Remote consultations in orthodontics: factors to consider for success

Telehealth is defined as the entire spectrum of activities used to deliver care remotely, without direct physical contact with the patient¹ and, in medicine, has been shown to confer advantages such as cost-effectiveness, improvements in quality of care provided to patients² and reductions in waiting times.³ Its use has been demonstrated globally, particularly in remote areas where access to specialized medical advice is challenging.⁴ Importantly, the safety, convenience and effectiveness of virtual clinics in medicine has also been reported⁵ and hospital trusts in the UK encouraged the use of telehealth during the COVID-19 pandemic as a method of maintaining communication with patients.

Teleorthodontics can be considered as a subset of telehealth, and is broad term that encompasses remote provision of orthodontic care, advice, or treatment via information technology rather than direct personal contact.⁶ Unlike telehealth, which has been widely used by GP practices for several years, teleorthodontics is a concept that may have been considered as fledgling or unusual prior to 2020, but which has been quickly thrust to the forefront of the orthodontic profession, largely due the COVID-19 pandemic.

Prior to the COVID-19 pandemic, which necessitated the use of teleorthodontics as the only available means of communicating with patients, examples of teleorthodontics in the literature were limited. There were occasional examples of specialists or consultants engaging with general dentists in order to facilitate treatment via remote methods, in order to make specialist advice more accessible.^7,8,9

In more recent years, with the advent of clear aligner therapy and as the development, ease of use and accessibility of technology has grown, there has been increasing interest in how the remote monitoring of appliances may improve patient convenience, while reducing chairside clinical time. Studies particularly regarding the use of apps, such as Dental Monitoring, have been published.⁶

With more people accepting telephone and video consultations as a convenient and secure method of communication, it seems likely that, even after the ramifications of the COVID-19 pandemic have dissipated, increased use of remote consultations will continue to be seen as desirable. It is therefore important that orthodontists and any orthodontic professionals who are involved in teleorthodontics ensure that they are aware of the limitations, as well as the benefits, of teleorthodontics and are able to consider their professional, as well as the medico-legal considerations, when offering remote consultations to patients. They should also feel confident and competent in how to effectively and appropriately carry out these remote teleorthodontic appointments.

This article discusses the benefits and risks of teleorthodontics, and outlines important aspects that should be considered to ensure that remote consultations are planned and delivered in an efficient, effective and appropriate way. A physical check list that splits the remote consultation into its critical stages is also presented (Table 1).

Benefits, limitations and patient experiences

Positive patient experiences of teledentistry and teleorthodontics have been reported^6,10,11 with a recent literature review advising that teleorthodontics has been shown to be capable of managing most emergencies, as well as reassuring and following patients remotely.¹² However, this conclusion came with the advice that these preliminary findings needed further investigation to objectively evaluate the efficacy, cost-effectiveness and long-term results of teleorthodontics. A list of potential benefits and limitations of teleorthodontics that should be considered is presented in Table 2. One particular limitation that has been identified is the potential for disadvantaging those who may find accessing teleorthodontics challenging, such as the older population, those from socio-economically disadvantaged backgrounds, or those with physical or learning needs.¹³ Orthodontists and their teams must, therefore, recognize these potential limitations pertinent to their local population and consider methods of overcoming these barriers if a change to the use of teleorthodontics within their practices and/or departments is going to be effectively and sustainably managed.

Getting ready for remote consultations

Planning the virtual consultation

The appropriateness of using a remote consultation will always need to be carefully assessed as some types of appointments in orthodontics will never naturally lend themselves to being effectively managed remotely. Each situation should be assessed individually, as well as taking into consideration the current circumstances in determining what types of appointments may be replaced by using remote methods of communication. Decisions will need to be based on local needs of the population. Table 3 outlines some examples of the types of appointments that may be considered appropriate for the use of teleorthodontics.

Consideration should also be given to the type of technology selected for the appointments, which in most circumstances will be the decision between using a video platform or using the telephone. While video-calling the patient has some obvious benefits compared with the telephone, particularly regarding the visual aspects of communicating with the patient and being able to examine removable appliances in particular, there will still be limitations to consider, particularly the increased planning required, as well as the increased risk of technology failure (Table 2).

The individual needs of the patient must also be considered in determining the appropriateness of replacing a face-to-face appointment. For example, patients with learning difficulties, or hearing or sight impairments, may find telephone or video appointments extremely challenging. This consideration should also be extended to the parents or guardians of patients who need parental consent.

Several challenges, particularly with video consultations have been reported^17,18 and selecting the most appropriate video platform as one way of reducing these challenges is important. Learning from the experiences of our medical colleagues with video applications is particularly beneficial.^18,19 While during the height of the pandemic, it was considered acceptable to use ‘off the shelf’ secure methods of communication, such as WhatsApp, in emergency situations, orthodontic practices should now be considering the long-term benefits and advantages of using professional and bespoke video platforms that have been specifically designed for remote healthcare provision. There is now a myriad of options available, with more sure to follow as this area continues to develop at pace (Table 4). It is important that a secure platform is chosen that will not risk data loss and the patient will need to be reassured of the safety of engaging in a remote consultation with their orthodontist. Certain features, such as the ability to screen-share may also be beneficial for certain consultations, and this should be borne in mind when selecting the most appropriate video platform for the expected application. Local policies and procedures should also be formulated and agreed upon by the practice, including ensuring the practice has a working-from-home policy if remote consultations are going to be undertaken from home by the clinician, and that an appropriate risk assessment has been carried out. The orthodontist should also read their indemnity provider's guidance regarding the use of remote consultations to ensure they are in compliance, as well as regularly checking for any updates in guidance from the General Dental Council as this technology continues to develop.²⁰

Technology

It is now easy and relatively inexpensive for practices to ensure they have the hardware in place to carry out remote video consultations. If the practice computers do not already have web cameras installed, all that is required is a ‘plug and play’ stand-alone webcam. It is however desirable to have two screens so that the patient's clinical notes can be viewed simultaneously during the consultation and therefore, using a tablet device alongside the regular surgery computer may be beneficial. To assist in ensuring patient confidentiality, the orthodontist may also wish to consider the use of a ‘boom’ headset for video consultations. Should more than one clinician need to engage on the call (ie a multidisciplinary clinic, or a call involving a treatment co-ordinator and orthodontists), the purchase of a good quality USB ‘plug and play’ microphone, could be considered to try and improve the ability of the patient to clearly hear all the clinicians involved in the consultation. Of course, there is also no point in the practice being technologically ready if the patient isn't, and appropriate pre-appointment information should be given, or sent out to the patient in advance of the appointment. This should include information on what technology the patient will need themselves in order to participate successfully in the remote consultation, as well as detailing what they can expect from the process itself, such as how long the consultation is likely to last.

Designing a specific consent form to be sent to the patient could also be considered beneficial in order to ensure that the patient engages with the remote consultation appropriately. Practitioners should note that medico-legal cover usually only extends if the patient is physically within the UK at the time of the remote consultation. Some video platforms have consent forms embedded within them and use of such a platform may advantageously reduce the administrative burden on the practice. The practice should, however, be prepared to guide some patients through this process, particularly if the patient is inexperienced with using video applications, or has concerns regarding the process. If the clinicians are also new to using the video platform themselves, then it is advisable to practice using the platform with friends, family or colleagues before using the platform to deliver a remote consultation with a patient.

Before the video consultation

Once the correct technical support has been installed and set-up, planning is required in order to ensure the remote consultation is successful and the orthodontist will most likely find that more planning is required to prepare for these appointments than for traditional face-to-face appointments. Referring to a checklist will ensure that nothing is accidently forgotten.

Table 1 gives an example of such a checklist. Another checklist, taken from pharmacy, is the CONSULT (consider, organize, necessary, start, undertake, listen, terminate) checklist,²¹ which could easily be adapted to orthodontic practice

Remote consultations should not be seen as inferior to face-to-face appointments, and the environment in which the remote consultation is going to take place should also be carefully considered. The orthodontist should ensure professional standards are maintained, such as being appropriately dressed and being mindful of the background that will be in view for the patient. Some platforms allow the background to be blurred or changed and these aspects will need to be particularly considered if the remote consultation is being carried out at home. Further aspects for the clinician to consider before the remote consultation are listed in Table 5.

Clinical records

Ideally the orthodontist should have access to the patient's clinical records at the time of the remote consultation, and record keeping of the remote consultation should be of the same standard as if the patient had attended for a face-to-face appointment. Access to all the patient's clinical photographs is an enormous benefit and therefore access to a Dolphin database (Patterson, MN, USA) or equivalent is essential for a quality consultation. The only additional element to record in the clinical notes is of the medium used for the remote consultation, ie telephone or video. At present, it is generally not considered necessary to record every remote consultation, although in the future, this may become part of the process. If the orthodontist is planning to record a remote consultation, the patient will need to be informed of this in advance and consent must be obtained.²² The patient will need to be advised why the consultation is being recorded, how it will be stored and for how long. This consent should be recorded in the clinical records. The recording will now be part of the patient's clinical records and should be treated in the same way as any other medical records.²³

During the remote consultation

In embarking upon the consultation itself, it is obviously extremely important that appropriate introductions are made and that the identity of the patient is clearly established prior to any clinical information being discussed. Although this should be outlined in the consent form, it would also be pertinent to ask the patient to confirm that they are somewhere private to talk, and that they are in the UK, as these are important medico-legal considerations to record.

As orthodontic patients are often under the age of 18 years, it is likely that a parent or guardian will be speaking on behalf of the patient, and it will also be important that it is confirmed and documented who they are and that they have parental responsibility for the child.

The first stage of the consultation conversation may thus proceed as:

‘Hello, I believe you are expecting a call from your orthodontist?

May I just confirm your name, date of birth and address to confirm I have the right notes?

Thank you, I am XXXXXX from XXXXX. I am calling you because…

Can I please ask you to introduce to me everyone who is in the room with you and who is with you that has parental responsibility for you?’ (If the patient is under the age of 18)

After establishing identities, it is important that the clinician next confirms a contingency plan with the patient in case the video technology fails. This may involve ensuring that the correct telephone number has been recorded for the patient with the clinician confirming that they will call them back on the telephone if the video happens to fail.

During the consultation itself, it is important that the clinician is mindful of challenges of interpreting body language, voice intonation and the patient's general demeanor during a remote consultation. Natural gaps in dialogue can seem to be much longer and more awkward, and care must be taken in how expressions are interpreted as people can sometimes look angry, serious or disgruntled when they are concentrating or listening. The clinician themselves should themselves try and avoid making rapid gestures and be mindful of their own facial expressions while trying to ensure they are speaking slowly and clearly. Patients may well be more demanding and have higher expectations than can be adequately satisfied remotely by the clinician. It is important that the clinician is honest with the patient about the limitations of the remote consultation, and gives the patient time and uses silence as needed.

Another clear challenge in a remote consultation is the difficulty in establishing who should be speaking. This can be caused by delays in the connection, and when this happens, the clinician should acknowledge the problem and either continue, or ask the patient to speak. Using a phrase such as ‘I lost the connection briefly’, the clinician can reassure the patient and allow a smooth continuation of the conversation.²¹

Because of the potential risk of greater communication issues remotely, it is important that before closing the call, the clinician checks the understanding of the patient, summarizes the key points that have been made during the consultation and clarifies with the patient what the next steps are, and what they should expect to happen moving forwards.

Again the use of a checklist, such as that outlined in Table 1, will ensure that none of these important steps to successful communication will be forgotten, and ensures that after the consultation, both the clinician and the patient feel that the consultation was successful and are happy with how the orthodontic care will be moving forwards.

Summary

Although thrust upon the orthodontic profession due to the circumstances of the COVID-19 pandemic, there is now an opportunity for the orthodontic specialty to use technology and supplement routine and necessary face-to-face appointments with convenient and cost-effective remote consultations in certain clinical situations. Practices and hospital departments wishing to provide these services will need to develop the systems to ensure that remote consultations take place appropriately, efficiently and effectively. It is likely that patient expectations surrounding traditional face-to-face consultations will change as a result of the COVID-19 pandemic, and the opportunity to investigate and explore new ways of working should be embraced. The use of checklists will ensure that the risk of human error is reduced while undertaking remote consultations in orthodontics.