Download QUse of videoconferencing for consultation in dental prosthetics and

RESEARCH
Original article
.................................................................................................................................
of videoconferencing for consultation in
Q Use
dental prosthetics and oral rehabilitation
Eino Ignatius*, Sami Perälä† and Kari Mäkelä‡*
*Seinäjoki Central Hospital, Finland; †EPTEK r.y., Seinäjoki; ‡Telemedicine Laboratory, Department of Biomedical Engineering, Tampere
University of Technology, Seinäjoki, Finland
Summary
We conducted a 13-month study to investigate whether videoconferencing could be used for diagnosis and for making
treatment plans for patients requiring prosthetic or oral rehabilitation treatment. The consultations took place between a
specialist dental treatment unit in a central hospital and general dental practitioners in seven regional health centres.
Videoconferencing was conducted using standard commercial units via an IP network, at bandwiths of 762 kbit/s –
2 Mbit/s. In total, 24 patients and 25 professionals (18 dentists, 2 dental hygienists and 5 nurses) took part. There were no
technical problems. In 24 out of 27 teleconsultations, a diagnosis or treatment plan could be made. All participating
dentists were satisfied with the consultation process and indicated that the technology used was of sufficient quality for
clinical purposes. A patient satisfaction questionnaire indicated that patients were also satisfied. Videoconsultation in
dentistry has the potential to increase the total number of dental specialist services in sparsely populated areas, such as
those in Finland.
Introduction
Methods
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Videoconferencing offers potential benefits in a sparsely
populated country such as Finland. Rural regions in
particular could benefit from the use of teleconsultation, as
travel time to health-care delivery locations could be
reduced, potentially saving money and time for
professionals and patients alike.1,2 Since there is a lack of
dental specialists in Finland’s rural regions, teleconsultation
might improve the availability of dental services.3
Videoconferencing has been used successfully for
teleconsultation by orthodontists in Finland.4 However, it
still remains relatively little used within dentistry in
comparison to other medical specialities, where results have
been good.5 – 8 Videoconferencing has been used for
educational purposes in dentistry,1,4,9 – 11 but there have
been few studies concerning clinical dental
consultation.2,12,13 – 16
Our aim was to determine whether videoconferencing
could be used for accurate diagnosis and for making
treatment plans for patients requiring prosthetic or oral
rehabilitation treatment. We also wanted to find out more
about the videoconferencing process itself and how patients
and professionals responded to teleconsultation.
The study was carried out in the hospital district of South
Ostrobothnia, in south-west Finland. The region covers an
area of nearly 14,000 km2 and has a population of about
200,000 inhabitants. Primary health care is provided by 26
local health-care centres with 83 dentists. There are also
some 44 private dental practitioners. There are five dental
specialists in the hospital district, of whom two are
specialists in prosthodontics. All inhabitants have access to
the health-care centres for basic dental care. For specialist
treatment, patients are referred to the regional central
hospital responsible for secondary care, the Seinäjoki
Central Hospital. The hospital’s department of oral and
maxillofacial diseases received 1054 referrals in 2007 and
there were 3748 outpatient visits to the department during
2007. The average wait for patients for non-urgent
treatment was approximately three months.
Dentists in primary care in regional health centres were
able to consult a specialist dentist at Seinäjoki Central
Hospital during a weekly videoconferencing session. The
consultation appointment times were pre-arranged. Patient
data and background information were gathered by the
health centre personnel prior to the teleconsultation. The
information included the clinical history, and when
needed, plaster cast models and dental X-rays. The health
centres participating in the study chose which patients
required teleconsultation. The choice was based on the need
to hear a specialist’s opinion in reaching the correct
Accepted 16 July 2010
Correspondence: Professor Kari Mäkelä, Seinäjoki Unit, Tampere University of
Technology, Koskenalantie 16, 60220 Seinäjoki, Finland (Fax: þ358 6 429 8801;
Email: [email protected])
Journal of Telemedicine and Telecare 2010; 16: 467– 470
DOI: 10.1258/jtt.2010.100303
E Ignatius et al. Videoconferencing for dentistry
diagnosis and treatment planning. This decision was made
by the health centre dentists. Without the availability of
teleconsultion, the patients would have been referred to the
central hospital. Patients gave written consent to participate
and ethics permission for the study was not required.
During the teleconsultation, a dentist in the health-care
centre could consult a specialist dentist on cases of
congenital or acquired dental insufficiencies. Different
treatment options were discussed during the
teleconsultation session. The treatment location was
decided, i.e. hospital or health-care centre, or possible
referral to a more specialised university hospital. The
teleconsultation provided an opportunity to question the
patient by the specialist being consulted if this was deemed
necessary or if it was wished by the patient. The patient was
also able to question the specialist.
Seven health centres from the hospital district participated
in the study (Ähtäri, Alavus, Jalasjärvi, Peräseinäjoki,
Kurikka, Kauhajoki ja Teuva). Twenty-five dental
professionals participated (18 dentists, 2 dental hygienists
and 5 nurses). The specialist in prosthodontics in Seinäjoki
Central Hospital acted as the primary referring consultant
and a specialist in othodontics in the hospital gave
additional support when needed. In a few cases an oral and
maxillofacial surgeon at the hospital was also consulted.
The teleconsultation project finished in January 2008,
after lasting for 13 months. User data and feedback was
acquired during the project, and during a follow-up study in
2009. The first four months of the project were used for
building up the network and training staff on the use of the
teleconsultation equipment. A total of nine hours, during
three days, were used for training. The first three hours were
used for training on the use of videoconferencing
equipment and the next three hours for clinical
photographic techniques. The last three hours were lectures
on photographic image processing. The aim was to give
professionals enough guidance on technical aspects to make
the consultation process run as smoothly as possible. In
addition to training sessions, a total of 14 hours, during 9
days, were used for consultations.
A user satisfaction survey was carried out in which patients
were asked to provide feedback immediately after each
consultation. Dental professionals received user satisfaction
questionnaires at the end of the study. The questionnaires
were validated by performing a small-scale pilot survey to
make certain that respondents understood the questions in
the way they were intended to be understood. The survey
results were also checked to make certain that all questions
complied with the appropriate response scale.
Videconferencing was used between the consultant
specialist dentist and health centres. In addition, digital
images, X-rays and images of dental casts or older dental
X-rays could be shown. All dental units used a set-top type
videoconferencing unit (Polycom VSX 7000) with a VGA
interface unit (Polycom Visual Consert VSX). In addition to
standard audiovisual equipment, laptop computers and
digital cameras (Canon EOS 400D, Macro EF-S 60 mm,
MR-14EX ring light) were also used (Figure 1). Dental cast
468
Figure 1 Display technologies used in the teleconsultations
study models were positioned on a rotating glass tray
(a microwave-oven tray). Videoconferencing was conducted
via an IP network (762 kbit/s – 2 Mbit/s). The security of
sessions was ensured by use of a VPN (virtual private network).
Results
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A total of 24 patients and 25 professionals (18 dentists, 2
dental hygienists and 5 nurses) participated in the study.
There were 27 patient cases, consisting of 24 individual
patients.
During the study the videoconferencing equipment
functioned reliably, and none of the consultations suffered
technical problems of any kind. The average time used for
each consultation was 31 min. In 24 out of 27 cases a
diagnosis or treatment plan was made during the
consultation. Three cases could not be satisfactorily dealt
with during the videoconference. In these cases the patients
were referred to a specialist in oto-rhino-laryngology, to
their general practitioner or to the hospital department of
oral and maxillofacial diseases for further examination and
treatment.
Both patients and professionals were relatively satisfied
with the consultation process. Patients were asked to give a
score between four (worst) and ten (best) for the
consultation. A grade of 9 or 10 was given by 65% of the
patients participating in the project (Table 1). As expected,
patients that lived furthest from the central hospital gave
the highest grades for the teleconsultation, and this result
was significant (P , 0.01). Those patients whose residence
was over 50 km away from the Central Hospital gave a grade
of 9 or 10 (by 81%); those who lived over 65 km away were
the most satisfied group (grade 9 or 10, by 100%). Patients
who lived closest to the hospital (21 –34 km) gave an
average satisfaction score of 8 (n ¼ 4).
Dental professionals gave an overall grade of 4.6 out of 5
for the overall suitability of videoconferencing for dental
Journal of Telemedicine and Telecare Volume 16 Number 8
2010
E Ignatius et al. Videoconferencing for dentistry
Table 1 Patient satisfaction with the teleconsultation proces (n ¼ 24).
Satisfaction was graded from 4 to 10 (4 ¼ worst to 10 ¼ best)
Distance of patient
residence from
hospital (km)
21 –34
35 –49
50 –64
.64
Total
In 2007 the average fee per patient visit to the department
of oral and maxillofacial diseases was E207. Other costs
incurred were the referring dental professionals’ wages.
Satisfaction score
4
5
6
7
8
9
10
Total
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
2
2
3
0
7
1
2
5
6
14
0
0
1
1
2
4
4
9
7
24
consultation (Table 2). There were no major technical
problems experienced during the study, and the
professionals were relatively happy about the way the
equipment functioned and gave an average score of 8.7 out
of 10 for its overall functioning. This question dealt with
the actual use and functioning of the various pieces of
equipment related to the videoconsultation. The
technology was judged to perform extremely well for
conducting patient interviews, as all users gave a score of
good or excellent, the average score being 4.9. The quality of
digital radiographs displayed during consultation was
deemed to be good, since 87% answered good or excellent.
Similarly, the quality of digital photographs shown was
judged to be good or excellent by 91%. The image quality of
cast models displayed via videoconferencing was deemed
good or excellent by 87%. There were no responses between
the grades four to six.
During the project the referring dentist was able to
participate in the consultation process and hence was able
to learn from a more experienced specialist during the
sessions. An average grade of 4.6 out of five was given by the
professionals when asked to grade the consultation as a
learning process.
Each videoconferencing system was leased for E197 per
month (E1 £0.8). The IP network used was already in
place, so no additional communication costs were incurred.
The Seinäjoki Central Hospital charged the local authority
from the referring region a set fee for each referred patient.
Table 2 User satisfaction for 23 dental professionals concerning the use
of videoconferencing in dental teleconsultation. Satisfaction was graded
from 1 to 5 (1 ¼ very bad to 5 ¼ very good), except for question 7
(scale 4 –10, 4 ¼ worst, 10 ¼ best)
Question
1. Suitability of videoconferencing technology for
consultations?
2. Quality of dental X-ray images shown via
videoconferencing?
3. Suitability of videoconferencing for showing
dental castor models?
4. Suitability of videoconferencing for showing
oral photographs?
5. Suitability of videoconferencing for conducting
patient interviews?
6. How did teleconsultation session function
as a learning process?
7. Overall functioning of videoconferencing
(scale 4 –10)?
Mean
score
SD
4.6
0.63
4.4
0.81
4.2
0.76
4.6
0.77
4.9
0.73
4.6
0.90
8.7
0.86
Journal of Telemedicine and Telecare Volume 16 Number 8
2010
Discussion
..............................................................
Since it was the first time that most of the dental
professionals had used videoconferencing or other
teledentistry equipment, it was clear that initial problems
due to inexperience were bound to occur. However, partly
because of the training provided, the performance of the IT
devices used was rated as adequate and both patients and
professionals were satisfied with the technology.
Dentistry has traditionally been a technical field of
medicine, and so dentists are used to adopting new methods
and technologies. The regional dental clinics which
participated in the study were small units where opportunities
to consult a more senior or experienced clinician were very
rare. Consequently, the consultation possibilities offered by
the project were enthusiastically received by the staff.
Broadband connections are becoming more readily
available in remote regions in Finland. Although relatively
high speed connectivity was available for the project, it
would be feasible to use slower connection speeds.
According to previous experience, connection speeds of
284 kbit/s are sufficient for good quality audio and image
transmission.11 Also, older networking techniques such as
ISDN connections can be used.13 Newer high definition
videoconferencing technologies offer even better image
quality than was used in the present study, but require
relatively high connection speeds, and may not be easy to
employ for teledentistry at the moment.
Teleconsultation can be a teaching process that can serve
to maintain or improve medical proficiency.17,18 In one
recent study, general dentists under supervision via
teleconsultation improved their proficiency by 35%, as
measured by the peer assessment rating index.19 Our results
support this finding. The use of teleconsultation also
resulted in a greater interactivity between specialist and
general practitioners, so most of the consultations can be
seen as a learning experience.4,9,10
A major challenge in teledental consultation is to set up
the service in such a way that it is cost-effective. One way to
achieve this is to train nursing staff so that they can be the
participating party in the consultation process in the dental
clinic, freeing the dentist to perform other duties. The
dentist’s working time that would be taken up by the
consultation can thus be avoided or saved.20,21
Consultations that do not require the physical presence of
the patient, i.e. those that can be performed by using dental
X-rays and dental casts, can be relatively rapid, thus
lowering costs. There were also working time savings for
dental professionals, as in most cases the consultation
reduced the need for follow-up visits to the referring dental
clinic.
469
E Ignatius et al. Videoconferencing for dentistry
It is relatively common for dentists to visit specialist
dental clinics for consultations based on dental X-rays and
dental cast models. This practice remains popular, especially
in orthodontics and when making diagnosis and treatment
plans. Teleconsultation, however, saves travel time and
costs. This can be significant in countries such as Finland
with long travel distances.
The present work showed that videoconferencing can be
used for diagnosis and treatment planning for patients
requiring prosthetic or oral rehabilitation treatment with
demanding problems. Telemedical applications of this type
are especially well suited to regions with long distances and
sparse populations. Telemedicine also makes it possible to
share expertise more broadly than at present, for instance
between countries or continents. For instance, developing
countries could access lectures from universities and dental
clinics. The investments in technology required for this may
be relatively modest.
Within the limitations of the present study,
videoconferencing thus seems suitable for long distance
consultation in dentistry. It has the potential to increase the
total number of dental specialist services in sparsely
populated areas in Finland.
6
7
8
9
10
11
12
13
14
15
16
17
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