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. Applications of Teledentistry
ICT provides opportunities to supplement traditional methods for: Tele-consultation Tele-diagnosis Tele-treatment Tele-education Tele-training

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

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. Inequalities in oral health
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 17

18. Inequalities in oral health
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* * 18

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

22. Methods RN Training involved: 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. 22

23. Methods
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. 23

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

31. Methods
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. 31

32. Methods 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 were recruited.
Both, the community health centres and the RCH, operated within current financial arrangements. 32

33. Methods
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. 33

34. Results Oral condition Cleft lip and palate Orthodontics Total
Age (mean and s.d.)
7.2 (4.3)
10.9 (2.6)
8.6 (4.2)
Sex
Male
Female
n (%)
18 (69.2)
8 (30.8)
8 (50.0)
26 (61.9)
16 (38.1)
Location
Shepparton
Geelong
Rosebud
10 (38.5)
13 (50.0)
3 (11.5)
7 (43.8)
- (0.0)
9 (56.2)
17 (40.5)
13 (31.0)
12 (28.5) 26 16 42

35. Results Oral condition Cleft lip and palate Orthodontics Total Outcome
Review next 3 months
Review at 6 months
Review at 12 months
Referral to CL&P/Ortho/RCH
Referral local clinic
Referral other
3 (12.0)
10 (40.0)
8 (32.0)
- (0.0)
1 (4.0)
2 (12.5)
4 (25.0)
3 (18.8)
7 (43.7)
3 (7.3)
10 (24.4)
7 (17.1)
8 (19.5) c

36. RCH Model - RCH study population (n=367)
Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia
Total Costs
(cost per appt)
RCH Model - RCH study population (n=367)
Costs to Patient
Transport
$61, ($167.31)
$102, ($280.37)
Accommodation
$13, ($36.97)
Productivity Lost
$27, ($76.09)
Costs to RCH
Paediatric Dentist
$38, ($104.09)
$55, ($150.92)
Orthodontist
$11, ($31.10)
Dental Assistant
$5, ($15.73)
Total RCH Costs
$158, ($431.29)
Teledental Model
Transportation
$18, ($51.25)
$32, ($87.68)
$13, (36.43)
$49, ($135.19)
Costs to CDC
Staff Training
$9, ($26.54)
$26, ($71.48)
TD Equipment
$1, ($4.77)
General Dental Practitioner
$8, ($24.44)
Total TD Costs
$108, ($294.35)
Total savings from TD
$50, ($136.94)

37. Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia
Based on postcodes, the TD model :
Equates to an extra half day session a week freed up to see patients
Increased capacity whilst using the same amount of space – no further infrastructure required

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 $ vs. $ 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 41

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 May 14;3(5). doi:pii: e /bmjopen 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): doi: /
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 May;23(3): doi: /j X 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(: doi: /
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: doi: / 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 Jan;23(1): doi: /j X 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
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:
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 Jul;82:504-8.

50. ECCAPP ECCAPPS will 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.
For outsiders who have not become accustomed to the ‘need’ for adjuncts to dental training here is an analysis of some of the cost/benefits.
Surgical training is usually via apprenticeship:
Trainees learn in the operating room or the clinic and are guided by a mentor;
The quality of surgeons produced by this model of training largely depends on the quality of the mentor, the quality of the training facilities, and the operative case load.
- as first step we looked at current training methods
- this is how surgical skills are developed in dental science
- this is how it's done at UOM and many other institutions
- explain what bench models are
- in 5th year there is still supervision but less of it compared to 4th year
- after that they go out and work as dentists
- a VR workbench can replace a whole range of bench models

51. The Information Component
Provides information about dental caries (ECC).
Oral health promotion
Allows the parents of children to take photographs for clinical assessment.
Gathers data and sends data back to the clinical facility where the risk and spread of carries can be analyzed and monitored.
For outsiders who have not become accustomed to the ‘need’ for adjuncts to dental training here is an analysis of some of the cost/benefits.
Surgical training is usually via apprenticeship:
Trainees learn in the operating room or the clinic and are guided by a mentor;
The quality of surgeons produced by this model of training largely depends on the quality of the mentor, the quality of the training facilities, and the operative case load.
- as first step we looked at current training methods
- this is how surgical skills are developed in dental science
- this is how it's done at UOM and many other institutions
- explain what bench models are
- in 5th year there is still supervision but less of it compared to 4th year
- after that they go out and work as dentists
- a VR workbench can replace a whole range of bench models

52. The Management Component
Is used to implement a protocol for managing and reducing the risk of ECC.
Sends reminders to parents when the prevention and treatment steps need to be performed
Guides parents through the steps required to reduce their children’s level of risk according to the protocol
Provides data back to clinicians for monitoring and, where necessary, intervention.
Reminds parents of dental visits.
For outsiders who have not become accustomed to the ‘need’ for adjuncts to dental training here is an analysis of some of the cost/benefits.
Surgical training is usually via apprenticeship:
Trainees learn in the operating room or the clinic and are guided by a mentor;
The quality of surgeons produced by this model of training largely depends on the quality of the mentor, the quality of the training facilities, and the operative case load.
- as first step we looked at current training methods
- this is how surgical skills are developed in dental science
- this is how it's done at UOM and many other institutions
- explain what bench models are
- in 5th year there is still supervision but less of it compared to 4th year
- after that they go out and work as dentists
- a VR workbench can replace a whole range of bench models

53. The Clinical Component
Will reside at a Oral Healthcare Facility or Hospital.
Will allow the clinician to bring up patient records, see what has been done and what steps of the protocol have been followed.
Will allow the clinician to schedule appointments and send these directly with the parents’ mobile phone
Will allow the clinician to modify the treatment plan when necessary.
For outsiders who have not become accustomed to the ‘need’ for adjuncts to dental training here is an analysis of some of the cost/benefits.
Surgical training is usually via apprenticeship:
Trainees learn in the operating room or the clinic and are guided by a mentor;
The quality of surgeons produced by this model of training largely depends on the quality of the mentor, the quality of the training facilities, and the operative case load.
- as first step we looked at current training methods
- this is how surgical skills are developed in dental science
- this is how it's done at UOM and many other institutions
- explain what bench models are
- in 5th year there is still supervision but less of it compared to 4th year
- after that they go out and work as dentists
- a VR workbench can replace a whole range of bench models

54. Stay connected
Thanks! 54