2020 IPEP CONFERENCE
Welcome to IPEP Conference 2020! In these extraordinary times, we have organised the conference to be held online. The theme this year is: "Communication", which covers two very relevant topics - Telehealth and First Nations Health. There are two parts to this conference:
Part 1 - Recorded videos, podcasts, and transcripts of insightful interviews conducted with experts and professors working and researching in Telehealth and/or First Nations Health which are available to you from Monday 14 Sept to Thursday 8 Oct (AEST).
Part 2 - A live Zoom session on Thursday 8 Oct, 7:30-9:30pm (AEST) to delve deeper into case studies with some of these experts.
Please head over to this link to register - https://forms.gle/djdp5gUGjzDre6wv8
If you have any questions, please email us: firstname.lastname@example.org
DR. JOSHUA CH'NG
Dr. Joshua Ch’ng is a dentist who is completing the final year of his degree in Doctor of Clinical Dentistry (Orthodontics) at the University of Melbourne. He is a fellow of the Royal Australasian College of Dental Surgeons. For his thesis project, he travelled to Ann Arbor (MI) to work on a collaborative research project with the Dental and Craniofacial Bionetwork for Image Analysis (DCBIA) in the area of 3D regional voxel-based registration techniques. He is passionate about the use of digital orthodontics to achieve excellent treatment outcomes for patients.
Telehealth for Dentistry [Video Transcript]
Presenter: Dr. Joshua Ch’ng, Final Year in Doctor of Clinical Dentistry (Orthodontics) at the University of Melbourne, Fellow of the Royal Australasian College of Dental Surgeons
Ian: Hi everyone welcome to IPEP’s conference for 2020. We are really proud to bring you a great line up leading up to the live discussion and case studies on October the 8th. I guess this is the first time that we will be doing it through Zoom. And as I'll be bringing up later, there's going to be lots of health changes delivered and transitions of daily life to online. Thus, the topic I’ll be focusing on today is telehealth.
My name is Ian I'm one of the interviewers for this conference today and I am part of the education sort of wing of IPEP. Today I am delighted to welcome Dr Joshua Ch’ng. He is a dentist complaining his final year of his degree in his doctor clinical dentistry (orthodontics) based at the University of Melbourne. He is a fellow of the Royal Australasian College of Dental Surgeons and for his thesis project travelled to Ann arbour (MI) to work on the collaborative research project with the dental and craniofacial part network or image analysis and I believe this involves 3D image analyses.
His passions and interests involved the use of digital orthodontics to achieve beneficial treatment outcomes for this patient. Would you like to add anything else, Josh?
Dr. Joshua: No, thanks for having me
Ian: I guess how we’ll start is, I'm not entirely sure where the previous interviews have gone so it's good to just open generally so how could you tell us a bit what is telehealth and how does it work?
Dr. Joshua: Sure. So I'm absolutely by no means an expert in telehealth and to be perfectly honest I didn't think too much into the concept prior to COVID19 and obviously with this pandemic, we've been forced into using telehealth to a much greater degree.
I really liked this definition from the paper I read and so it was it was a paper by this person called. E Ray Dorsey who published in the New England Journal of Medicine and he defined telehealth as the provision of healthcare remotely by means of a variety of telecommunications tools including telephones smart phones and mobile wireless devices with or without video connection.
So, I thought it was a really nice, succinct and simple definition. I suppose tele-dentistry which is kind of what I do is obviously a subset of telemedicine and telehealth and just looking through a few papers I think it used to be defined quite narrowly.
Another definition was the practice of using video conferencing technologies to diagnose and provide advice about treatment over a distance. Newer definitions included using telecommunications for the purposes of patient care but also education as well the education of health practitioners which is what I've or we’ve all been involved in quite heavily in the last few months
Ian: Hm, a lot of healthcare student have had their placements modified in the past few months. Regarding yourself, has your practice implemented or utilized telehealth?
Dr. Joshua: Absolutely. So just a bit about myself - At the moment, I'm specializing in the area of orthodontics. I'm a general dentist where I worked in private practice for about four years and then after that in 2018, I started my course at the University of Melbourne. So at the moment we are treating patients at two locations so the first is The Royal Dental Hospital of Melbourne where we see public patients. We also we also see patients in a private clinic called Melbourne dental clinic so show a lot of you be aware of that one which is on Swanston street close to KFC next to ridges where obviously the outbreak was. But we were seeing patients and been using ‘telehealth’ before Covid 19 but so much greater degree now. I'll just outline like a few areas in which we are using it now.
Screening and triaging - a few patients who may have emergencies during lockdown. What they will do is they will email us and often they'll send photos. For example, they might have some pain, they might have a wire from their braces which is poking into their cheek, they may have some broken brackets and sometimes they’re not sure how to describe it exactly.
They'll take a photo and then send it to us by email. Based on their description and the photos we can decide whether it is severe enough to get them into the clinic.
We've also been doing teleconsultations for new patients, so I have seen a few new patients through the online appointment I'll get them to take a few photos of the teeth or link them with a video on how to do it. Also, we will get them to take a couple of radiographs if they haven't had them done them recently and to fill out a new patient form. After all that, we will do an online consultation.
We've done a lot of monitoring as well with the appliance that we place. Sometimes they are active and so we need to closely monitor the progress via email. Patients will take photos and send them to us. We will send emails back and see how they are going. So those are a few areas we have been using telehealth.
Ian: There are many different uses of telehealth as you mentioned such as how it can be used to triage, monitor and provide education. In terms of dentistry, there are a lot of things that you might have to educate a patient on. For example, how to brush correctly, take care of your orthodontics. How have you been dealing with that patient education side in telehealth?
Dr. Joshua: So as far as oral hygiene - I think telehealth whichever platform you use whether it's by SMS or email or in phone call, it helps patients. We have educated them before when they were in the clinic, and repetition helps to reinforce the message.
The fact that we are following them on them it makes them feel like they are being observed by us, so they feel in need to comply to our instructions. That is probably another factor. But certainly, as I said before all those all those means like phone call, email, sometimes SMS you know we use all of these things to try to educate. Also sending them links to videos is another thing that that we sometimes do
Ian: you mentioned that there are various platforms [for telehealth] in the public and private practice which are the main ones you use regularly?
Dr. Joshua: Prior to COVID-19 we were already doing all the sort of traditional ways that many people would be using so things like email - we'd already been doing a lot of that. We use email to send certain instructions as I mentioned before, monitoring treatment progress and also when patients have emergencies, they email the photo, phone call etc.
So, it's one of the main differences now during Covid is the use of video conferencing - things like zoom because prior to Covid we hadn't really been using it. This had been a tool that was available, but I guess we did not see the need for it at the time. But since Covid we have been using it a lot more. Aside from consultations which I mentioned before I also use it for things like inserting certain passive appliances.
For example, after orthodontic treatment after we take off the braces, we need to give patients retainers stop the teeth removing. What happened was that I had a few patients just before lockdown were taken braces off but unfortunately couldn’t see them.
One good thing about telehealth is that we were able to mail patients the retainers and then arrange for an online appointment where I got them to put the retainers in. Then I try to make sure that it fit well and gave patients the instructions in.
Also, for those who aren’t aware, in orthodontics we do a lot of braces but we also do a lot of clear aligner therapy so I'm sure people would have heard about Invisalign it's into probably the biggest company that offers clear line of services and so with clear aligner therapy.
Clear align therapy involves wearing a series of clear plastic aligners or trays which sequentially move your teeth to the desired position. So, after we do the planning, we look at where your teeth start and we plan where they should end and then in between the company fabricates whole series of aligners who might be 20 - 30 alignments and each one will gradually move your teeth so quite position. After you've planned it and you fabricate all the alignments you can actually issue essentially a whole box for patients and it's quite it works quite well with telehealth.
You can issue some aligners but you don't want to let them do it without monitoring so you can monitor their progress every few weeks and set up an online appointment. This makes sure that they are doing it properly and make sure that things are tracking.
Ian: I never knew that there were that many series that you must go through. It must be useful to be able to catch up with your patients and to make sure everything is going okay.
In general, how have your patients received the newer versions of teleconferencing and the healthcare delivered in this way
Dr. Joshua: Yeah look I think generally well. There are a lot of benefits to doing it this way. For certain patients who are quite busy - we have a lot of patients who are working. Particularly clear aligner therapy.
Working adults were seeking this kind of treatment, they want something that's aesthetic, cosmetic to wear. So, a lot of them when they come and see me, they have to take time off work and sometimes they take time off during lunch or they'll get the last slot in the day.
But there is still a degree of inconvenience. With telehealth it saves them a visit to the to the office and so looking into the future if there are certain appointments that can be cut down on and do them online - I think it will be well received.
On the point of rapport, you can go both ways. Having done some new patient consultations. I did find it was a little bit difficult in seeing somebody for the first time online so there's a part of me that prefers you know doing it in person.
But it’s not it's not too bad, particularly for patients who I have seen before say you've done say a subsequent consultation. For example, I did one the other day with the patient and in the background, I could see that there were decorations around the house. This was for celebrating her husband's 50th birthday and that was kind of nice. I also got to meet the husband - it’s as though she kind of let me into her home so that was a little bit different.
Ian: I guess you get to see a different aspect of the patient in that way, not just in the clinic. You mentioned how you have to be a bit more creative in terms of how you examine patients like using videos and pictures - are there any other ways in how you examine patients like using self-manoeuvres and things like that?
Dr. Joshua: Prior to the consultation I’ll send patients instructions on how to take good photos and those photos are really important for us to see them. I will see them but sometimes they just really can't take the photos during the appointment. Like the other day I tried to get the patient to sort of position themselves like really close to the camera and then I told them to just relax their lips so I can see where your teeth are sitting. I guess you can try your best to do that but obviously it's not the same as a physical examination.
It’s always going to be you know like limitations to this - but certainly it’s reasonable enough that you can give the patients on some idea about what they might have and what sort of treatment options might be appropriate. Obviously, we need to do proper examination and possibly more investigations to say for sure to say you know what they have. But I'm sure there's a lot of things that I haven't so to fully taken advantage of with zoom just because we’re still getting used to it. Hopefully I'll learn and learn off other people as we do this a little bit more.
Ian: You mentioned the difficulty regarding there being a lack of physical exam. Were there any other challenges that you faced particularly at the initial period of the pandemic working with telehealth and zoom as well as other healthcare delivery modes?
Dr. Joshua: So, with in terms of challenges I suppose one of the concerns that I had about telehealth was the legality and the and the ethics of it.
All these questions in my mind I just had never really thought about it. As we mentioned before the inadequate clinical assessment, ensuring not giving patients advice that is based on inadequate information. I tried to get around that by just letting them know that it’s not a replacement for the physical exam.
The other thing was the security of records. I mean we have patients who email the photos to us and it's in my inbox but there's the question of security of my email account. There is the fact that I'm at home I have to call patients with my own phone and I tried to get around that by using by blocking my caller ID but there have been some instances where I have had to call them with my number because they simply just won't pick up with the blocked ID.
I know that particularly in America they have issues with licensing like a barrier between the states but it's I suppose that's not really a big problem here for us in Australia as dentists or any healthcare practitioner I suppose (AHPRA) given that we have like a national license.
Some other challenges were obviously technical difficulties with zoom which happens less now than it used to. But people drop out of calls, not being able to share this screen with the Internet, video lagging and losing audio and what not. That's definitely improved now that we're a bit more used to it
As I mentioned before as well that's something I found a little bit difficult the one last thing I'll mention is that we still need a lot more studies to actually prove that treating patients via telehealth will achieve the same health outcomes.
For example, what I mentioned before about aligners, when you issue aligners the traditional way - you’ll get the patient in every 6 to 8 weeks and make sure that they fit in really well. We don't know whether monitoring via telehealth will result in the same outcomes. I suspect if you're still getting your patients in frequently enough it will be fine. However, I suppose there is that uncertainty because there just haven't been enough studies on this. There are questions about standards of care - providing the same standard of care to patients while trying to make it more convenient for them and for us
Ian: Is there s body like a general Australasian or Australian specific body that's constantly updating and creating zoom or telehealth specific resources?
Dr. Joshua: We have the Australian Dental Association which is national and looks after all dentists and their state branches. They have been helpful they put out some guidelines on how to use telehealth so that was quite good at the start of the pandemic.
They helped guide us with regards to medical legal advice and they also introduced a new code because for item number because prior to do that I don’t think we actually had one. I'm getting reimbursed and remunerated for services, so it was good that they did that. But I suspect it will be them that will be putting out resources. Online forums have been helpful as well, we have our dental forums on Facebook and other social media.
Ian: I guess as we look towards better and Covid-free days how do you think telehealth will change once the pandemic is over? Do you think it will be something that is going to be integrated within dentistry and orthodontic practice or is it something that you expect to recede?
Dr. Joshua: Yeah absolutely, we were already using telehealth to some degree, but we just hadn't really thought about it. But now we are using a lot more and using platforms like video conferencing which we were not using as much or at all.
Certainly, video conferencing will be used a lot more in the future for consultations. A lot of clinics were using Teleconferencing for new patient consultations and monitoring so that will certainly be done to improve access to care. I've got some patients were living in in Sale, some in Tasmania. We can now that monitor their treatment progress.
As I said for monitoring, we will probably try to keep an eye on our patients who well currently in treatment. Making sure everything is fine not just through zoom but also through emailing photos and things these things we could have done before, but now that patients are more used to sending in photos. That is probably something will use a little bit more.
Something I haven't mentioned is meeting with other colleagues and other professionals to discuss cases. That is something we have been doing more so. At the hospital we see patients who require combined orthognathic surgery and orthodontics. We then can meet with the surgeon to discuss the treatment plan - that is something we've been doing more of during pandemic.
In these sessions we will screen share our PowerPoint and then go through the treatment plan and discuss exactly how to treat the patient, so I think all of those we will do more.
Just another thing that I will mention is that we will continue to use and will continue to evolve as we use it to a greater extent is this thing called dental monitoring.
What it is it, it allows dentists to monitor patients and the treatment progress and involves three platforms. The first is this mobile phone app that allows patients to take photos of their mouth and send them to me that's not there so different to what we talked about before. They also got a movement tracking algorithm that tracks the patients progress. For example, they will take a photo of their clear align therapy and teeth. The algorithm will be able to see whether the aligners fit. Sometimes if it doesn't track, they'll see there's a gap in between the aligners and the teeth and then so they will though be notified of that. It will track things like their oral hygiene - you know if they're not brushing well or if they're not brushing that well in the gums are really puffy and inflamed.
The third platform is this dashboard that allows the dentist to see what the algorithm said so they get notified if there are problems then they can contact the patient. That's kind of similar to what we were talking about before but with that added algorithm which is a little bit more sophisticated. That’s technology that already exists and has been used by a few people like a few orthodontists in Melbourne but its use isn’t widespread yet, but you know looking into the future we probably will use it more.
Ian: Maybe going forward not only communication technologies but AI can be well integrated in the future as well.
Dr. Joshua: Yeah and there's the argument that it is not only more convenient for the patients but also for the clinician. It hasn't been proven yet, but it may result in better treatment outcomes. This is because the patient is being monitored so frequently, they need to take these photos of the teeth every week, so their progress is being more frequently. This is more than what it would be if they were going in to see the dentist orthodontist every six to eight weeks. Because they are monitored in some way.
Ian: Well, those were the questions I wanted to ask you today Josh. I learnt a bit about not just telehealth but dentistry and orthodontics. Thank you for your time
Dr. Joshua: Yeah, no worries – it was nice to have a chat about this.
Ian: If that’s all thanks once again and I’ll hopefully be able to post this section of podcast as well as this transcript on our website. So, stay tuned!