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Using digital workflow and teledentistry to improve multidisciplinary assessment for hypodontia patients in a rural area: does it work? Pamela Ellis Teniola Oyeleye Angharad Truman
BDS (Hons), MFDS, M PROS, FDS (Rest Dent) RCSEd, MSc, PGCME, FHEA, Associate Postgraduate Dental Dean (DCT) Wales, Consultant in Restorative Dentistry, Musgrove Park Hospital, Taunton; Associate Professor for Restorative Dentistry, Plymouth University
The authors of this article have designed a multidisciplinary clinic in Dorset that reduces travel for hypodontia patients in rural areas and uses a digital workflow. Patients attend a clinic with their consultant orthodontist and are joined by video calls (Microsoft Teams) from their consultant in restorative dentistry. The authors have evaluated the effectiveness of this clinic from the viewpoint of both patients and clinicians. Participants in the evaluation included 53 patients who attended the clinic and six clinical team members. The results showed that patients and parents overwhelmingly felt the new clinic structure was successful. Clinicians felt it brought numerous benefits, including enhanced data gathering, greater collaboration and increased teaching opportunities.
CPD/Clinical Relevance:
CPD/Clinical Relevance: This article provides an example of how a digital workflow and teledentistry can reduce travel for hypodontia patients and could be replicated in other regions, particularly in more rural locations.
Article
Multidisciplinary hypodontia clinics in the UK were first established over 25 years ago at the Eastman Dental Hospital.1 Clinics typically consist of patients being assessed by a range of specialists from two or more of the following specialities: orthodontics, restorative dentistry, paediatric dentistry and oral surgery. McSwiney1 reported that 61% of teaching hospitals, but only 8% of district hospitals, had multidisciplinary clinics dedicated to managing hypodontia patients. Many district hospitals, particularly those in rural locations, do not employ a consultant in restorative dentistry. Although orthodontic care can be carried out locally, patients may have to travel for a multidisciplinary assessment and pre- and postorthodontic restorative care. Traditionally, clinics have been face to face. However, following the implementation of lockdown measures to stem the spread of COVID-19, dental teams were challenged to explore alternative patient assessment methods. Many dentists used teledentistry techniques, including video conferencing and telephone clinics, to maintain NHS services and continuity of care.
The use of teledentistry to enhance the care provided is not a new concept, with units such as Bristol2 piloting its use since 1997. Videoconferencing, the primary mechanism of teledentistry, has been shown to provide several benefits, including increased access to patient services, greater clinical collaboration, cost savings, and increased efficiency. Limitations included high initial startup costs, variable internet connections, requirements of additional training and acceptance hesitancy.3
The COVID-19 pandemic brought an explosion of digital activity in the NHS, which has widely been demonstrated to have helped maintain NHS service provision and improved access to services for many.4 Given the resounding approval for these services and the additional perceived benefits, the UK government has stated that it is keen to continue the digital transformation of the NHS via a three-pronged attack of digitizing, connectivity, and transformation in its white paper digital delivery plan: ‘NHSX Delivery Plan’.5
The incorporation of teledentistry in a hybrid virtual clinic fits the brief by enabling better access to services in a timely manner using digital technology, allowing for personalization of care, sharing of information between healthcare providers and effective delivery of care.
Although remote clinical consultations in restorative dentistry have been found to be effective for patients referred from primary care,6 the effectiveness of remote restorative dentistry clinics for hypodontia patients requiring multidisciplinary care has not yet been evaluated.
Previous hypodontia care pathway
Prior to COVID-19, all hypodontia patients in West Dorset requiring restorative dentistry input in the management of their care were referred to the nearest teaching hospital, Bristol Dental Hospital, which is over 50 miles away. Dorset County Hospital (DCH), like many other district hospitals in rural locations, does not have a local consultant in restorative dentistry. Prior to the patient attending the clinic, a written referral, including radiographs, a patient photo montage and provisional treatment plans, were sent to the nearest teaching hospital. During these clinics, patients would be assessed by a consultant in orthodontics and a consultant in restorative dentistry, together with one or more registrars. The consultant orthodontist at this clinic was not the consultant who would deliver the orthodontic care. This presented issues as the plan was formulated by clinicians who were unfamiliar with the patient, in particular, their dental history and ability to cope with complex and lengthy multidisciplinary plans.
Despite these shortfalls, this had been a well-established referral pathway for over 30 years. Although patients and parents had to travel a great distance, many were willing to do so in the knowledge they were receiving multidisciplinary assessment and a commitment to receive their postorthodontic restorative dentistry care. The cessation of these clinics during the COVID-19 lockdown period and subsequent social distancing restrictions when services resumed, led to long waiting times of a year or more for multidisciplinary assessment. As a result, this cohort of patients experienced an even greater delay at the start of treatment than their non-hypodontia counterparts, so the orthodontic consultant team at DCH sought to investigate ways to rectify this situation.
The hybrid teledentistry clinic model
The new clinic model involved the physical attendance of a consultant orthodontist, an orthodontic registrar, an orthodontic dental nurse, the patients and a parent. The consultant in restorative dentistry, who was physically based in Taunton, attended virtually via the Microsoft Teams application. Figure 1 demonstrates the clinic set-up.
Figure 1. HVC clinic setup.
Prior to the clinic, records were shared with the consultant in restorative dentistry, including a digital intra-oral scan, standardized clinical photographs, and radiographs. The consultant orthodontist also shared details of the patient's concerns and an assessment of their ability to cooperate with the orthodontic and restorative aspects of care through a proforma. These records were securely emailed to the clinical team in advance of each clinic to allow for clinical assessment and familiarization of the case. The benefits of using the digital case notes include remote access, secure transportation, the digital threedimensional orientation of models, mapping of models enabling space analysis and the ability to produce digital Kesling set ups, which could be 3D printed on request.
Development of the hybrid teledentistry clinic
A pilot clinic with a test patient was set up to test areas/steps that may interfere with the smooth running of the clinic. This initial clinic consisted of a pre-clinic multidisciplinary meeting held an hour prior to the start of the clinic without the presence of the patient or parent. During this meeting, the clinical team discussed the options for managing the case. This approach allowed the team to discuss the risks and benefits of each treatment option and to ensure consensus among the clinical team regarding which options would be presented to the patient and/or their parent. This pre-clinic meeting worked well and has been adopted into the clinic model. Following a pilot clinic, DCH also purchased restorative demonstration models (Figure 2), which were helpful in describing bridges or implants. Initial audio issues were addressed by buying a USB speaker.
Figure 2.
(a–c) Visual aids used during the clinic.
Clinics ran with a mean of five to six patients per session, with a post-clinic debrief after the last patient.
During the consultation with the patient and a parent, treatment options were discussed, and the patient and parent perspectives were gained. This gave the patient ‘a road map’ of the options available and what to expect from treatment. There is also an additional opportunity for further discussions with the patient before the final plan is determined and/or treatment is commenced. This allows the patient to have a greater understanding of the treatment process and so empowers the patient to take an active role in the shared decision-making process.
Figure 3.
(a–e) An example of a proforma used for a hybrid hypodontia clinic.
Evaluation of service
To evaluate the running of the new clinic format, two questionaries with five-point Likert scale questions were developed, one for the patients and one for clinicians (Figures 4 and 5, respectively). The questionnaires were distributed to all patients following the clinic and to the clinicians over an 8-month period.
The patient's questionnaire was analysed using a text readability consensus calculator7 to evaluate readability ease. The questionnaire was then submitted to DCH's Patient Advice and Liaison Service (PALS) to ensure the questionnaire was patient friendly and suitable for the patient population. PALS also assessed whether patients had the opportunity to fully express their views on the service provided.
The questionnaires sought to review the patient's and clinicians’ opinions on the hybrid model and consisted of seven and 10 questions, respectively. The questions were regarding the organization and running, satisfaction, perceived advantages and disadvantages of the clinic. Both groups were also asked if they would prefer a completely virtual clinic or return to the traditional clinic model.
Results
Following the implementation of the hybrid clinic, waiting times for the hybrid hypodontia clinic from initial new patient consultation were reduced from 12–18 months to 3–5 months. Patients are now more informed of the wait times, as these are under the control of the local team.
Where a patient required restorative treatment (typically at the conclusion of their orthodontic treatment), this was delivered by either the consultant in restorative dentistry or by their general dental practitioner following a prescription from the consultant in restorative dentistry.
Opinions of patients and/or parents
Questionnaires were completed by 53 patients and/or parents (100% response rate). Of those, 55% of the forms were completed by the patient and parent, 38% by the patient and 8% by the parent alone. The demographics of the patients included 37 females and 16 males (ages 12–20 years) with a mean age of 14 years.
This style of clinic was recommended by 98% of respondents to others. All the respondents (100%) felt that the clinic ran smoothly and were able to discuss their care easily at the time of the consultation. Regarding the clinic model, 87% of the patients and/or parents indicated they would choose to attend again. A purely face-to-face clinic was preferred by 9% of respondents, and 4% would choose a fully virtual clinic.
Patients and parents felt that the new clinic style helped reduce waiting times and travel expenses. They felt it gave them an opportunity to discuss what their treatment involved and to voice their thoughts and aspirations of what treatment would achieve for them. The respondents said they valued being seen in familiar surroundings and the continuity of care achieved by being seen in the orthodontic department where their orthodontics would be performed and have access to specialist services closer to home. Reference was also made to limiting the amount of people in a room owing to reducing the risk of the spread of COVID-19.
Patient and parent comments
‘It was great to have both in person and video with the dentists’
‘You don't have to travel as far as you would have to if you went to see them in person therefore it reduces your carbon footprint and is better for the environment’
‘No need for all parties to be together in person. Especially since COVID’
‘Easy to see both people in a closer location’
Opinions of the clinical team
Six members of the clinical team had attended at least one clinic in the new style and were asked to complete a questionnaire. The response rate was 100%. This cohort consisted of two orthodontic nurses, a consultant orthodontist and a consultant in restorative dentistry, and two orthodontic registrars.
When asked about the clinic model, 100% of the cohort felt that the clinic ran smoothly, was an important step in the hypodontia pathway, effectively used resources, and provided an informative teaching opportunity. All the respondents indicated that they would recommend this clinic style and felt that this model could be used for other clinics.
The clinical team felt that the benefits of this model for patients included reduced travel costs and times, particularly for patients who had already travelled a long way owing to the large geographical area of West Dorset. The familiarity of surroundings and staff, a smooth and systematically run clinic with optimal time for patients and clinicians to participate in shared decision making.
The clinical team felt the enhanced use of the digital workflow provided a greater depth of knowledge for each case prior to the clinic. These respondents also felt that the combination of face-to-face and teledentistry improved the limitations that a teledentistry clinic alone would yield.
The clinical team believed this model could be applied to different clinics, increasing the opportunity for clinicians to work directly with colleagues outside of their immediate specialty. The clinicians also felt that the current model could be adapted further by incorporating other teams in a virtual capacity.
The orthodontist within the clinical team felt that they were able to have a direct input into the treatment plan compared to referring outside the department.
In the clinical team, the registrars felt that the clinic opened up additional teaching opportunities. Trainees could participate in the clinic and its organization while observing the consultants in practice. Trainees attending in a virtual capacity proposed that even more trainees could attend and benefit.
Clinical team comments
‘Patients and clinicians are required to travel less, whilst maintaining a high standard of clinical care’
‘I've learnt a lot during this clinic, especially the potential for virtual clinics to improve patient experience’
‘I can really see how this model can could be translated to other MDT clinics. It would work well when patients needed dento‑alveolar treatment too’
‘It's a great format, I think it would be even better with more patient demonstration models’
Discussion
This structure allows patients to attend a clinic in their locality, in which they are both familiar with the surroundings (having previously attended at least a new patient clinic and a records appointment) and with the orthodontic team members undertaking their treatment. Additionally, with the consultant in restorative dentistry having a virtual presence, this reduced travel for both patients and the dental team.
Despite an initial drive to run entirely virtual clinics during the COVID–19 pandemic, many departments have now returned to the traditional face-to-face clinics. Many reported 8,9,10 that although these clinics served their purpose at that moment in time, there were disadvantages, including:
Not being able to perform a clinical examination;
Lack of an appropriate chaperone;
Difficulties accessing records by all members of the team;
Unpredictable patient access to the internet and/or functioning audiovisual equipment.
The novel approach taken by the authors to the problems raised above (combining both face-to-face and virtual elements) appears to address these problems. Additionally, the following benefits have been raised by both patient and clinical staff:
Greater flexibility in work locations for clinical staff, enabling them to work remotely or in a clinical setting.
Increased opportunities for more specialists and trainees to participate in patient care without raising the number of people physically present in the clinic.
The clinic could also be shown to reduce health inequalities. A key objective set out by the 2019 Long Term plan,11 a UK government initiative launched in 2019 to modernize the NHS with the aim of improving the level of care provided, but with a strong focus on getting value for money from taxpayers’ investment. Key concepts of this initiative include:
Coordinating care by bringing different professionals together;
Enhancing the autonomy of service users on treatment options and care locations;
Optimizing the use of data and technology to improve service delivery and patient outcomes.
The authors believe the service evaluation supports the described model's ability to facilitate the NHS initiative objectives. It is equally effective as a traditional, face-to-face multidisciplinary clinic in coordinating care and patient engagement. It is superior to many face-to-face multidisciplinary clinics in the use of data and technology. The clinic performed this by limiting the distances patients had to travel to a hospital where all consultant members of the MDT are present (at least for an initial consultation) as a result of the patient's rural location or distance from the hospital.
A study by Barber et al12 exploring whether the hypodontia care pathways promoted shared decision making (SDM) found that the models researched failed to support SDM. Through patient and parent evaluation of the clinic, there was overall agreement that this model allowed patients to have a voice in their care planning. The authors believe it is equally as effective as face-to-face multidisciplinary clinics in allowing patients time and space to understand their malocclusion and work in partnership with clinicians to decide on management. The clinic also cultivates an environment in which patients better understand their condition and the available management options by incorporating visual aids. Visual aids have been demonstrated to better equip patients in the SDM process.12,13,14 By broadening the use of visual aids and trying other approaches such as decision aids in future iterations of this model, it is hoped SDM may be improved further.
Limitations of the current model
Although face-to-face assessment by the consultant in restorative dentistry before or at a multidisciplinary clinic would be the gold standard of care, the authors feel that good use of digital records and their virtual attendance at the clinic makes it a viable alternative. This downside is offset by the reduction in travel time and shorter waits for assessment.
The specialists involved in this clinic are currently limited to orthodontics and restorative dentistry. Some patients require input from oral surgery colleagues or a paediatric dentist at an additional appointment. West Dorset is unusual in that oral surgery support is provided by a neighbouring district hospital and not at the hospital where the orthodontics is delivered. This has made it difficult to include them in the multidisciplinary team. The authors are exploring how their services can be incorporated into the model to streamline the service further and increase efficiency and access to a high standard of care.
The evolution of the clinic model described would seek to incorporate other specialties, look at expansion to different sites, and explore options for delivery of post-ortho-restorative dentistry care closer to home. In doing so, it is believed these modifications would seek to improve the hypodontia pathway further.
Many departments may currently be unable to fund digital scanner systems on which this clinic model is heavily reliant. However, given the government's plan to increase the digitalisation of the NHS as outlined in its NHSX delivery plan and the subsequent 2019 Long-Term Plan, funding may be available to address this deficiency.
In the study by Berndt et al16 in which real-time video camera footage was live-streamed to the virtual clinician, this may be a realistic alternative to scanners, allowing some of the elements of the face-to-face consultation to remain.
Conclusion
The service evaluation showed that the clinic model described benefits patients and clinicians. Satisfaction levels were very high, with 98% of patients recommending this style of clinic. Many respondents reported previous experience with clinics adhering to the traditional model, either personally or through family members. Only 9% would choose a purely face-to-face assessment (although not at the expense of the advantage of decreased travel), and 4% would choose a purely virtual assessment. This is a service evaluation as per guidance set out by the National Research Ethics Service (NRES). All data was anonymized with no patientlevel identification possible, and no intervention was implemented; hence, ethical approval was not required. Consent was sought from participants in this body of work. Participants were asked whether they were happy to complete the questionnaires used in this work and advised that refusal would not impact on any element of their care (patients) or working environment (clinicians). Participants were also advised on the purpose of the data generated.
