Telehealth for oral medicine

By Ramesh Balasubramaniam
OAM Associate Professor in Oral Medicine, UWA Dental School

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Telehealth in Oral Medicine is a relatively new concept that has revolutionised the delivery of Oral Medicine services. “TeleOralMedicine” allows patients to receive Oral Medicine services online, which is especially beneficial for those who live in remote, regional, or rural areas or are physically incapacitated.

There are additional benefits and advantages of telehealth in Oral Medicine including improvements in patient outcomes, cost savings, flexibility, patient satisfaction, continuity of care, and levels of communication.

Despite telehealth being utilised globally by Oral Medicine Specialists during the Covid-19 pandemic and subsequent lockdowns, sectors of the Australian dental community remain apprehensive about telehealth services. Some concerns from the dental community related to telehealth include:

Quality of care: It is postulated the Oral Medicine Specialist may not have access to the same level of information and resources through telehealth as they would with an in-person consultation; leading to inaccurate diagnosis and treatment. There is a belief that video consultations limit the ability of the Oral Medicine Specialist to conduct a physical examination of the patient.
This could lead to difficulty in establishing an accurate diagnosis and providing appropriate treatment, compromising quality of care. To alleviate this concern, the Oral Medicine Specialist must work with the referrer to gather information they would otherwise obtain from a face-to-face consultation. For example, the referral process must include high quality photographs of the pathology in question. A head and neck examination to exclude lymphadenopathy must also be carried out by the referring dentist with findings outlined in the referral process. As such, concerns about quality of care are alleviated by collaborative care between the referring dentist and the Oral Medicine Specialist.

Privacy and security: Concerns exist regarding the potential for data breaches, hacking, and unauthorised access to patient data. This concern is largely unfounded. Telehealth services are required to adhere to the Privacy Act regarding patient information. Specialised purpose-built online platforms exist to conduct a secure telehealth consultation.

Access to care: Telehealth services may not be accessible to all patients, particularly those in very remote locations without access to the internet or the required technology. It may be true some very remote locations around Australia may not have access to the necessary technology and internet. However, it is also highly likely these individuals in need of Oral Medicine Services may be able to travel significantly shorter distances to access the necessary technology rather than having to travel to an Oral Medicine clinic in a major city. Unfortunately, if an individual is physically incapacitated, any travel may not be viable.  TeleOralMedicine offers a majority of patients options to reduce their barriers to access of care.

Reimbursement: Insurance reimbursement for telehealth services is still evolving and is yet to be recognised by all private health insurance schemes. This may discourage some referrers and patients from engaging telehealth services as patients may experience out of pocket expenses. Nevertheless, the cost of travel and loss of income to visit an Oral Medicine Specialist in a major city will be more significant than the out-of-pocket expense of telehealth services.
With any paradigm shift, it takes time for patients and dental practices to adapt and adopt the change. Of relevance, the recently updated 13th Edition of “The Australian Schedule of Dental Services and Glossary” has recognised the importance of telehealth services in dentistry and included 3 distinct item numbers: 919, 920 and 921. As such, you are encouraged to familiarise with these item numbers and their applications.

Follow-up care: Follow-up care may be perceived as difficult for telehealth patients and may not be as easily scheduled as in-person visits to monitor patient progress. Telehealth services is an opportunity for dentists and dental specialists to collaborate in the interest of patient care. Consulting a patient via telehealth must include treatment planning for follow-up care via telehealth or a scheduled in-person visit. To avoid any failure in duty of care with follow-up appointments, the Oral Medicine consultation must include a detailed report with clear instructions on any necessary treatment and follow-up appointments. This report must be sent to the referrer, the patient and other health practitioners involved in the patient’s care.  Communication between the specialist and practitioners involved in their care should be mutual and timely.

Building trust: The lack of personal interaction and the inability to read body language and facial expression may make it difficult for the Oral Medicine Specialist to build trust with patients through telehealth services.
It is probably true that a face-to-face consultation will likely facilitate building trust and rapport with patients. To facilitate trust and rapport, telehealth consultations should ideally include video. Guidelines exist to facilitate a high-quality telehealth appointment including good lighting, position of the camera, use of illustrations, delivery of patient education material, etc. Ultimately, trust and rapport are built by establishing an accurate diagnosis and treatment plan, and clearly communicating this information to the patient.

Access to diagnostic testing:
Telehealth services may limit the ability for patients to access diagnostic tests, including blood tests, imaging, and biopsy. In cases where diagnostic testing is necessary, the Oral Medicine Specialist will work with the referrer to facilitate the relevant tests. For example, if a patient requires a lesion excised under general anaesthesia, the Oral Medicine Specialist will work with the referrer and if required the treating surgeon to coordinate
the appointment.

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There are now over a dozen studies and published scientific articles on telehealth for Oral Medicine. It is anticipated the demand for telehealth services will continue to grow. It is conceivable, in the future, travel for Oral Medicine services will be strictly limited to clinical situations that warrant an in-person appointment for services that could not be provided remotely.