronous teledentistry models, teleden-
tistry screenings helped increase completion
rates of recommended dental treatment in rural
and urban underserved pediatric populations.
Teledentistry holds promise to improve access
to care, especially among disadvantaged chil-
dren; improve patient satisfaction; potentially
reduce costs to the oral health care system, in-
cluding reducing dental staff members’ and pa-
tients’ time and mileage; and foster treatment
completion. As was reported recently, delivering
telemedicine or teledentistry services does not
require expensive equipment, and the initial cost
of establishing telehealth services at FLCH did
not exceed $15,000.17 To leverage our teledentis-
try program for better integration with FLCH
and the University of Rochester, we need to de-
velop an effective marketing plan and a solid,
comprehensive, and transparent business plan
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to manage our resources. Furthermore, the cre-
ation of an advisory board with well-connected
and committed oral health champions would
help us be successful and sustainable.
For teledentistry to become a viable adjunct
to mainstream clinical dentistry, various chal-
lenges to the widespread use of teledentistry
should not be discounted. They include dissim-
ilarities in state and federal laws, limited reim-
bursement, logistical encounters, and concerns
about data quality and security. To date, our tele-
dentistry program has been funded by research
grants, including those from the Aetna Founda-
tion, Monroe County Department of Health, Na-
tional Institutes of Health, Health Resources and
Services Administration, and US Department of
Agriculture. In 2015 New York State’s Medicaid
program expanded its telemedicine coverage to
include article 28 facilities that provide dental
services (for example, freestanding health care
facilities such as EIOH) and federally qualified
health centers. Telemedicine consultations (in-
cluding teledentistry) are covered when medical-
ly necessary and when several requirements are
met, including patients being physically present
at the originating “spoke” site and the consulting
practitioner being located at the “hub” site. The
practitioner at the hub site who is performing the
consultation must be licensed in New York State,
enrolled in New York State Medicaid, and cre-
dentialed and privileged at both the hub and
spoke sites according to the applicable setting-
specific standards.
The request for a telemedicine consultation
and the findings of the distant-site practitioner
must be documented in the patient’s medical
record. Lastly, the telemedicine consultation
must be in real time and provided via a fully
interactive, secure, two-way audiovisual tele-
communication system. At present, the asyn-
chronous store-and-forward modality is not cov-
ered by New York State Medicaid. With the
establishment of a well-adjusted and thoughtful
framework for the practice, use, and reimburse-
ment of teledentistry in a mainstream clinical
dentistry operation, patients, dental providers,
and oral health care systems will be able to real-
ize the full potential of teledentistry. Thus far,
efforts at EIOH to implement teledentistry mod-
ules have been limited to underserved urban and
rural pediatric populations. However, teleden-
tistry has substantial potential to serve other
populations, including geriatric populations
and patients with special needs or those who
have mobility or other barriers that impede ac-
cess to care. Clearly, populations that lack access
to oral health care—especially people who reside
in assisted living facilities, group homes, or
nursing homes where dental care is limited or
not available—would benefit from the availabili-
ty of teledentistry.
Moreover, a synchronous teledentistry consul-
tation module has substantial broader implica-
tions for improving access to oral health care,
especially among rural pediatric populations.
This undertaking supports the expanded role
of teledentistry in reducing barriers to oral
health care delivery, enhancing and improving
oral health outcomes, increasing use of oral
health care resources, reducing costs, and lead-
ing to the establishment of a dental home for
underserved children. The live-video consulta-
tion modality might also allow multiple pro-
viders to interact with a rural patient simulta-
neously. The advancement of teledentistry
underscores the need for its integration with
local, regional, and national telehealth pro-
grams to establish a balanced framework for tele-
dentistry services within the overarching health
care system.
Possible future uses of teledentistry include
the ability of licensed professionals to supervise
the care provided by dental students, residents,
or midlevel providers (that is, dental therapists)
at distant sites. State laws and practice norms
would need to be followed. However, applica-
tions such as the use of teledentistry may help
facilitate the care of underserved populations.
They may also help alleviate the documented
faculty shortages that many institutions report,
by allowing one faculty member to supervise
multiple distant learning or care sites at the same
time.
The teledentistry initiative at EIOH is not yet
integrated with the Center for Health + Technol-
ogy (CHeT) in the University of Rochester Medi-
cal Center. The CHeT telemedicine team runs
both clinical studies and patient care programs
centered on virtual visits. Our short-term goal is
to leverage the successful application of our cur-
rent models and integrate teledentistry with the
CHeT telemedicine program to become part of a
multidisciplinary telehealth initiative. Merging
with CHeT could give the teledentistry program
much-needed institutional support and increase
its visibility and sustainability; it would also
strengthen CHeT. Our long-term goal is to ex-
pand teledentistry services to other populations
of patients, including geriatric patients and
those with special needs. The first national tele-
dentistry conference, in conjunction with the
American TeleDentistry Association, will be held
in June 2019 in Rochester. This conference will
focus on topics relevant to incorporating tele-
dentistry into the overarching health care system
and will discuss regulatory and operational chal-
lenges, including the development and promo-
tion of policies to guide the expansion and sus-
tainability of teledentistry. ▪

The presented work was partially

supported by the National Institutes of
Health, Health Resources and Services
Administration, US Department of
Agriculture, and Aetna Foundation.

NOTES
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