Incorporating Teledentistry for Better Chronic Disease Outcomes

Now more than ever, dental providers are on the front lines of chronic disease. How? Before the pandemic, the Centers for Disease Control and Prevention (CDC) reported that older adults were more likely to visit a doctor than a dentist. Even though older adults with chronic conditions were more likely to have severe tooth loss than persons without chronic conditions, national data showed dental visits lagged behind medical.

Since early 2020, what has changed since the beginning of the pandemic? Use of telehealth for primary care and teledentistry, that’s what. Secondly, since chronic disease monitoring may be impacted compared to in-office primary care visits, dentists can fill in the gaps.

During 2020, patients turned to telehealth for medical care, with telehealth visits rising as much as 35% in the second quarter of 2020. A cross sectional analysis of audited data of 125 million primary care visits from Jan 2018 to June 2020 US National Disease and Therapeutic Index of 10 calendar quarters, (quarter 1 of 2018 to quarter 2 of 2020) showed that in-person medical office visits were down by half. Meanwhile, telehealth visits jumped to 35 million during the second quarter of 2020 compared to 1.4 million during the first quarter of 2018-19. Even though comparable second quarter data for dentistry may not be useful because dental offices were closed most of the 2nd quarter, about 34% of dentists report using teledentistry currently on in the near future, according to a survey of dentist in August 2020 by the DentaQuest Partnership.

How does this translate into dental providers being on the front lines of chronic diseases? Detection, monitoring and maintenance of chronic diseases are especially important now since some key monitoring and maintenance of chronic diseases by a primary care medical provider may be less than usual. For example, blood pressure level assessments decreased to 9.6% from 69.7% with in-person visits; cholesterol screening decreased to 13.5% from 21.6% and new medication decreased by 26.0% for in-person visits from similar 2nd quarter 2018-2019 levels.

Telehealth should be a bidirectional system between dental and medical providers- especially when chronic diseases impact the mouth and vice versa. However, the definition of what constitutes a comprehensive telehealth visit needs to change to include the assessment and monitoring of chronic diseases in dental offices and to accommodate the use of teledentistry, when appropriate. Here’s why:

Since according to CDC, chronic conditions are associated with increased tooth loss, tooth loss is also associated with chronic diseases. In the CDC report cited earlier, the prevalence of severe tooth loss was found to be more than 50% higher among adults with fair or poor general health, rheumatoid arthritis, asthma, diabetes, emphysema, heart disease, liver conditions, or stroke history, than people without these conditions.

Unfortunately, diabetes is the only chronic condition that has a recommendation from the American Diabetes Association to screen for oral disease, just as there is a recommendation for routine foot and eye screenings. When hip, knee or shoulder replacements are warranted, a dental clearance letter is required from an orthopedic surgeon. Yet, with chronic conditions, dental conditions are rarely referred to dental practitioners.

Quality and enjoyment of life in eating is impacted from losing many teeth. Although tooth loss is preventable, more can be done to educate our colleagues in medicine, especially primary care, about the importance of good oral health.

Improved collaboration between medical and dental providers may improve both the quality of life and overall health care outcomes of shared patients. Before the pandemic, it was known that insured members who received a course of periodontal treatment as part of their annual plan reduced medical costs by 12%.

What’s more, a literature review of published studies found that patients had an increased risk for developing periodontitis, or gum disease, when they had an increased percentage of body fat, body mass index, serum lipid levels, and waist circumference.

Cytokines are implicated in inflammatory conditions in the body. There are two intrinsic factors modulating cytokines found in fats that are called TNF-alpha and IL1-6, or tumor-necrosis factor-α and interleukin-6. The strong association between obesity, periodontal disease, and inflammation from cytokines has been established. These cytokines impact metabolic disorders, such as obesity and type 2 diabetes mellitus.

Meanwhile, medical primary care providers have started using mHealth services during the pandemic to reduce in-person office traffic. However, skipping, or postponing care may result in more serious health effects of chronic disease. This is especially true when routine screenings and monitoring fail to occur.

Although telehealth adoption is increasing, there is a decrease in care management, particularly among people with chronic conditions this year. According to a Luna survey, 94% of patients reported that telehealth and mHealth tools would be beneficial for managing their chronic health issues, with more than 80% of those surveyed saying they are either comfortable or somewhat comfortable with using telehealth. A whopping 90% were satisfied or somewhat satisfied with past telehealth visits, with 64% of patients saying that they expect to use telehealth more often.

Finding the “just right” place between in-person and telehealth platforms, as well as convincing patients that care management can be done virtually, is part of today’s script in most medical offices.Because of delays in routine visits caused by COVID-19 and the need to avoid contact with other persons, teledentistry may be invaluable when it comes to early detection and prompt referral to telemedicine providers, as well as being a useful tool in the maintenance and monitoring of chronic diseases.

Using a provider-directed, patient-friendly teledentistry platform such as TeleDent™ by MouthWatch, is useful for a dental referral, after an in-person visit to the medical office or to help physicians assess patients who report acute dental pain. If there is no airway impairment from oral swelling, the patient can be assessed for treatment with either analgesics or antibiotics, or both, until in-office dental care can be provided.

Just like using telehealth with electronic medical records, teledentistry visits must be recorded through electronic dental records, with informed consent and HIPAA . As with a regular in-office visit, at the end of the teledentistry appointment, the dentist must document the usual SOAP findings- subjective, objective, plan, and assessment- for the visit.

Teledentistry used in conjunction with telemedicine will also be useful to help in reducing the burden on overloaded health systems during this pandemic, as well as into 2021. Detection, monitoring and maintenance of patients with chronic disease can be done now, and even after this pandemic response for efficiency of managing patient health outcomes.  

So, what are other advantages of dentistry and medicine? Dr. Silk, who is co-PI, Center for Integration of Primary Care and Oral Health, says this best when addressing social determinants of health, “Overcoming health inequities requires creativity and persistence - these can be achieved through efforts that include interprofessional teamwork integrated through shared EHRs, telehealth, and smart devices, allowing us to access all patients where they live on their own terms and sharing that information between providers. We have the technology; we just need the will and bold reimbursement models that realize money will be saved, if we work smarter and together.” The integration of teledentistry and telemedicine can help with this too.”

Recently, a commentary in a leading dental journal noted that COVID-19 has added to additional issues impacting access to oral health care among older adults. In addition to social determinants of health, these include polypharmia, comorbidities, complex oral health status and a scarcity of geriatric dentists.

We know that adults, especially those over 80, are particularly susceptible to severe COVID-19 infection and mortality. All of these studies and commentaries on the relationship between chronic disease and oral health underscore one key takeaway: Dentists can develop a safe oral health care plan for a physician colleague’s patients. They can educate and provide care to seniors and their other health care providers about enhanced infection control measures used in today’s dental practice and use teledentistry, whenever possible, to assist primary care providers in assuring that proper detection, monitoring and maintenance of chronic diseases occurs.

The Year 2030 objective for the Nation, published by the U.S. Department of Health and Human Services,noted the importance of oral health in overall health and wellness, as well as its first appearance in the Nation’s Leading Health Indicators. These are a subset of the larger set of health objectives for the U.S.

Do we need to wait until 2030 to achieve what existing technology can accelerate in these unprecedented times?

Through private sector ingenuity, we have achieved creation of a novel vaccine, with unprecedented cooperation and corporate innovation. Dentists are providing vaccines, along with their medical colleagues, so we know they can work together. Now, it is time to dismantle the siloed systems of dentistry and medicine to create a truly patient-centered care model with that same drive and innovation to tackle chronic diseases.

Author Margaret Scarlett is an infectious and chronic disease prevention specialist, practicing dentist, and author. For 30 years, she has provided expert guidance on infectious diseases and infection control as a consultant to the CDC, 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.