Review articleOrthodontic referrals via TeleDent Southwest☆
Section snippets
Background
Telemedicine, the delivery of health care and the exchange of health care information across distances [1], is currently an accepted part of modern health care provision [2]. Recent publications indicate that primary care dentists in the United Kingdom [3], [4] would welcome the availability of diagnostic support by such means.
Almost all children who receive orthodontic care in the United Kingdom do so within provisions of the United Kingdom National Health Service (NHS). More than half of
Method
Because full details of the protocol are to be published elsewhere [21], they are only summarized in this article. Six participating general dental practitioners were recruited by interview after an initial advertisement placed in the United Kingdom dental press. A further general dental practitioner joined the trial on an informal basis, and his data are also included in this article, although he did not provide a complete set of pretrial data. (He is referred to as Dentist G.) The closest
Clinical examination
To ensure that the consultant had all the necessary information with which to assess a referred case, the dentists were provided with a further piece of in-house produced software: Jeremiah 2000. This rule-based expert system incorporated fuzzy logic, which was developed from an earlier program [12], [22], [23]. This highly interactive program guides the dentist through a full orthodontic examination (Fig. 1). The consultant did not accept cases unless the clinical information had been gathered
Obtaining advice
During the trial, a dentist who believed that he or she had a case in need of orthodontic advice or treatment could access this advice at three levels (Fig. 2).
Technical support
Although dentists with claimed basic information technology (IT) skills were selected for the study, and despite the fact that two half-day sessions of training were provided, all but one of the dentists required significant additional support in the early weeks of the project. Mainly this support related to simple file handling and unfamiliarity with the Internet. Most of this support was provided during scheduled video conferencing sessions, for example, when undertaking the pretrial tests of
Use of equipment and the process of referral
All but two of the dentists located their computer in their own operatory, which suited them although it was sometimes a bit cramped. The advantages were that it enabled them to prepare or continue cases between patient appointments and demonstrate the benefits of the system to patients. Two of the dentists used an adjacent unoccupied room. Two of the dentists said that they would have preferred to have the equipment installed at home because they worked part time and lived some distance from
Capturing clinical data
The time it took general dental practitioners to collect clinical data using Jeremiah 2000 was similar: approximately 10 minutes per case. The time taken to capture the images was much more variable and took from 5 to 25 minutes. The dentist with his own digital camera took the least time. On a test case of the duplicated records that were sent by surface mail to all the practitioners, the overall time to complete a referral, including transfer of the whiteboard by file transfer protocol,
Cases referred
During the trial the referral system worked well, no cases were lost, and none was misdirected. The highest number of cases referred in any one week was 13, with an average of 5 cases per week. A total of 163 cases, made up of class I, 50%; class II division 1, 29%; class II division 2, 10%; and class III, 11%, was seen during the trial. This is similar to the distribution found in studies of malocclusion in the United Kingdom population, except that the level of class III was raised to reflect
Was the advice from TeleDent what was needed?
Although only one clinician (C.S.) was used to provide advice in the trial, an earlier prospective peer review study of orthodontic treatment plans had shown that this author enjoyed a high level of peer approval from his consultant and specialist colleagues [24].
The dentists were happy with the advice that they had received, and there was general agreement that TeleDent SW was a good way of obtaining this. Advice was always returned to the dentist within 7 days, and 50% of referrals received
The effect on patient care
There were wide variations in the effects that the availability of TeleDent SW had on the participating dentists' practices. This seemed to depend on a dentist's level of orthodontic expertise, distance from an orthodontic specialist, and whether he or she was in the habit of referring cases regularly to the local orthodontic consultant. Dentist C, who received additional training in orthodontics, had been treating cases for himself and his associates for some time with conventional advice from
Avoidance of late or inappropriate referral
Table 1summarizes the dentists' answers to the questions posed in the box and indicates the overall effect that they believed TeleDent SW advice had on patients' treatment. These results do not suggest that there were a large number of cases that were saved from inappropriate orthodontic treatment by the availability of online advice, but a study of results achieved with and without Teledent advice would be necessary to confirm this finding.
Of the 12 cases in which the dentist intended to
The effect on the dentists
All dentists undertook three standardized tests of their orthodontic knowledge, appliance design skill, and accuracy of case assessment before the start of the trial. These tests were repeated a year later. On both occasions, the tests were performed online and without prior warning. Only the scores of the case assessment skills tests showed a significant improvement (mean pretest score, 37.6; mean posttest score, 48; t = 2.97; P<0.02).
At the end of the trial the author agreed to continue to
Summary
The information presented in this article must be interpreted with caution. Ideally the trial should have lasted longer because five of the seven participating dentists said they felt constrained from taking in more cases because access to TeleDent advice would cease before completion of all but the shortest of treatments.
Second, the number of practitioners recruited into the trial was small, and the dentists chosen were highly selected. Third, almost all the data are based on the opinions of
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This work was supported by grant RDO/90/42 of the UK National Health Service Primary Dental Care Research and Development Programme.