Evaluating remote care by tele-dentistry

1. Evaluating remote care by tele-dentistry Rodrigo Mariño Early Childhood Oral Health Symposium 28 September 2016

5. e-Health “to encompass the rapidly evolving discipline of using computing, networking and communications - methodology and technology - to support the health related fields, such as medicine, nursing, pharmacy and dentistry" (WHO)

6. e-Health “products, systems and services that go beyond simply Internet-based applications. They include tools for both health authorities and professionals as well as personalised health systems for patients and citizens.” (EU)

8. Major areas of tele-health applications

9. Teledentistry “Body of knowledge that focuses on the organisation, management and distribution of information in support of dental education, practice, research and administration”

10. Reasons for Teledentistry Teledentistry has the potential to benefit oral health care by: • enhancing early diagnosis, • facilitating timely treatment of oral diseases, • reducing isolation of practitioners through communication with peers and specialists, • reduce health care inequalities. For example access to specialists in rural (geographical or by resources) or underserved areas.

11. Applications of Teledentistry

12. Applications of Teledentistry Background • 1950’s dental education. • In use since the early 1960s and covers a broad range of technologies. • The largest teledentistry undertaking in the world is being undertaken by the U.S. military. • Slow adoption of teledentistry.

13. ICT provides opportunities to supplement traditional methods for:Tele-consultationTele-diagnosisTele-treatmentTele-education Tele-training Applications of Teledentistry

14. Overcoming geographical barriers for community health Inequalities in oral health

15. Backgound • Face-to-face patient examinations are regarded as the most accurate method for correct oral health diagnosis. • However, members of specific groups of the community are less likely to have access to a dentist. • For example, the elderly (homebound or living in nursing homes).

16. Backgound Information from the Australian state of Victoria indicates that: • 11% percent of residents have seen a dentist in the past 12 months, • few dentists are available to provide dental care for residents of aged care facilities, • half of Victoria’s dentists reported providing care to residents of RACFs, and • These spent on average only one hour per month providing care in this setting.

17. Overcoming geographical barriers for community health Field testing of remote teledentistry technology Rodrigo Mariño, David Manton, Parul Marwaha, Richard Collmann, Andrew Stranieri, Matt Hopcraft, Michael McCullough, Ken Clarke Inequalities in oral health

18. Overcoming geographical barriers for community health High Definition 3-D tele-medicine applications for the empowerment of patients in health care facilities and the home* *http://www.hpc.unimelb.edu.au/~dirk/HD3D/hd3dtelemedicine/ Inequalities in oral health

19. Broadband 3D tele-health applications • Four proof-of-concept projects: • Teledentistry, • Teleoncology, • Telepsychiatry, and • Telewound management

20. Objectives To assess the feasibility of using teledentistry to screen for oral diseases and conditions and to develop treatment plans for older people living in Residential Aged Care Facilities (RACF).

21. Three nursing homes in Victoria Two metropolitan One rural. Five registered nurses. Fifty RACF’s residents. Methods

22. RN Traininginvolved: 3 hours of direct contact, a 66-page training manual with contents organized in 6 modules. Module 1: Uses of teledentistry Module 2: Oral health in older adults Module 3: Oral and dental anatomy: practical issues Module 4: How to conduct the intraoral teledental examination Module 5: Use of the dental camera for teledentistry consultation Module 6: Capturing and forwarding information from dental examination up to 10 hours of practice examinations , and compensation for their time. Methods

23. Registered nurses performed a ‘virtual dental examination’ on a group of residents. 10 residents (with no cognitive deterioration). 10 repeated face-face exams. The information obtained from this examination was transmitted to a server. Information was registered on a conventional chart for the generation of treatment plans by qualified clinicians at the Melbourne Dental School, University of Melbourne. Methods

28. The Implementation of teledentistry for Pediatric Patients Rodrigo Mariño, David Manton, Parul Marwaha, Kerrod Hallett, Ken Clarke, Matthew Hopcraft, Michael McCullough, Ann Borda

29. Objectives To assess: • the feasibility of using teledentistry for teleconsultation in children/adolescents living in rural/remote areas of the state of Victoria, • participants’ views about the structure, content and delivery of the program, • whether it could be implemented under current financial arrangements.

30. Sites for the project: -RCH (Main central site) - Shepparton Urban Rural - Frankston - Geelong Methods c

31. Three local general dental practitioners (GDP) were trained to manipulate an intra-oral camera and use ICT infrastructure to send the information for remote examinations. Teleconsultation specialists at the Royal Children’s Hospital of Melbourne/ Dental School, University of Melbourne. Methods

32. 3 oral health conditions were selected: Cleft lip and palate Dental trauma Orthodontics Patients from the RCH’s patient database who lived in the selected locations wererecruited. Both, the community health centres and the RCH, operated within current financial arrangements. Methods

33. Parents were given a questionnaire to assess his/her views on the teledentistry approach. GDPs self-completed a questionnaire to assess: their overall experience with the approach, the utility of the instructional training kit, and other issues. Methods

34. Results

35. Results c

36. Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia

37. Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia Based on postcodes, the TD model :

38. Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia • 367 TD appropriate consultations were found in the dataset. • Average cost of a RCH consultation $431.29 vs. $294.35 for TD. • TD was more cost effective for those travelling greater distances. • 36.7 days of clinic time may be freed up in the RCH clinic. • These results were robust when performing one-way sensitivity analysis. 

39. Conclusions • The teledentistry approach proved to be feasible a viable solution, in terms of time, stress, and money saved for parents and children. • When taking a societal perspective, the implementation of TD is likely to be a cost-effective alternative compared with the standard practice of face-to-face consultation at the RCH.

40. Conclusions • From the RCH perspective, the potential reduction of inappropriate referrals with the concomitant reduction of waiting lists for specialist consultation, are important advantages of teledentistry, which are clinically important and also have budgetary implications. • This reduction was achieved without increasing costs to the oral health provider.

41. Consumer medical and health information Oral Health Promotion Multimedia Web Enhancement Oral Health Promotion Program for Older Adults Funded by BUPA Foundation

44. mHealth

45. Lab-on-a-smartphone • Personalised medicine approach in which consumers monitor their own health using devices attached to their smartphones. • These would comprise attachments that convert smartphones to optical microscopes and related instruments.

46. Dental Trauma Tracker Dental Trauma Tracker

47. Mobile Applications for the Prevention and Management of Early Childhood Carries (ECC) ECCAPP

48. The solution To develop and validate a new mobile phone-based communication and monitoring application, for the detection, prevention and management of early childhood caries. • The application is called ECCAPPS. • This application, will combine multimedia web and mobile technologies with personalized assistance as required.

49. Pukallus M, Plonka K, Kularatna S, Gordon L, Barnett AG, Walsh L, Seow WK. Cost-effectiveness of a telephone-delivered education programme to prevent early childhood caries in a disadvantaged area: a cohort study. BMJ Open. 2013 May 14;3(5). doi:pii: e002579. 10.1136/bmjopen-2013-002579. Print 2013. Plonka KA, Pukallus ML, Holcombe TF, Barnett AG, Walsh LJ, Seow WK. Randomized controlled trial: a randomized controlled clinical trial comparing a remineralizing paste with an antibacterial gel to prevent early childhood caries. Pediatr Dent. 2013;35(1):8-12. Plonka KA, Pukallus ML, Barnett AG, Holcombe TF, Walsh LJ, Seow WK.A longitudinal case-control study of caries development from birth to 36 months. Caries Res. 2013;47(2):117-27. doi: 10.1159/000345073.. Pukallus ML, Plonka KA, Barnett AG, Walsh LJ, Holcombe TF, Seow WK.A randomised, controlled clinical trial comparing chlorhexidine gel and low-dose fluoride toothpaste to prevent early childhood caries. Int J Paediatr Dent. 2013 May;23(3):216-24. doi: 10.1111/j.1365-263X.2012.01248.x. Plonka KA, Pukallus ML, Barnett AG, Walsh LJ, Holcombe TF, Seow WK. A longitudinal study comparing mutans streptococci and lactobacilli colonisation in dentate children aged 6 to 24 months. Caries Res. 2012;46(:385-93. doi: 10.1159/000339089.. Plonka KA, Pukallus ML, Barnett AG, Walsh LJ, Holcombe TH, Seow WK. Mutans streptococci and lactobacilli colonization in predentate children from the neonatal period to seven months of age. Caries Res. 2012;46:213-20. doi: 10.1159/000337353. Epub 2012 Apr 19. Plonka KA, Pukallus ML, Barnett A, Holcombe TF, Walsh LJ, Seow WK. A controlled, longitudinal study of home visits compared to telephone contacts to prevent early childhood caries. Int J Paediatr Dent. 2013 Jan;23(1):23-31. doi: 10.1111/j.1365-263X.2011.01219.x. Epub 2012 Jan 18. Onetto JE, Uribe S, Lira. Impacto en el índice ceo en población preescolar mediante aplicación de un modelo de intervención temprana. Proyecto FONIS SAO4I2123. Informe final. 2008. Uribe S, Onetto JE, Lira P, Mariño R. Effectiveness of early diagnosis and intervention for early childhood caries. International Association of Dental Research. 86th General Session. Toronto, Canada, July 2008 Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. The effects of chlorhexidine gel on Streptococcus mutans infection in 10-month-old infants: a longitudinal, placebo-controlled, double-blind trial. Pediatr Dent. 2003;25:215-22. Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. A longitudinal study of Streptococcus mutans colonization in infants after tooth eruption. J Dent Res. 2003 Jul;82:504-8.

50. ECCAPP ECCAPPSwill have three major components: • Information (using gamification) • Management • Clinical • The Information and Management Components will be on mobile devices • The Clinical component will be at a hospital or dental clinic.