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Virtual visits peak during crisis

Hands holding a tablet with the image of someone on the screen talking
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Dentists’ conversations about teledentistry have varied through time. The progression went a lot like this: “Why in the heck would we ever need that?” to “It may be feasible;” to “It may be useful for patients under some conditions.” 

Then COVID-19 came along and a new conversation emerged: “Virtual visits are integral to dental practice during this crisis.” 

That’s because some 80% of dentists nationwide closed their doors for anything beyond urgent or emergency care. They did it to help slow community spread, preserve medical supplies and relieve emergency departments from caring for dental patients. But that didn’t stop patients from needing attention. For starters, most dental conditions are such that patients require their dentist’s assessment to know if urgent care is needed. 

The ability to triage and evaluate patients suddenly depended on telecommunication technology. The conversation about teledentistry — using technology to deliver dental care and information at a distance — became a conversation about access to care, even for patients who have always had a dentist right down the street.

Insurers agreed. In many cases, carriers changed policies to benefit procedures when performed via teledentistry, which hadn’t been done before. For example, carriers had always paid for D0140, but now they reimburse for a D0140 — limited problem-focused evaluation — if done through teledentistry, which is a new change. Some changes are in place for three months or a year and others an undefined period. 

The delivery of services via teledentistry must comply with each individual state’s scope of practice laws, regulations or rules. Some restrictions imposed were eased by executive order due to the extraordinary circumstances of the COVID-19 crisis, such as allowing use of cell phone pictures and digital platforms that good teledentistry practice would not allow under normal circumstances. 

Dr. Julia Heinrichs believes the defining moment for all future conversations about teledentistry is here. It came for her personally back in 2011 after the Joplin tornado. Practicing in Joplin, Missouri, and also serving as president-elect of the Southwest Missouri Dental Society, she saw firsthand how patients were affected by the destruction. More than one-third of the dental practices in the area were demolished and many others were so severely damaged that patients couldn’t be seen. Some 161 people were killed and more than 1,100 were injured. Adding to the chaos, tornadoes, wind damage and flooding extended across southwest Missouri and made roads impassable.

“That’s when I learned telecommunication technology is essential,” said Dr. Heinrichs, who had previously seen the need for virtual visits for nursing home and some rural patients. “I realized then that I wanted this access for all patients.”

Her initial exploration of teledentistry’s potential began with a desire to eliminate the patient access issues a natural disaster can inflict. Now she advocates for its much wider breadth. Her belief that teledentistry encompasses many areas of practice and provides solutions for patients and dentists under many circumstances guided her creation of Teledental Solutions.

Through her team’s services, she seeks to help dentists provide quality teledentistry. “It’s a mistake to think that teledentistry is only about the exam,” said Dr. Heinrichs, adding, “especially considering the technology available.”

While new telehealth equipment and applications are a draw to the already initiated, COVID-19 marked many dentists’ first foray into serving patients remotely. Limited-focused evaluations of existing patients were virtual visits performed frequently by dentists in March and April of 2020.

The Office for Civil Rights said that during the COVID-19 public health emergency, it would not impose penalties for HIPAA noncompliance against health care providers that serve patients in good faith through everyday communications technologies, though providers should notify patients such applications potentially introduce privacy risks. Under the extraordinary circumstances, dentists had the chance to begin by doing evaluations with telephones that have audio and visual capability and using popular digital platforms (not public-facing) that allow for video chats, such as Apple FaceTime, Facebook Messenger, Google Hangouts video, Zoom and Skype. 

“Many dentists have been observing how it is being used for some time but COVID-19 really accelerated interest,” said Dr. Heinrichs. “For example, in Kansas — a state not particularly receptive to teledentistry — dentists have been asking questions about it.” 

Some 25% of dentists used virtual technology/ telecommunications to conduct remote problem-focused evaluations (CDT Code D0140), during the week of April 20, 2020. The findings are according to respondents of the biweekly tracking poll conducted by the ADA Health Policy Institute. The query was part of data collection to better understand the impact of the COVID-19 pandemic on dental practices. Investigating the potential of teledentistry has the long-standing support of dentists like Dr. Joy Poskozim, who began practicing 21 years ago. The Chicago-based general practitioner hopes new understanding of the utility of telecommunication technology won’t have a time limit or eventually fall by the wayside.

“We need it now, and we’ll need it in the future too,” she said. Dr. Poskozim estimates that one-third of her patients who need an evaluation won’t attempt an in-person visit anytime soon because of continuing fears about contracting COVID-19.

Access to care has long motivated Dr. Poskozim. Her decision to treat patients that might be described as shut-ins at home or in long term care facilities followed observing her grandmother’s circumstances in a nursing home. She thinks the advantages of advances in mainstream technology have helped her provide better care. Since smart phone technology began allowing her to do so, she has been assessing nursing home patients’ conditions on an ad hoc basis via images. “If I have a picture, I can see what’s going on so I know what equipment to bring to the facility,” said Dr. Poskozim. 

Recently, a nursing home visit required her to see a COVID-19 patient. She didn’t have knowledge of the patient’s status in advance, which was one thing. But as it turned out, the visit to that patient was completely unnecessary. Called in for a broken tooth, Dr. Poskozim found a broken crown.

“There was no reason for me to have been in the room,” she said. “I could have made that judgment and diagnosis if I’d had a photo. Should the onus have been on the nursing home to make that judgment? No. It should have been on me — the dentist. And it would have been if I had the opportunity to see the photo.”

Dr. Poskozim described a trauma situation that happened early on in the COVID-19 outbreak, wherein a boy who is an existing patient was roughhousing and chipped a lower tooth. Concerned, his mother sent a photo to learn if he needed attention and Dr. Poskozim was able to conduct a limited exam. “How many times do we do this for our existing patients,” she asked rhetorically. “I never considered billing for it but dentists should be making some of the revenue that is due them for these evaluations. I’m happy to see the policy change allowing payment for the procedures when performed using telecommunication equipment,” she said. “You have to have the photo and the narrative to explain the situation and every dentist knows how to do that.” 

The ADA advises that all patient encounters using telecommunication technology are appropriately documented in the patient’s record, including date, time, reason for visit and duration, and any related clinical notes. 

Dr. Heinrichs said she hopes dentists will be in the lead on future conversations about teledentistry. “Dentists want to be better prepared for the possibility of going through another wave of this virus or being hit with any natural disaster,” she said. 

Teledentistry resources:

  • ADA Health Policy Institute, COVID-19 Economic Impact on Dental Practices available at ADA.org/COVID19Impact

About the author

Author photo for Arlene FurlongArlene Furlong is a Chicago-based journalist and editor with more than 20 years of experience writing about dentistry.