Teleorthodontics: a patient and orthodontist perspective

Objective

The objective was to conduct a clinical service evaluation, with the primary outcome of assessing the feasibility and acceptability of conducting new patient (NP) RCs, and a secondary outcome of identifying the barriers and facilitators to this intervention.

Methods

In response to the COVID-19 lockdown restrictions, Queensway Orthodontic group in north-east England implemented a secure virtual clinical system, Doxy.me (Rochester, NY, USA). Of concern with any online solution in healthcare is confidentiality. Doxy.me is a fully Health Insurance Portability and Accountability Act 1996 (HIPAA) and GDPR compliant solution, with encrypted point-to-point connections and provides a business associate agreement to ensure the security of the protected health information.⁷ Doxy.me offers a robust browser-based platform that requires no software installation, allows interface customization, an appointment management system, embedded teleconsent forms, live chat functions and video-chat sessions.

Over a 4-week period, consecutive NPs in five orthodontic practices belonging to the Queensway Orthodontic group, were selected for participation in this service evaluation. Historically, these patients would have been offered a FTFC for a NP assessment as a first contact. The protocol developed for managing these clinics remotely is shown in Table 1.

The teleorthodontic model used was a combination of real-time video consultations with the patient (and person with parental responsibility), alongside radiographs from the GDP from the referral and/or intra-oral photographs provided in advance by the patient, to aid decision-making. If additional diagnostics or a clinical examination were required, an FTFC was arranged. Inappropriate referrals were triaged, and the correspondence to the referrer discussed the reasons for rejection of the referral on each occasion.

The core features of an orthodontic NP consultation were identified (Table 2). The RC process evaluated in this study is compared to this ‘baseline standard’, with the following key features:

Results

Demographics and professional characteristics of participants

In total, 93 patient survey forms were completed, and 159 service evaluation forms were completed by four orthodontists; 23 of which reported the patient ‘was not brought’ (WNB). The patient age range was 6–18 years of age, with a mean age of 13 years (Table 3). The ratio of female to male patients was 3:2. Of the patient participants, 86% reported no previous experience using telehealth (Figure 1). Over the 4-week period no patients declined the RC and requested an FTFC.

Table 3. Demographics of participants.

		Patient survey response	Orthodontist survey response
Characteristics	Age range (years)	6–18	6–18
	Mean age (SD)	13 (2.1)	13 (2.3)
Gender	Female	56 (60%)	92 (58%)
	Male	37 (40%)	67 (42%)

Ease of use of the teleorthodontic system

The majority of patients reported that the system was easy to use (99%) and felt it was easy to access a smartphone, tablet or video-enabled computer for the RC (98%) (Figure 2). In total, 84% of patients reported that it was easy to upload the images of their teeth prior to the appointment; however, only two-thirds of the photographs were reported to be of acceptable quality by the orthodontist (Figure 3). The most frequent criticism was that unacceptable images were ‘too dark to make an orthodontic assessment’. In one-third of cases, orthodontists neither agreed nor disagreed that the quality of the photographs provided were of acceptable quality and reported that, although ‘the photographs [were] not good enough to complete the whole orthodontic assessment, they could identify…the need for orthodontic treatment’ and patients were placed onto appropriate waiting lists.

Patient respondents (89%) and orthodontist specialists (84%) agreed or definitely agreed that they could easily hear and speak, while 6% of patients stated that they could not hear the orthodontist and so a subsequent telephone call was carried out. The remaining patients (5%), who neither agreed or disagreed, reported that, ‘the sound quality was poor, but the orthodontist resolved the issues promptly using a combination of phone call for sound and online for video.’

Orthodontist satisfaction and outcome

Most orthodontists (87%) reported that the RC system worked well: 84% of all patients attended the consultation on time, and did not require contacting prior to the appointment (Figure 4). However, 14% of patients were not contactable, and the outcome of the RC was that the patient WNB.

Orthodontists were unable to identify the IOTN in only 11% of cases (Figure 5). Half of all consultations resulted in the patient being placed on the NHS waiting list, a further 4% on the priority NHS waiting list and 16% of patient referrals were rejected due to inadequate dental development, suboptimal oral hygiene and not meeting the IOTN threshold for treatment. A subsequent FTFC was required for 11% because radiographs were required (1%) or a clinical examination to allow a full assessment of the problems (10%) was needed (Figure 6).

Discussion

Implementation theory⁹ suggests that, to be successful, any telehealth system must be simple to use, must also be seen to be an advance over existing technology, and ideally integrate with existing work patterns and surgery computer systems. Although, Doxy.me was implemented and evaluated in this study, the authors recognize that other HIPAA-compliant video consultations are available, for instance, Attend Anywhere (AA), Zoom for Healthcare and VSee. AA is already used nationally by NHS Scotland and extensively across England and Wales. To use AA, participants are required to have the Google Chrome web browser or can download an app for Apple devices.¹⁰ Zoom for Healthcare includes tools designed for the telemedicine industry, including integrations with medical devices and electronic health records, but does not offer services such as billing features or appointment scheduling. VSee enables a pan–tilt–zoom camera control that is helpful for remote examinations.

Several challenges with video consultations have been reported (Table 4),¹⁰ and selecting the most appropriate video platform as one way of reducing these challenges is important. Learning from the experiences of our medical colleagues who have used video applications is particularly beneficial.^10,11 Local policies and procedures should be formulated and agreed upon by the practice, including a working-from-home policy if RCs are going to be undertaken from home, and an appropriate risk assessment must also be carried out. The orthodontist should also be familiar with their indemnity provider's guidance regarding the use of RCs to ensure that they comply, as well as regularly checking for any updates in guidance from the General Dental Council as this technology develops.¹²

Connecting remotely provides the ability to assess patients in their own homes, in a known and safe non-clinical environment. A reduction in footfall and clinical contacts, prevents unnecessary exposure of patients to COVID-19 or asymptomatic carriers, including healthcare workers¹³ and improves safety of medically compromised groups.

When active orthodontic interventions are not required, RCs offer convenience, avoid the need for travel, reduce pressures on car parking and associated costs. Staff are able to provide an outpatient service for those patients in self-isolation or those with childcare responsibilities.

Teleorthodontics is an innovative method of health service delivery that can aid triaging of orthodontic patients and stratifying the outcome of the consultation. To our knowledge, this is the first study that evaluated the use of teleorthodontics from a patient and orthodontist perspective during the COVID-19 pandemic, in primary care. Our results show that the overwhelming majority of patients and orthodontists were extremely satisfied with using teleorthodontics in all five domains: ease of use; the effectiveness (including increasing access to clinica services); reliability of the teleorthodontic system; patient and orthodontist satisfaction. Patients reported that they would be happy to consult with a healthcare professional using RC in the future.

Stakeholder feedback and engagement is very encouraging. Similarly, RCs can be implemented in other areas of orthodontic care, where active treatment or adjustments are not required. Emergency appointments, retainer reviews, treatment reviews, growth and development reviews and MDT consultations have been evaluated using e-dentistry.⁶ Owing to the practical nature of orthodontic treatment, teleorthodontics can only ever augment traditional clinical appointments.

The benefits of RCs need to be considered against potential risks that include missed diagnoses and health inequalities due to a digital divide,¹⁴ legal issues due to patient confidentiality,¹⁵ diminished patient–orthodontist rapport¹⁶ and missed safeguarding needs.¹⁷

Clinicians must be vigilant since there is a risk that referrals may be rejected inappropriately and had the patient been seen for a FTFC, their orthodontic need may have been identified. For four patients in the study, an IOTN diagnosis could not be made from the information gathered during the RC and the referral was rejected without offering a FTFC. The reasons for rejection of these referrals despite a lack of IOTN diagnosis included poor oral-hygiene and insufficient dental development. A way to safeguard against potential misdiagnosis could be to arrange FTFC in cases where there is uncertainty based on the information gathered from the RC, and to always provide correspondence to the GDP advising them of why the referral was rejected.

The 2020 consumer digital index revealed that approximately 16% of people in the UK cannot undertake basic digital activities, such as turning on a device, connecting to wi-fi or opening an app.¹⁸ It is recognized that the most vulnerable, disadvantaged, elderly and persons with a physical or learning disability are most likely to be digitally excluded and this can contribute to worsening healthcare inequalities. Feedback from one parent of a patient diagnosed with ASD, however, reported to the contrary; the RC acted as a proxy visual aid and assisted in acclimatizing her son to the orthodontist responsible for his ongoing treatment.

The Royal College of Paediatric and Child Health recommend the approach for RCs should be the same as that adopted for FTFC when assessing a child's safety, presence of a chaperone and a child's ability to make decisions.^17,19 While potentially offering an insight into a young person's home environment, safeguarding needs can be missed, such as subtle non-verbal cues. Use of digital consultations should be combined with a consistently low threshold for FTFC should there be any suggestion of safeguarding concerns.

Similarly, WNB pathways should also be followed in respect to virtual appointments. NHS Improvement²⁰ highlighted factors that affect the missed appointment rate and include the distance that patients need to travel, plus the requirement for patients (or parents) to get time off work (or school). NHS Improvement anticipated that both of these factors would be either removed or alleviated by the introduction of virtual consultations. Interestingly, the WNB rate (14%) was doubled following the implementation of the RC system, when compared to the FTFC pre-COVID WNB data. The sample size of this study is, however, small and may not be strictly comparable to pre-COVID rates.

NP consultations rely on good-quality patient records and it is been suggested that first visits/NP appointments must be carried out in-office.²¹ Importantly, a significant minority of patients were deemed to benefit from an FTFC, as a clinical examination or supplemental radiographs were required. The former was often a consequence of suboptimal photographs taken by the patient prior to the consultation. Some may perceive an FTFC outcome as a failure from this teleorthodontics system; however, the RC is invaluable for service preparedness planning, where initial history taking, and consent can take place. The FTFC that follows would include the examination, investigations if required, confirmation of diagnosis and treatment, potentially, in one clinical contact.

GDPs are reported to generally support teleorthodontics for NP orthodontic referrals. Mandal and colleagues in 2005 carried out a randomized control trial, in which GDPs had to provide patient demographics, history, overjet, extra- and intra-oral photographs and radiographs electronically. GDPs were, however, concerned about the costs, increased surgery time and remuneration.²² Providing appropriate resources to support patients in taking their own photographs can aid in minimizing surgery time. Patient involvement in obtaining good records is advocated by the British Orthodontic Society.²³ Queensway Orthodontics provide instructional videos for patients to take their own photographs using tablespoons as cheek retractors. Potentially this service could evolve to provide the patient with examples of suboptimal photographs, such as those with insufficient lighting, to improve the acceptability of the images.

Remote consulting presents particular challenges for young people and carries potential risks, such as safeguarding and digital exclusion due to socio-economic status and access to technology. Further research is needed to assess whether RCs contribute to worsening healthcare inequalities for orthodontic patients. Despite the vast positive patient feedback, teleorthodontics will not suit all orthodontic patients. Retaining choice and control over how to consult will be critical.

Conclusion

Teleorthodontics has the potential to augment traditional clinical services, such as during the COVID-19 pandemic and beyond. An overwhelming positive response towards teleorthodontics was obtained from patient and specialist orthodontic stakeholders. The applications of teleorthodontics should be assessed with future research, both in primary and secondary care.