From a Distance

Paul Feuerstein, DMD


Over the past few months, most of us have been interacting with patients and staff via phone calls, texts, emails, and video chats. We have often asked patients who had urgent issues to use their smartphones to send a “selfie” or photo of their problems, often of a broken tooth or lost crown. Many times, we were able to talk them off the ledge and reassure them that the problem was not as urgent as they had assumed. And, as we know, the tongue seems to magnify that “giant hole” or piece of tooth or filling that disappeared. Some did require a trip into the office, while others were able to be stabilized with over-the-counter cements/fillings or medications. Many practitioners used Zoom, FaceTime, Skype, or other phone apps that allowed a face-to-face consultation and discussion and to perhaps make a plan for when the offices opened for “nonessential” treatment. Taking this a step further, the primary doctor might have decided to make a referral to a specialist and forwarded this information, along with the photos and patient information, using these same pathways. There is a basic issue with this approach: None of these portals are secure, and they are contrary to HIPAA rules. It seems that due to this unique circumstance, rules were relaxed, and fines were not imminent.

What this did accomplish, though, is that it created in patients and providers more familiarity of this method of communication and triage. Many of us are now using these same pathways as a common method for patient/office communication. This whole process is now back under scrutiny and has to be addressed. It has been simply stated in the HIPAA recommendations that emailing patient information is not compliant or secure. Many states have rules in place stating that any information from attorneys, accountants, banks, or medical providers has to be sent through secure email portals. You have all received an email stating that General Hospital or Mr. CPA has sent you a message—just click on this link to read it. When you do, a screen comes up asking you to set up a password and brings you to the “messages” page. Your reply securely goes from there back to the initiator. There are many variations on this theme, but the idea is that the messages go through an in-between place that is secure. The office must subscribe to these services and set up accounts for the staff, usually for a monthly or annual fee. These services also allow for collaboration between multiple accounts: for example, when multiple specialists are required to develop a treatment plan. As far as video conferencing, it is debatable how secure some of these common portals are. They do require password protection, but as we have seen recently, they can be easily “hacked,” leading to some uncomfortable intruders, and, of course, medical information can be seen and stolen. Just as there is encrypted email, there are totally encrypted video channels that are labeled “teledentistry.” These products are far more than just encrypted video chat software. They have multiple functions for group consults, record sharing, referrals, and more complex consults. The earliest player was MouthWatch (, which created a platform that incorporates its affordable intraoral camera (in addition to any images) to give real time doctor-patient communication that allows for live consults with specialists or even with the dental lab.
As the quarantine evolved, many insurance providers agreed to reimburse for remote exams, some for a limited time. There is actually an ADA teledentistry code (D9995). This is not always reimbursed, but if charged in conjunction with a limited oral evaluation (D0141), many of the insurance carriers do pay for the exam, assuming the patient has proper coverage. Dental offices can, of course, charge a reasonable fee for any service irrespective of insurance.

Moving out of the crisis arena, as we get back to “normal” practice, this concept can be used in many ways. These virtual visits can still be used to screen emergencies by the person answering the phone to schedule the patient more efficiently. But virtual consultations for anything from answering questions to actual smile design consults can be done with several options. These have been around for a long time, but the concept was previously hard to explain to patients. Now everyone is familiar with virtual meeting products, such as Zoom, and understands how they are useful. This can also be a vehicle for postoperative questions in general as well as for reviewing treatment plans. Very often, we schedule a block of time with a patient to review some details of a plan and answer patient questions. As teledentistry removes the time and costs required for room- and PPE-preparation procedures, it can be a great method of followup. A visit can be made even more spectacular using, for example, screen sharing. The patient at the remote location can be shown photos, intraoral images, and even radiographs for further explanation. Two of the companies, MouthWatch and Dentulu
(, have inexpensive USB intraoral cameras that can be lent or actually sold to patients to allow a close-up look at the followup for healing or even new problems. Keep in mind that, although remote, we still have to be sure to give accurate information as liability extends beyond the walls of the practice.

There are now many companies that have these secure portals for patient interaction. There are too many to list here, but they can be referenced on the Dentistry Today app or found online at
This is indeed a reset of our practices.