In 2017, more than $650,000 was paid out in health benefits for my husband and me. This is crazy! Having observed much of this treatment, the best I can say about our healthcare system is that there was no negative intent underlying the care that we received. It involved many dedicated professionals working like busy ants. Henry David Thoreau said, “It’s not enough to be busy; so are the ants. The question is: what are we busy about?” In the end, it is important to realize that healthcare “busy-ness” does not necessarily equate to healthier outcomes. Value-based healthcare is an emerging care delivery model in which providers, including hospitals, physicians, and dental professionals are paid based on patient health outcomes.
What Is Teledentistry?
The father in the Big Fat Greek Wedding movies constantly insists the root of every word is from Greek. He is correct in that tele- is derived from ancient Greek. Tele- is combined with another word to mean far off, afar, at, or to a distance.
Teledentistry is the ability to provide dental advice and treatment remotely. There are many definitions of teledentistry, which can vary from state to state.
National organizations have defined teledentistry as:
- a combination of telecommunications and dentistry involving the exchange of clinical information and images over remote distances for dental consultation and treatment planning1
- the utilization of technologies, including, but not limited to, telehealth, as a means to reduce oral health disparities2
- the remote delivery of healthcare services and clinical information using telecommunications technology, which comprises a wide array of clinical services, including teledentistry, using internet, wireless, satellite, and telephone media.3
Teledentistry is a disruptive innovation and a rising trend. It’s a game-changer that expands the reach and capability of the traditional dental practice. Additionally, teledentistry represents the next phase of oral healthcare, bridges the gap between supply and demand, and has tremendous potential to improve equity of oral healthcare and improve cost effectiveness.
In other words, teledentistry can help pave the path to healthier outcomes.
Implants Represent Failure
I bet that I got your immediate attention and raised some hackles with that subhead! I am not anti-implant. Implants are now a standard of care in dentistry.
As a typical baby boomer, the majority of the damage to my teeth occurred before the age of 16. Since that time, even as an RDH with impeccable hygiene, there has been a cycle of repair, followed by re-repair, and then further re-repair. Like many baby boomers, I have 7 endodontically treated teeth, one implant, and more! Only my 6 mandibular anterior teeth have not been touched by a bur.
All of that amazing dentistry costs a lot. It has been the foundation of our business model. The more unhealthy our patients are, the more income that is created through the treatment.
The American Academy of Periodontology has stated that periodontal disease can be prevented.4 In addition, numerous studies and groups support the thought that dental caries is a preventable infectious disease.5-7 In his 2012 book, Oral Precancer: Diagnosis and Management of Potentially Malignant Disorders, Dr. Peter Thomson says that there are many excellent textbooks encompassing the etiology, diagnosis, and management of oral cancer. But the problem is in looking for already present and developing cancer. His work demonstrates a different approach with the focus on finding and treating precancerous oral lesions that precede the development of invasive squamous cell carcinoma.8
Our model for oral healthcare from diagnostics to treatment is generally looking for moderate-to-advanced disease. We then try to reduce the damage after the horse has already left the barn, calling it “prevention.” We must go beyond our current model.
Reframing the Discussion
Oral health can and should be addressed in many places and in different ways by a variety of health providers. Improving oral health outcomes requires that these providers offer oral health services embedded across community institutions, using different kinds of effective approaches. The DentaQuest Foundation commissioned the FrameWorks Institute to conduct a Strategic Frame Analysis. Its 2017 report, “Unlocking the Door to New Thinking: Frames for Advancing Oral Health Reform,” presents reliable, research-based recommendations for reframing oral healthcare thinking.9
Landscape Volume to Value
Medicine has been transitioning from a volume-based to a value-based payment system for some time. The shift has not happened in dentistry yet, but will soon. Though unintentional, placing the incentives on volume over value, fee-for-service fails to create incentives for preventive care and coordination among providers. Value-based dentistry on the other hand, helps dentists deliver individualized treatment options to patients that align with their values and health objectives. Values-based payment models reward achievement of healthcare goals with enhanced payments. It is driven by data because providers must report to payers on specific metrics and demonstrate improvement. The metrics of coding provides us with the opportunity to measure important data. It is a beginning step.
Power of Metrics
For the first time, teledentistry codes are included in the 2018 edition of the ADA’s Code on Dental Procedures and Nomenclature (CDT Code). These codes are game-changers! Having a code provides the measurement tool (metric) and the opportunity to measure outcome data.
The term metric is somewhat new in healthcare since it can be interpreted in different ways depending on the circumstance. The basic definition of metric is a standard of measurement—simple and clear.
Metrics give us the power to quickly arrive at data-driven decisions that can improve outcomes and performance, drive cost saving, and enhance quality of care and patient satisfaction.
The value is the quantification of breakdown and measurement of the results of healing strategies. These data support the dental-medical necessity for treatment in a teledentistry encounter.
Teledentistry is already impacting dental care and creating exciting opportunities. Teledentistry services are designed differently and programmed to meet the specific needs of the populations, including traditional dental practices.10 Teledentistry can be used as a catalyst for collaborative care and increased referrals. Teledentistry connections create a very strong communication/referral system inter-professionally and intra-professionally.
Inter-professional: A network that connects a dental setting with a medical setting, such as:
- a private medical practitioner (ie, oncologist, cardiologist, pediatrician, obstetrician, etc.)
- an emergency room or acute care facility
- any institution that provides residential accommodations.
Intra-professional: A network that connects different entities within the dental industry together, such as:
- specialists to general practitioners
- provider-owned remote clinics with hygienists/assistant providers
- dental service organizations with resource sharing
- dental lab to dentists.
Adopting teledentistry within an existing private practice or dental service organization (DSO) is an organizational change impacting every member of the organization. Dentists, hygienists, assistants, office managers and other team members must be on board with the new virtual workflows.
It’s about finding the right fit for the practice and the practitioner. Teledentistry Pathway to Prosperity (dentalcodeolology.com) is a workbook that assists in making the critical choices to find that right fit.
Learning From Ants
Give a colony of garden ants a week and a pile of dirt, and they will transform it into an underground edifice about the height of a skyscraper in an ant-scaled city. Dynamic ant behavior might provide insight as to how to approach teledentistry. We are all working hard in our current practice models, but busy-ness does not equate to health. In fact, a myriad of studies supports the concept that prevention costs less than treatment. To reach teledentistry’s potential to improve equity of oral healthcare, cost-effective change is needed. The belief that oral disease is preventable must become the basis of our efforts. Teledentistry can move dentistry toward an outcomes/values-based system.
How much of the $650,000 could have been saved in the case of my husband and me if the treatment had occurred within an outcomes/values-based system? This is unknown; yet, it’s my strong opinion that it’s definitely the direction that we must go.
- House passes guidelines on teledentistry. ADA News. December 7, 2015. https://www.ada.org/en/publications/ada-news/2015-archive/december/house-passes-guidelines-on-teledentistry. Accessed September 8, 2018.
- American Dental Hygienists’ Association. Policy Manual. https://mymembership.adha.org/images/pdf/ADHA_Policy_Manual.pdf. Accessed September 8, 2018.
- American Telemedicine Association. About Telemedicine. http://www.americantelemed.org/about/about-telemedicine. Accessed September 8, 2018.
- American Academy of Periodontology. Preventing periodontal disease. https://www.perio.org/consumer/prevent-gum-disease. Accessed July 20, 2018.
- American Dental Association. Action for dental health: bringing disease prevention into communities. A statement from the American Dental Association. December 2013. https://www.ada.org/~/media/ADA/Public%20Programs/Files/bringing-disease-prevention-to-communities_adh.ashx. Accessed July 20, 2018.
- California Society of Pediatric Dentistry, California Dental Association. The consequences of untreated dental disease in children. https://www.cda.org/Portals/0/pdfs/untreated_disease.pdf. Accessed July 20, 2018.
- American Academy of Pediatric Dentistry. The state of little teeth. http://www.aapd.org/assets/1/7/State_of_Little_Teeth_Final.pdf. Accessed July 20, 2018.
- Thomson P. Oral Precancer: Diagnosis and Management of Potentially Malignant Disorders. Hoboken, NJ: John Wiley & Sons; 2012.
- FrameWorks Institute. Unlocking the door to new thinking: frames for advancing oral health reform. 2017. http://frameworksinstitute.org/assets/files/PDF_oralhealth/oral_health_messagememo_may_2017.pdf. Accessed July 20, 2018.
- DiGangi P, Purdy C. Teledentistry: Pathway to Prosperity. DentalCodeology, 2018.
Ms. DiGangi is an international speaker who is passionate about prevention issues in dental care and working with dental professionals to improve practice profitability. She is the author of the DentalCodeology book series and recently authored a chapter in the ADA’s CDT 2017 and CDT 2018 companions. She can be reached at firstname.lastname@example.org.
Disclosures: The author has reported no disclosures.