Within the past decade, significant

ABSTRACT Teledentistry and its use in dental education JUNG-WEI CHEN, D.D.S., M.S.; MARTIN H. HOB- DELL, B.D.S., M.A., Ph.D.; KIM DUNN, M.D., Ph.D.; KATHY A. JOHNSON, Ph.D.; JIAJIE ZHANG, Ph.D. Within the past decade, significant changes have occurred in information technology and telecommunication technology in health care fields that have had a positive impact on practice style. This new technology makes access to health care easier and faster. New terms like telemedicine, teledentistry and telepharmacy have caught the public s Teledentistry provides an opportunity to supplement traditional teaching methods in dental education. attention. Although many disciplines exist within the health care field, they all share an important common denominator: the use of telecommunication technology as an important role in health care practice. In the same way, teledentistry provides new opportunities for education and delivery of care that offer much potential and challenges. In this article we review the development of teledentistry, its use in dental education, its limitations and its future role. DEFINITION OF TELEDENTISTRY Teledentistry s roots lie in telemedicine. Telemedicine has been practiced since the late 1950s, 1 and a substantial amount of money has been spent on research and demonstrations. However, telemedicine still has no universally accepted, all-inclusive definition. One of the best definitions of telemedicine is that expressed by the Association of American Medical Colleges, or AAMC: Telemedicine is the use of telecommunications technology to send data, graphics, audio, and video images between participants who are physically separated (i.e., at a distance from one another) for the purpose of clinical care. 2 This definition is more inclusive than many Background. Teledentistry is a relatively new field that combines telecommunication technology and dental care. Most dentists and dental educators are unaware that teledentistry can be used not only for increased access to dental care, but also for advanced dental education. Type of Studies Reviewed. The authors describe teledentistry as it is applied worldwide, as well as its uses in education. Teledentistry in education can be divided into two main categories: selfinstruction and interactive videoconferencing. Both of these methods have been used in several studies and countries. Results. The type of network connectivity used greatly affects the feasibility of teledentistry education. Furthermore, no optimal type exists, but health care professionals should choose the mode based on budget, geography and technical support available. Of the two main categories of teledentistry in education, the interactive videoconferencing method has had better results because of its ability to provide immediate feedback. Clinical Implications. Teledentistry can extend care to underserved patient populations, such as those in rural areas, at a reasonable cost. Teledentistry provides an opportunity to supplement traditional teaching methods in dental education, and will provide new opportunities for dental students and dentists. and provides an overview of the breadth and depth of existing practice. We can amend this definition slightly to include oral health care and education. The initial concept of teledentistry developed as part of the blueprint for dental informatics (a new domain combining computer and information science, engineering and technology in all areas of oral health 3(pp3-17) ), which was drafted at a 1989 conference funded by the Westinghouse Electronics Systems Group in Baltimore. 3(pp53-64) Three groups of workshop participants addressed 342 JADA, Vol. 134, March 2003

issues relating to dental informatics and telecommunications used in dentistry. Only the first of these is relevant to teledentistry, and its focus was a discussion of how to apply dental informatics in dental practice to directly affect the delivery of oral health care. The term teledentistry was used in 1997, when Cook defined it as the practice of using video-conferencing technologies to diagnose and provide advice about treatment over a distance. 4 The state of California considers telemedicine to be the practice of health care delivery, diagnosis, consultation, treatment and education using interactive audio, video, or data communications. 5 The federal government, in its 1997 Telemedicine Report to Congress, defined it as the use of electronic communication and information technologies to provide or support clinical care at a distance. 6 HISTORY OF TELEDENTISTRY The Internet and broadband high-speed connections. Teledentistry often has been narrowly defined as only the videoconference mode of dental care. As discussed above, however, teledentistry is not confined to that narrow scope. It also includes data exchange through telephone lines and fax machines, as well as exchange of computer-based documents. When this broader definition is included, we find that teledentistry has a long history. 7,8 Changes within the past decade in the speed and method of data transfer have prompted clinicians and information technology experts to re-evaluate teledentistry as a highly valuable health care tool. The cornerstones of modern teledentistry are the deployment of the Internet and broadband high-speed connections, which have helped teledentistry enter a new era. U.S. Army Project. The U.S. Army s Total Dental Access Project is seen as being at the frontier of teledentistry. 9 Begun in 1994, this project initially used a traditional plain old telephone system, or POTS, with two different communication methods: real-time and store-and-forward. 9 The real-time method transfers the information immediately, whereas the store-and-forward method allows data to be stored in a local database to be forwarded as needed. POTS goes through the telephone company with low-speed and unreliable connections. Higher volumes of phone use worsen this situation. As a result, video and audio signals can be severely delayed, and quality sometimes is sacrificed to increase the speed. Nevertheless, patients have remarked that they received better care than that received from the traditional referral process when this system was available. 9 POTS still is used frequently in teledentistry because of its low maintenance and technical support costs. In 1995, Rocca and collegues 9 conducted a pilot study in Haiti to connect a general dentist to a dental specialist in Washington, D.C., via a low-bit-rate satellite system. The results showed that the video quality of the teleconsultation (consisting of intraoral photographs and dental radiographs) was insufficient for accurately diagnosing most pathological conditions. 9 Integrated Services Digital Network. Two years later, Integrated Services Digital Network, or ISDN based teledentistry was tested in Germany, Belgium and Italy. 10 ISDN provides a higher speed, and information can travel in both directions simultaneously, which increases accessibility to and reliability in teledentistry. Because setting up an ISDN network is very expensive (a major determinant of cost is distance in feet), it is not the ideal infrastructure for the U.S. Army s dental practice. Army dental practice must be positioned worldwide, and in the event of an emergency, the support of specialists may be needed. Building an international ISDN network is too expensive and impractical. Even though the network speed of ISDN is very good and the system provides good-quality images, it is more suitable to city or suburban clinics, such as those in Germany, Belgium and Italy. 10 Studies also have been conducted in Scotland, Japan, England and Taiwan to examine ISDNbased teledentistry. 11-14 The next generation of teledentistry practice uses a combination of the World Wide Web for videoconferencing and POTS for sending patient records. The Web is popular and available in most cities. Web-based teledentistry, unlike the ISDN, does not require a special network and, hence, is more cost-effective. However, the Web-based network poses privacy and security concerns because of hackers (that is, people who are proficient with computers but do no malicious damage) and crackers (people who use various tools and techniques to gain illegal access to computer platforms and networks). (An ISDN network, on the other hand, is connected from one point to another with no network sharing.) Studies conducted in Australia 15 and at JADA, Vol. 134, March 2003 343

the University of California, Los Angeles 16 mentioned that privacy was one of the major concerns for Web-based teledentistry. TELEDENTISTRY IN DENTAL EDUCATION Web-based self-instruction. Formal online education can be divided into two main categories: Web-based self-instruction and interactive videoconferencing. The Web-based self-instruction educational system contains information that has been developed and stored before the user accesses the program. 17 The advantage of Webbased self-instruction is that the user can control the pace of learning and can review the material as many times as he or she wishes. Johnson and Schleyer 18 studied Web-based dental continuing education, or CE, courses and evaluated them on the basis of a set of well-designed guidelines using the Design of Educational Software (developed by the American National Standards Institute Standards Committee for Dental Informatics). Disadvantages of Web-based self-instruction also have been noted in areas of satisfaction and accuracy. In 2001, Spallek and colleagues 19 conducted a survey of participants in several Webbased dental CE courses (38.8 percent response rate). The researchers found that the lack of faceto-face communication with peers and instructors was one of the main reasons for dissatisfaction. A study of electronic mail based oral medicine consultations 16 found that face-to-face patient examinations are more accurate in establishing a correct diagnosis for oral mucosal pathoses than are transmitted descriptive patient data alone. Interactive videoconferencing. Interactive videoconferencing (conducted via POTS, satellite, ISDN, Internet or Intranet) includes both a live interactive videoconference (with at least one camera set up where the patient s information is transmitted; however, cameras at both locations are ideal) and supportive information (such as patient s medical history, radiographs) that can be sent before or at the same time (for example, via fax) as the videoconference (with or without the patient present). The advantage of this educational style is that the user (typically the patient s health care provider) can receive immediate feedback. Positive feedback. According to a 1999 U.S. Army study, teledentistry can be a very good tool for teaching postgraduate students and even for providing continuing education for dentists. Although a complete evaluation of interactive videoconferencing has not been performed, studies have shown positive reactions from both the educator and student. 20 In interactive videoconferencing, patient information is evaluated first (with or without the patient present), which allows for interaction and feedback between the educator and students. Patient cases can be reviewed thoroughly and at the students pace. Cook and colleagues 13 studied a pilot teledentistry system (videoconferencing) for offering orthodontic advice and found very good results. They received positive feedback from the participating general dentists, patients and patients parents. The authors stated, From a clinical service standpoint, videoconferencing has not been an essential part of the system. However, it has played a significant role in training and maintaining the enthusiasm of participants, in addition to providing valuable feedback. 21 The general dentists participating in the pilot study stated that teledentistry taught them when to refer a patient and how to treat more complicated cases, which changed their practice style and gave them more choices in treating patients. In Japan, the staff of the Rural Health Center in Hokkaido 12 participated in videoconferencing for more than one year (1998 to 1999). The study s results showed that teledentistry significantly elevated health care knowledge and computer skills. The U.S. Army has been using teledentistry in its postgraduate dental residency programs for several years. 20 In its experience, orthodontics and periodontics are especially well-suited to teledentistry because much of the hands-on care can be rendered by dental assistants and hygienists. Dental radiology and imaging is another specialty area that is well-suited to teledentistry in education. 22 In all of these specialties, the cases can be discussed after all the clinical data have been collected and transmitted, without the patient being present at the scheduled meeting. According to our literature review, interactive videoconferencing is more effective than Web-based selfinstruction because of the ability to generate immediate feedback, which enhances students enthusiasm for learning. 11-13,16,19-23 Dental chat rooms. In addition, teledentistry is used widely and less formally at the grass-roots level. Dental chat rooms are available through 344 JADA, Vol. 134, March 2003

Dr. Chen is a clinical assistant professor, Department of Pediatric Dentistry, University of Science Center, Dental Branch, 6516 MD Anderson Blvd., Room 357, Houston, Texas 77030, e-mail chen27@hotmail. com. Address reprint requests to Dr. Chen. variety of topics. Dr. Hobdell is a professor and chair, Dental Public Health and Hygiene, University of Science Center, Dental Branch. Dr. Dunn is an assistant professor, Health Informatics, School of Health Information Science, University of numerous dental organizations and study clubs, as well as through individual practitioners who exchange information on a HOW TO USE TELEDENTISTRY IN DENTAL EDUCATION Although teledentistry looks promising within the realm of dental education, users need to understand its limitations and certain critical factors. Legal issues exist, including licensure, malpractice, privacy, security and ethics. Educational technique issues relate to protocol design, sustainability, standards, uniform charting, use of diagnostic codes and selection of instructors. Potential problems. Just as every state has its own licensing and dental requirements for the practice of dentistry, telemedicine and teledentistry licensure requirements also vary from state to state. 24 One of the advantages of teledentistry is its ability to increase access to dental care, but users must be careful when providing consultations across state lines. If technical problems occur during data transmission that cause a misdiagnosis or medical error, issues of responsibility and malpractice need to be considered. In addition, privacy and security are important issues in cyberspace. 24,25 If patient data are lost or stolen during the process of transmission, the entire project may need to be discontinued, especially once the Health Insurance Portability and Accountability Act becomes law. 26 Maintaining teledentistry courses. In additon to the need for speed and cost-effectiveness, sufficient efforts are required to maintain and sustain a course. The educational team must continually update the course material and schedule consultations between the consultant and the patient. 27 A clear, nationwide teledentistry protocol is needed (covering, for example, Dr. Johnson is an assistant professor, Health Informatics, School of Health Information Science, University of Dr. Zhang is an associate professor, Health Informatics, School of Health Information Science, University of forms, equipment recommendations, privacy and security requirements), which would enable organizers to control the problems caused by different standards and result in a more objective program evaluation. A standardized recording system would make the data-collecting process much easier and decrease the learning curve. 28 Diagnostic codes pose another problem. Because no universal dental diagnostic coding system exists that would enable users to maintain uniform records (the Code on Dental Procedures and Nomenclature, as printed in the Current Dental Terminology 4 manual, is for clinical procedures only), confusion over various systems might ensue. Need for experienced instructors. In addition, more is required of instructors for teledentistry education courses because they need to have both teaching experience and computer knowledge. 19 Educational courses should be guided by instructors who are experienced in leading online communication, able to promote discussion and familiar with the use of computer technology. Because of the diverse nature of CE courses, participants ages and computer skills can be varied. Instructors should recognize this problem and have the ability to assist most participants. Furthermore, before any teledentistry videoconference begins, it is necessary to test all of the connections. 7,13 A backup communication system and technical support group (for example, made up of network technicians, computer hardware and software technicians and security experts) also are needed. Reimbursement for CE courses is another issue that needs to be addressed. Currently, no insurance company has a particular reimbursement scheme for teledentistry. Without reimbursement from insurance companies, the financial support for these projects is limited to grants and other limited resources. 19 Sustaining such high-maintenance projects after the grant period ends can be a serious problem. Finally, most of the teledentistry-based education programs are in English. Since the Internet is a JADA, Vol. 134, March 2003 345

worldwide tool, future goals should include consideration of more multilingual programs. SUMMARY We have reviewed the definitions, history and use of teledentistry in clinical oral health care and education. In rural areas, where there is a shortage of specialists, the lack of comprehensive and sophisticated health care is a problem. 29 Primary health care professionals in rural areas must treat a large number of low-income patients, while earning less money than they otherwise would. 30 Teledentistry can extend care to additional patient populations at a reasonable cost, as well as ease the problem of a shortage of specialized dental consultants and professional isolation in rural areas. Choosing the right type of network connection depends on the characteristics of the practice (for example, budget, geography, maintenance requirements and available technical support). Teledentistry clearly can be a valuable tool for long-distance CE programs. The interactive videoconferencing system is more effective than the Web-based system because of its ability to provide immediate and adequate feedback. Teledentistry in dental education can provide primary care professionals with easy access to efficient consultation and case-based CE opportunities. Some barriers still exist for teledentistry practice, including legal, educational and insurance issues. Most important, an experienced instructor is required for designing protocols, instructing students and providing necessary technical support. A well-designed teledentistry practice needs to consider all of these issues. With thorough planning, however, teledentistry has a bright future. 1. Viegas S, Dunn K. Telemedicine practicing in the information age. Philadelphia: Lippincott-Raven; 1998:12-44. 2. Association of American Medical Colleges. Medical school objectives project: Medical informatics objectives. Washington: Association of American Medical Colleges Publications; 1998. 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