Guidelines for Teledentistry

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In certain circumstances where a patient is seeking care from a dentist but is unable to attend a dental clinic in person, it may be necessary to conduct a consultation by audio or through a videoconferencing platform such as Microsoft Teams, Skype, Google Meet or Zoom. Videoconference services are the preferred approach for substituting a face-to-face consultation. Regardless of the application used, practitioners must ensure that their chosen telecommunications solution meets their clinical requirements and satisfies privacy laws.

It should be noted that a service may only be provided by teledentistry where it is safe and clinically appropriate to do so. This item number is not intended to be used for offering routine assessments, advice or oral health instructions. It is a patient-led service.

Ideally teledentistry services should only be offered to existing patients or those referred by another practice.

The appropriate item number to use from the Australian Schedule of Dental Services and Glossary is:

919 Teleconsultation

The remote provision of a consultation to a patient in exceptional circumstances which prevent face to face consultation. It may include the provision of oral health or treatment information and referral.

The item number may be used with other relevant item numbers, e.g. 019 Letter of referral.

What steps should I take in conducting a teleconsultation appointment?

All patients are potentially suitable for teleconsultations. Patients may contact the clinic for an appointment by either phone or email.
The teleconsultation appointment may be booked as a normal appointment in your clinic’s practice management software. The patient should also be sent teleconsult joining instructions via SMS or email. Most videoconferencing platforms will send this information automatically. If not, this information should include:
The patient should be made aware, at the time of booking and at the start of the meeting, of the limitations of teledentistry and that dentists are providing the best advice possible in the absence of face–to–face consultation. Any method of communication used should ideally be secure.
Patient consent for the consultation must be attained prior to the meeting either verbally or in written format.
At the start of the meeting, the identity of the patient should be confirmed using at least three patient identifiers such as name, date of birth, and address The patient should be informed of who is present in the clinician's room and able to hear/see the conversation.
The patient’s current clinical records should be available for reference. You may therefore choose to either conduct the teleconsult at your clinic, or by accessing your practice management software through a remote secure channel.
A detailed record of the consultation should be written contemporaneously in the patient’s clinical records, including:

What security is required when conducting a teleconsultation appointment?

Choose a secure platform

Dental healthcare providers should use one of the following videoconferencing systems which are listed in order of security level preference:

Microsoft Teams
Skype for Business
Google Meet
CISCO Webex or Jabber
VIMED Teledoc (Victorian Stroke Telemedicine program)
Zoom

Do not use ‘social media’ platforms such as Facebook, Twitter or WhatsApp. These platforms, as the name implies, are designed for social interactions and are not secured for clinical consultations or discussions.

Manage your attendee list

When using video conferencing keep your meetings small and short to control security and privacy.
Ensure you invite only people you know and need for the meeting, do not allow on-forwarding of your invitation to third parties.
Always set up unique conference Identification (ID) and Password for each session, where the application supports this functionality.
Keep attendees in a ‘waiting room’ or ’lobby’. Admit only when they are verified.
Keep an eye on the attendees throughout the session, watch for ‘rogue attendees’.
Terminate session immediately if you suspect there is an unverified attendee.
Reschedule with new conference ID and Password.

Manage what you share

Allow file sharing from the host only. Attendees should forward files to be shared to the host prior to the meeting.
Avoid sharing classified information on screen.
Close all unnecessary windows to avoid accidental sharing.
Share patients’ clinical documents only, when necessary and not by default.
Remove any sensitive information in your background for video calls, for example, whiteboards, documents and computer screens.

If you are using Zoom

Although Zoom is not recommended for patient-care provider interactions, we recognise its increasing popularity in accessibility and ease of use. If there is no viable alternative to using Zoom, follow the steps below when setting up each session. The following may also be used as a general guide to setting up videoconferencing.

1. Use a randomly generated ‘Meeting ID’

Using an automatically generated code (ID) means you have a different link for each meeting, which increases security.

2. Add a Meeting Password

You can add a password when scheduling your meeting in the Meeting Password section:

This means even if someone manages to guess or steal your Meeting ID, they are unable to easily join without your Meeting Password. It changes the meeting link you send with an encrypted password, for example:

it changes your direct link from this: https://agencyx.zoom.us/j/518730239
to this, with the password encrypted: https://agencyx.zoom.us/j/518730239?pwd=UndycENZS2lQbGRrZ25nOWhIVWQyQT09

The session invite must be sent with the Meeting ID and the Meeting Password together.

3. Utilise the ‘waiting room’

When scheduling your Zoom session, you can also use a ‘waiting room’. Anyone attempting to enter your session will be sent to a waiting or holding area. You will need to manually allow them entry into the session. To manually allow entry into the session you must be logged into Zoom as the host.

4. Do not use ‘Enable join before host’

The ‘Enable join before host’, Zoom tick box allows sessions to be scheduled by another person in your organisation. This leaves the Zoom Meeting ID open outside of the session time. If you must use this option, make sure you use risk mitigation steps 1, 2 and 3 above.

Do not use this function as a general practice:

5. Check your background

Ensure there is no sensitive information in your background. Zoom allows you to have a virtual background for increased privacy.

To learn how to enable virtual backgrounds click on the link below: https://support.zoom.us/hc/en-us/articles/210707503-Virtual-Background

In summary

Stay cyber safe by staying alert in your sessions:

know who is in the meeting
limit what you share
do not leave the session open after the call
end the session immediately upon evidence of an intruder

Do I need to conduct the teleconsultation from my normal clinic?

No, you do not need to be in the dental practice to provide telehealth services, but you should ensure you have secure access to patients’ clinical records.

You may use your provider number for your primary location and must provide safe services in accordance with normal professional standards.

Can I delegate responsibility for conducting a teleconsultation to another staff member?

Only if the person who conducts the consultation is the holder of a provider number.

Which patients are most suited to a teleconsultation?

Any new or existing patient who requires oral health care may be suited for teleconsultation. However, typically it is any patient who is in pain and/or dysfunction, has complications related to a recent dental procedure and requires follow up or is presenting with a potentially serious oral health problem. You may find teleconsultations especially useful in situations such as:

Outside of normal practising hours.
Who are unable to attend the clinic due to illness, isolation, or quarantine. Such as:
Individuals who are unable to attend the clinic during a pandemic due to being identified as a person of high risk for morbidity or mortality.
Individuals who reside at remote locations where access to care is limited or unavailable. E.g mine site, serviceperson on a vessel or off-shore facility.

When would a teleconsultation be appropriate?

Outlined below is a series of examples where it would be appropriate to conduct a consultation remotely.

Toothache

The following suggested questions may help you to determine if it is an acute odontogenic infection.

Is this new or recurrent?
Has the patient recently undergone a dental procedure?
Have they been prescribed antibiotics for this problem before?
Do they have an elevated temperature?
Do they have facial swelling and pain, trismus, neck swelling, difficulty swallowing, difficulty breathing or a compromised airway? If the patient has a spreading infection/cellulitis, they should present to the nearest emergency department and the dentist should call the hospital and provide details of the referral.
If an existing patient, do they have any changes to their medical history, including allergies, medications. If new patient, detail full medical history.
Determine the site of the pain.
Determine how long the patient has had the pain.
Determine the nature of the pain. E.g. Stabbing, throbbing, etc.
Determine if the pain radiates.
Any other signs and symptoms.

If the patient does not meet admission criteria for hospital, consider if the patient needs pharmaceuticals and/or if their management can be deferred. Please refer to the Therapeutic Guidelines Oral and Dental V3 for the appropriate prescription of analgesia and/or antibiotics.

Broken or loose tooth

Ascertain from the patient the degree of mobility of their tooth or teeth. If there is no pain and the tooth is not mobile enough to be aspirated, management may be deferred.

If the tooth has broken, the patient should be asked if there is any pain or hot/cold sensitivity. Treatment should be deferred if the tooth is asymptomatic.

If the tooth is broken or chipped, or causing soft tissue irritation, patients may be directed to file it down themselves with some sandpaper or a nail file. Orthodontic wax might also be suggested.

Trauma

In cases of dental trauma, determine if the management of this may be deferred or if urgent visual inspection is required. You may wish to ask some or all of the following questions to help in determining the extent of the injuries.

Which area of the face was there trauma to?
Is the tooth sore to touch?
How loose is it?
Is the tooth broken?
Is the gum around the tooth bleeding?
Is there bleeding from the lips, gums or other tissues?

Please refer to the International Dental Trauma Guide: https://dentaltraumaguide.org/free-dental-guides/permanent-teeth/

Orthodontics

Remote monitoring of cases is now common and should be encouraged.

Ascertain if this is a situation for which the management may be deferred. The patient can contact their orthodontist if their arch wire has come loose, or the bracket has come loose for advice.

If there is soft tissue irritation, the patient may be directed to place some orthodontic wax or sponge (from a makeup remover pad) over the sharp area.

Broken dentures/crowns/bridges

Broken dentures should not be worn if they are an aspiration risk.

Management of broken crowns and bridges should be deferred. Broken or loose crowns should be kept safely until treatment can be provided in the clinic.

Patients should not be encouraged to recement any of these due to an aspiration risk.

Oral Medicine

Telehealth is warranted for patients with orofacial pain and headache, temporomandibular disorders and painful or potentially sinister orofacial pathology. In many cases, a working diagnosis and recommendations including triaging can be delivered via telehealth. Patient should be offered a telehealth consultation if the following conditions are suspected:

Orofacial pain - such as acute TMJ arthralgia, TMJ disc displacement without reduction, TMJ dislocation, severe masticatory muscle pain/spasm, psychosocial distress secondary to chronic pain
Neurological changes - facial palsy, sensory deficit, altered sensation
Trigeminal neuralgia or other painful orofacial neuropathies
Orofacial swelling
Oral ulceration- including episodic, recurrent and/or persistent
Oral mucosal lumps, areas of pigmentation/discolouration, white or red patches
Oral mucosal blisters