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Teledentistry, a solution for our new coronavirus reality

May 1, 2020
Dr. Margaret Scarlett describes how dental offices can limit patient contact while still providing care through teledentistry during this time of pandemic.

Recently, the American Dental Association (ADA) announced that dental offices should limit their practices to emergency care until the current situation improves. Their recommendations suggest nonemergent care such as examinations, prophys, most restorative work, etc., be deferred. The new normal is that dental professionals have an urgent need to limit patient contact, while still providing continuity of care for patients and keeping their practices running during a global pandemic.

Dentists are asking themselves questions like, “What now? How can I prioritize or defer care? What can I do later? How should I provide emergency dental care at this time? And what is the definition of  ‘urgent care’?” Dental practices are scrambling to figure out what to do. Hopefully, this article will assist in that decision process.

The dental industry’s role in flattening the curve

Here are a few science-based facts. First, keep in mind that dentistry is part of the overall outpatient national health-care system. Today, dental practices must help slow the spread of COVID-19 so that our health-care system, including hospitals, can catch up with patient diagnosis, treatment, care, and maintaining operations.

Dentists are not the only health-care providers who must focus on urgent care. Based on projected rapid increases of critically ill COVID-19 patients, the surgeon general recently announced that hospitals cancel all elective surgery to free up hospital beds to care for the most critically ill patients. Also, the American College of Surgeons released recommendations that elective surgeries in hospitals be deferred. We are not alone in making big changes in health-care delivery.

Did you know that a leading cause of visits to many hospital emergency rooms (ER) is oral pain? Dentists can help to reduce these ER visits to free up space for critically ill patients, especially those with severe COVID-19 symptoms. What’s more, dentists can do this at a fraction of the cost.

At the very least, we can prescribe antibiotics and pain medicines. We can do our part by using teledentistry to keep dental patients out of the ER. But there is much more we can do in the new normal of COVID-19.

The main driver for expanding our value to our patients and the overall health-care system during this crisis will be through the use of teledentistry platforms such as TeleDent (MouthWatch).

Dental professionals can help flatten the epidemic curve of COVID-19 and the SARS-CoV-2 virus that causes this disease in many ways. Here’s how:

Use teledentistry to evaluate dental emergencies

First, define true dental emergencies for your practice. We know that if oral surgery is indicated, we can perform extractions or refer to dental specialists, such as oral surgeons, endodontists, or periodontists. We do this every day anyway. The new normal is that we can evaluate emergencies—at least initially, without patients coming to the office—with teledentistry. We can also prioritize and defer some patients for later treatment, based on their medical history and symptoms.

Adjust your billing for teledentistry

This is a process to assist you with your regular care, using your regular billing. Two CDT codes are currently being used for teledentistry as a process to provide care, along with the actual procedure codes (for limited exam or evaluation, etc.).

The CDT procedure codes applicable to teledentistry are:

  • D0140—limited oral evaluation, problem focused
  • D0170—reevaluation, limited, problem focused (established patient; not postoperative visit)
  • D0171—reevaluation, postoperative office visit

The specific teledentistry codes are:

  • D9995 teledentistry—synchronous; real-time encounter
  • D996 teledentistry—asynchronous; information stored and forwarded to dentist for subsequent review

The advent of COVID-19 has prompted many dental boards and practice acts to relax or reassess their individual regulations on teledentistry. While this is rapidly evolving, always check with your state dental board on how dentists, hygienists, and assistants can use teledentistry in your state. You can decide whether teledentistry is a fee for service or billable through the patient’s insurance, after checking with dental insurance companies that you use.

Protect your older patients by deferring dental care when possible

While keeping up with the rapidly emerging COVID-19 science is difficult, we do know that older adults (over age 60) who contract COVID-19 are at greater risk for illness, complications, and death. This has implications for your scheduling of older patients.

Because of the dramatic rise in the number of older Americans across the US over the last 20 years, many dental practices see a large number of older patients. Many of our older patients have underlying conditions, such as heart disease or diabetes, or are immunocompromised or taking multiple drugs. These patients over 60 are the most vulnerable to complications of COVID-19. We have an obligation to protect the health and safety of these older adults.

Teledentistry can help dental practices evaluate their ongoing care for older adults and help balance the risks versus benefits of treatment. Dental practices can utilize teledentistry to reassure older adults that they can defer a cosmetic procedure or other elective treatment a few months in the future, and thus limit their risk of contracting COVID-19.

Infection control overhaul: Reduce bioburden of aerosols in your office

While the science doesn’t tell us the infectious dose of COVID-19, reduce the risk to yourself, your team, and patients by reassessing and changing your infection control practices. The first step is to prevent patients with COVID-19 symptoms from entering your office. Teledentistry can help prescreen your patients for symptoms (e.g., fever, dry cough, etc.) or a recent COVID-19 test result to defer treatment in order to protect your other patients. Take time to review your policies. Consider your front office procedures. Remove the chairs from your waiting room to reduce one source of potential contamination for your patients.

Now is the time to assess your infection control practices. This may require rethinking how to limit aerosol spread. Data from a recent New England Journal of Medicine article suggests that SARS-CoV-2 can remain in the air for a few hours and on surfaces for up to three days, especially on stainless steel and plastic. Adjust your infection control processes as appropriate. Remember to read the label of your surface disinfectant to see if it is effective against coronaviruses.

In addition, let your patients know that you are reassessing your infection control practices. Reassure them that the Centers for Disease Control and Prevention (CDC) and Organization for Safety, Asepsis and Prevention (OSAP) are providing interim guidance on infection control specifically for dental practices. These organizations are aware of shortages of personal protective equipment (PPE) and know how to address this in the dental practice, as well as upcoming issues (e.g., engineering controls, etc.) to limit aerosol contamination.

Let your patients know that lingering in the waiting room, for now, is a thing of the past. Depending on your climate, asking patients to wait in the car and then ushering them through an open door to the operatory seat is the new normal. They will probably view this as being more convenient.

Categorize and schedule your patients by risk of transmission

With no definitive prevention, treatment, and/or vaccine for COVID-19, our practices will have to live with new screening requirements. Prioritize your patients based on health history, dental needs, and age. You can decide the proper algorithm for prioritizing patients in your practice. Here are some considerations:
While scheduling ahead may present a challenge due to the emerging status of the epidemic, we can schedule older, more fragile patients later, probably safely in a few months.

If you see younger adults and children, schedule them first. Remember that children are less likely to show symptoms, but they can still spread the virus.
Let older patients know that you will confirm their appointments as you keep up with the changing science and the status of your local outbreak of COVID-19. Assess their medical risks, underlying conditions, oral needs, and whether or not they are immunocompromised. 

Last, but not least, defer the highest risk patients until later this year. In the meantime, you can use teledentistry to assess patient need for oral care, including medical management of caries or periodontal disease (e.g., chlorhexidine rinses, high-fluoride mouth rinses, remineralization products, or other methods you use in your practice) until their next scheduled prophylaxis. Your hygienist might be able to perform these services, depending on state practice acts. Check with your patient’s dental insurance company to determine if this is fee for service or a covered service. The ADA is updating its coding and billing guidance as more information becomes available.1

Continue using teledentistry beyond the COVID-19 crisis

Work with your dental team to assess their roles in teledentistry going forward, as well as their individual medical risks in your dental office. Determine when you will use teledentistry before appointments to review current and past medical history and to assess patient risks for being infected with COVID-19. What questions will you now use to ask about symptoms prior to dental treatment?

Check with CDC.gov and OSAP.org for the latest guidelines. Of course, check with your local health department and state board for any changes in teledentistry regulations in this world of rapidly changing policies. Plan on how you want to incorporate teledentistry in your practice. Visit mouthwatch.com for more details on using teledentistry to respond to COVID-19.

Final thoughts and comments

Human immunodeficiency virus (HIV) was the most recent pandemic that caught the attention of dental practices, necessitating use of gloves. Sadly, it is not our last ongoing one. Now, we have a pathogen that spreads by respiratory and aerosol contamination. Based on my experience with previous pandemics, COVID-19 is here to stay. Thankfully, so is teledentistry. Take this time to explore how to incorporate teledentistry into your practices to create your own new normal.

Implementing teledentistry is not that difficult. Over a few short weeks, more than 30 million schoolchildren across America have adapted to home-based digital learning because of school closings. Similarly, their parents are learning to work efficiently with technology from home as more workplaces are closing or allowing employees to work remotely.

Seemingly overnight, we are changing the way we think about telecommunications technology from a “nice to have” to a “must have” to quickly create a “new business as usual” paradigm. Dental professionals must adapt this same mindset and do the same, adopting teledentistry, into their practices as the new normal.

More: Teledentistry: How visual treatment planning goes virtual

NOTE

  1. American Dental Association. COVID-19 Coding and Billing Interim Guidance. Updated April 8, 2020. https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf
MARGARET SCARLETT, DMD, is an infectious and chronic disease prevention specialist, dentist, and author. For 30 years, Dr. Scarlett has provided expert guidance on infectious diseases and infection control as a consultant to the Centers for Disease Control and Prevention, the World Health Organization, the Pan American Health Organization, the United States Agency for International Development, the American Red Cross, and many consumer health companies. Contact Dr. Scarlett at [email protected] or (404) 808-9980.