Teledentistry installation diagram
The clinician viewed the incoming video via a PC connected to a large monitor. The large screen facilitated simultaneous viewing of both the intra-oral camera video as well as that from a second web-cam, a high definition Logitech model C920 model, capturing the overall interaction between patient and the intra-oral camera operator. This was also streamed as an mpeg4 video of minimum 3 Mbit/s bandwidth. Mpeg4 audio was also transmitted at 128 kbit/s along with the images via the use of Clear One Chat 50 model microphone/speaker units also connected via USB cables. This allowed excellent quality audio communications between the patient and clinician nodes.
Fourteen volunteer patients received two oral examinations. One examination was a standard real-time (the clinician present in front of the patient) full mouth oral health examination including dental, periodontal and oral mucosal assessments. A second and ‘virtual’ examination was conducted using an intraoral camera operated by a teledentistry assistant in communication with a remote examiner who was also a registered oral health professional. The information obtained from this examination was video recorded and an oral health professional performed a ‘virtual dental examination’. Findings were recorded in conventional dental charts.
Information from the remote examination was compared with a real-life dental examination. The level of intra-examination reliability for the degree of consistency of the two sets of examinations was assessed using the kappa statistic. The intra-examiner agreements for dental and periodontal examination parameters were reported as excellent, 0.94, and good, 0.74, respectively. These results indicate that the proposed teledentistry approach for oral health screening using an intraoral camera proved to be feasible and reliable as an alternative to traditional oral health examination.
10.3.2 Field Testing of Teledentistry Technology in Residential Aged Care Facilities
This study represented field testing of teledentistry technology to enhance older adult assessment in residential aged care facilities to provide regular and timely oral health checks using trained non-oral health professional assistants in the first instance. Improvements in oral health in Australia over the past 50 years have translated into a greater proportion of elderly individuals retaining more of their natural teeth, increasing the prevalence of caries and periodontal disease. Older people living in residential aged care facilities (RACFs) have been identified as a significant risk group for oral diseases in Australia, and the changing demography and oral health needs of older Australians will present many challenges for the dental profession over coming decades.
In 2005 more than 41,000 Victorians lived in high or low-care residential facilities on a permanent basis; with just over half being dentate and having high dental treatment needs [3, 15]. However in Victoria only 11 % of aged care facility residents have seen a dentist in the past 12 months, as there are few dentists available to provide dental care for residents [14, 16]. Furthermore, older people are proportionately over-represented in rural and regional Australian communities and these communities are ageing more rapidly than their metropolitan counterparts. Therefore, this intervention potentially targets a rapidly expanding segment of the population with special oral health needs.
Three RACFs within the state of Victoria, Australia, were successfully approached to participate in this stage; two in metropolitan Melbourne and one in rural Victoria. Five non-oral health professional teledental assistants (e.g., registered nurses) in these facilities were trained to manipulate an intraoral camera and use existing and introduced ICT infrastructure to transmit video images for remote examination and diagnosis. A manual was prepared to assist them with use of the intraoral camera and teledentistry procedures.
Once informed consent was provided, patients underwent a baseline assessment performed at the RACF, by the intraoral camera operator. A review system was established within the Melbourne Dental School, The University of Melbourne (MDS), either as a two-way interactive consultation, or stored and forwarded repository maintained by the MDS. A Store and Forward version was developed that enabled the mpeg4 file to be stored on a central server for asynchronous download by the dentists. Each examination lasted approximately 15 min and each minute of video created a file of approximately 1 GB.
Fifty residents from the three RACFs participated in the trial. A total of five trained intra-oral camera operators (registered nurses) recorded, and transmitted video images to qualified clinicians at the MDS who performed a ‘virtual dental examination’, recorded findings and developed a treatment plan for each participating resident. Results of the examination of each participating resident were communicated back to the RACF.
The study also aimed to identify barriers to the adoption of a teledental approach. On completing the virtual oral examination each participant was asked to complete a seven-item assessment questionnaire to assess his/her views on the teledentistry approach. As further verification of the scheme, there was an interview with the RACFs teledentistry staff to assess their attitude, acceptance and practice of the approach and to discuss any other issues encountered by them during the project. Residents expressed high levels of satisfaction with the teledentistry service.
Additionally, the trial tested the utility of an instructional training kit, and assessed residents’ views of their overall experiences during delivery of the program, as well as feedback and information provided during the teledentistry consultation itself. There was general agreement that the material presented was clear and relevant to the purposes of this project. RNs also agreed that the scope of the material was appropriate.
10.3.3 Field Testing of Teledentistry for Paediatric Dentistry
The project targeted children and adolescents living in traditionally underserved regional and remote locations within the Australian state of Victoria to provide them with sustainable dental services. These are high-risk segments of the population with special oral health needs. The conjecture was that initial assessment by a consultant, using teledentistry, would decrease the number of times a patient would need to attend the Royal Children’s Hospital in Melbourne (RCH) to see a specialist (i.e. orthodontist, paediatric dentist). In addition, the use of teleconsultation can help to categorise treatment priority and avoid the need for the patient to travel to an often distant centre for assessment.
In this study, three general dental practitioners (GDP) working in community dental clinics in Victoria (Rosebud, Shepparton, and Geelong) were trained to manipulate an intraoral camera and use existing ICT infrastructure to communicate with the dental specialist at RCH and transmit video images for remote examination. Training was provided for the GDP involved in the project and a manual was prepared to assist with use of the intraoral camera. A review system was established within the RCH as a two-way interactive consultation, almost equivalent to a real-time examination.
The trained GDP identified the reason for consultation, manipulated the intraoral camera and recorded findings for each participant. An off-site paediatric dentistry consultant located at the RCH, performed the ‘virtual dental examinations’. The remote examiner screened patient and assessed their need for future intervention and provided advice on treatment to each participating patient and to the GDP and health staff at the local Community Health Centre. The remote examiner provided advice and follow-up to the GDP on how to manage the condition locally or refer for specialist care.
Participants were recruited from the RCH’s patient database for cleft lip and palate (CL&P) and orthodontics living in the selected locations. Patients were introduced to the study by the GDP. When the patients, or their primary carers, expressed interest in participating, each received a Plain Language Statement describing the study and a Consent Form. Once informed consent was provided, patients underwent a baseline assessment. In common with the previous project, patients/parents of patients participating in the study completed a questionnaire to assess their experiences of the various aspects of the program; satisfaction, acceptance and practice of the teledentistry approach and to discuss issues associated with the project.