Teledentistry at ATSU-ASDOH

What is teledentistry?
In this video, patients can learn about teledentistry and how it is used to help connect them to their oral health providers.

Reviewing teledentistry technology
In this video, patients are introduced to the technology that is needed for a teledentistry visit (a phone, computer, or tablet) and how they will connect with their oral health provider during their teledentistry visit. 

Preparing for a teledentistry visit
In this video, patients will be guided through the ins and outs of a teledentistry visit and the steps they can take to ensure a successful visit. 

The teledentistry visit
In this video, patients will learn about how a teledentistry visit will be conducted so that it is successful for both them and their provider. 

Before your appointment

• Using communication technologies, such as Zoom, your provider can meet with you so that you don't have to travel to the office.
• Teledentistry can save you both time and money as you will avoid unnecessary trips to the dental clinic.
• You can be anywhere for your teledentistry visit, including at home or work.
• Visits such as treatment plan presentations, surgical post-op visits, sedation consults, and pain consultations can be done with teledentistry.
• If you are unfamiliar with Zoom, please go here to access different websites on Zoom and how to use it.
• Go here to join a Zoom test run. When the site opens, click the blue "Join" button. This will help you become more familiar with Zoom if you have not used it before.

What device should I use?

• Any device that can connect to the internet can be used for a teledentistry visit. This includes smart phones, tablets, laptops, or desktop computers.
• The device you use should have a built-in webcam. You can also use an external webcam if your laptop or desktop computer does not have a built-in camera.
• We recommend downloading the Zoom app for your device. If you are using a computer, download "Zoom Client for Meetings." If you are using a mobile device, such as a smart phone or tablet, download "Zoom Mobile Apps." Click on the appropriate icon (App Store for Apple and Google Play for Android) to download the app.
• Ensure you have a strong internet connection. Internet connection requirements from Zoom. To test your internet speed, click here and press "Go."

Emails with visit information

• You will receive an email from accteledentistry@atsu.edu with information about preparing for your teledentistry visit.
• You will receive a second email from accteledentistry@atsu.edu with the link to join your teledentistry appointment.  Please save this email so that you can join your appointment at the right time.

Ensuring your privacy

• Avoid using a public wi-fi network.
• Try to be in a private location, so strangers do not overhear your conversation with your provider.
• Use a private wi-fi network that is password protected.
• Do not sure the email with the link for your visit with anyone who you do not trust.
• You are welcome to invite family or friends to your visit. Just let your provider know who you are inviting at the time of your visit.
• An email with your teledentistry visit link will be sent using encryption software. Click here to learn more about this software.

Camera tips

• Whether using a device with a built in camera, or an external webcam, make sure the camera is stable.
• Do not hold the phone or tablet in your hand. Support it with something like a heavy book or against a wall.
• Do not put a laptop on your lap.
• If using a smart phone or tablet, the screen can be vertical, or horizontal.

Lighting tips

• Your provider will want to see you as clearly as possible.
• Do not have a window or bright light behind you.
• If possible, avoid having a light on just one side of your face.
• It's best to have a light shining directly on your face and behind your camera, or as an alternative have the light above you.

Positioning yourself on camera

• Try not to be too close or too far from the camera.
• If possible, position yourself so the top of your head is at the top of screen
• The image should capture just below your shoulders.
• If needed, move the camera or your body to fit yourself in the fame as seen in this picture.
• Don't worry about things being perfect. The ATSU-ASDOH provider or staff member will help you make any necessary adjustments.

Commonly used buttons on Zoom

• If your provider can't hear you, try pressing the microphone button.
• If your provider can't see you, try pressing the camera button.
• If there is a red slash through the camera or microphone, it means that device is turned off.
• If you are still not able to be seen or heard, click this link to learn more about testing your video and audio.
• If you are unable to fix the video or audio issue, your provider will decide if you can simply talk on the phone or if you will have to come for an in-person visit.

Final suggestions

• Please wash your hands before your appointment. Your provider may ask you to feel in and around your mouth.
• Be ready for the visit about 5-10 minutes ahead of time to ensure your device is on and working.
• Join the appointment using the link from the email that was previously sent to you.
• A dental assistant will meet you to ensure everything is working properly.
• If you wait more than 15 minutes for your appointment to start, please call 480.248.8107.
• We will avoid an in-person visit unless it's absolutely necessary. If the provider determines an in-person visit is necessary before the teledentistry visit, then the teledentistry visit will be cancelled and you will be scheduled to be seen in the clinic.

• Your provider might need to schedule additional follow-up visits. These may be via teledentistry or in-person. The front desk will call you to schedule this appointment.
• If you receive a link to complete a survey about your visit, we'd be grateful if you could complete it. These surveys help us to continuously improve our teledentistry visits for all of our patients. Thank you.

Securing your home network and mobile devices. By taking some simple steps to secure your home network and mobile device, you will decrease the chance of an unwanted person from accessing private information.

Reading an encrypted email. ATSU-ASDOH uses a program called Virtru to send you confidential information, including the link for your teledentistry appointment. After signing into your email, you'll need to access your secure message following the instructions on this site.

Download Zoom. If you don't download Zoom, it will automatically download to your device when you click on the link for your appointment.

Conducting a test of Zoom. You can initiate a "test meeting" to become more comfortable with Zoom.

Frequently asked questions about Zoom

Joining Zoom for a teledentistry appointment

Testing video or audio

My video/camera isn't working

Configuring audio and video

System requirements, including internet speed

Running a speed test on your computer. Zoom only needs 3.8Mbps (up) and 3.0Mbps (down) for your teledentistry appointment. If you run a speed test on your device and it's less than this, please call us at 480.248.8107.

Zoom troubleshooting (including video/camera not working, hearing an echo, and audio isn't working on mobile device)

For more troubleshooting help, please watch this video.

Before the appointment

• Direct to patient teledentistry can be used with various types of patient appointments but there are two primary reasons you would consider using direct to patient teledentistry: 1) New patients who need to be triaged before coming to the clinic and 2) Existing patients who need some kind of follow up appointment but don't need to be physically in the clinic for that appointment.
• Treatment plan presentations, post-op visits, oral facial pain follow-ups, and sedation consults are just some of the visits where teledentistry is being used at ATSU-ASDOH.
• The providers are responsible for letting the front desk know if they want to schedule a visit using teledentistry.

• The front desk will contact the dental providers if a new patient is calling in that might qualify for a new patient teledentistry exam. Providers will then let the front desk know if they should schedule a teledentistry visit or an in-person visit.
• If the patient schedules a teledentistry visit, the front desk will email the provider the link for the teledentistry appointment. This link will also be placed on the patient's appointment on the schedule in axiUm Ascend. Just click on the appointment and look under the "Notes" section on the right hand side of the screen.
• To see if the Teledentistry Room is available, check the "Telede" column on axiUm Ascend (it is the last column on the right).

During the appointment



Starting the appointment

• In most situations, the dental assistant will start the appointment for the provider and ensure the patient is ready for the provider. But if a dental assistant is not available, use the email from the front desk or check the appointment in axiUm Ascend for the link.
• If the assistant is not available, please go to the staff page to see how to prepare the patient for the appointment.
• Ensure the "Teledentistry appointment in session" sign is posted on the outside of the room and close the door before beginning the appointment.
• Do not talk to anyone off camera. This can be concerning for a patient and makes it difficult for them to trust the use of teledentistry.

Positioning yourself on camera

• Try not to be too close or too far from the camera.
• If possible, position yourself so the top of your head is at the top of screen.
• The image should capture just below your shoulders.
• If needed, move the camera or your body to fit yourself in the fame as seen in this picture.

Commonly used buttons on Zoom

• If your patient can't hear you, try pressing the microphone button.
• If your patient can't see you, try pressing the camera button.
• If there is a red slash through the camera or microphone, it means that device is turned off.
• If you are still not able to be seen or heard, click this link to learn more about testing your video and audio.
• If you are unable to fix the video or audio issue, decide if you can simply talk on the phone with the patient or if you will have the patient come for an in-person visit.
• If someone is in the "Waiting Room," click the "Participants" button and then you can admit them. Additional information on waiting rooms can be found here.

Additional items to consider

• At the end of the appointment, click "End" and then "End Meeting for All." Be sure to sign out of Zoom.
• If you need to take a screen shot, check out this link. Save the screen shot to the computer then upload it to axiUm Ascend (or ask an assistant to upload it).
• For additional Zoom tips and tricks, see the "Troubleshooting" section below.

When not in the ATSU-ASDOH Clinic

• If you are not able to be at ATSU-ASDOH for the teledentistry appointment, it is important to keep several items in mind.
• Use a password protected, private wi-fi visit. Do not use public wi-fi.
• Ensure no one in your home/around can hear you.
• Close the door to the room you are in and request to not be disturbed.
• Avoid having any doors or windows behind you and if possible the wall behind you should be unadorned. You can also use the teledentistry virtual background options: click here for the blue background, or click here for the white background. You must be logged in an ATSU account to access this.
• Ensure there are no bright lights behind you. Lights should be directly in front of you or above you.
• Avoid using a smart phone or tablet and if possible use a dual monitor set up, but a single monitor will be ok.



After the appointment


Steps to complete after the visit
• Set the appropriate codes complete. D9995 should always be used in conjunction with a direct to patient, live video conference, teledentistry visit.
• Notify the front desk if there are any necessary follow up appointments, either via teledentistry or in person.
• Complete the post-teledentistry appointment survey.

What is teledentistry?
In this video, dental providers will learn about teledentistry and how it is used to help connect them to their patients.

Reviewing teledentistry technology
In this video, dental providers will learn how they should prepare for an upcoming teledentistry visit with a patient.  

The teledentistry visit
In this video, dental providers will learn how a teledentistry visit is conducted so that it is successful for both them and their patients. 

Teledentistry troubleshooting
In this video, dental providers will be given some troubleshooting tips should they run into any issues during the teledentistry visit. For more information on troubleshooting, please see the "Troubleshooting" section below. 

Before the appointment

The right type of appointment

• Direct-to-patient teledentistry can be used with various types of patient appointments but there are two primary reasons you would consider using direct to patient teledentistry:

1. New patients who need to be triaged before coming to the clinic
2. Existing patients who need some kind of follow up appointment but don't need to be physically in the clinic for that appointment.

• Treatment plan presentations, post-op visits, oral facial pain follow-ups, and sedation consults are just some of the visits where teledentistry is being used at ATSU-ASDOH.
• The providers are responsible for letting the front desk know if they want to schedule a visit using teledentistry.

What does the front desk do?

• The front desk will contact the dental providers if a new patient is calling in that might qualify for a new patient teledentistry exam. Providers will then let the front desk know if they should schedule a teledentistry visit or an in-person visit.
• If the patient schedules a teledentistry visit, the front desk will email the provider and the dental assistants the link for the teledentistry appointment. This link will also be placed on the patient's appointment on the schedule in axiUm Ascend. Click on the appointment and look under the "Notes" section on the right hand side of the screen.
• To see if the Teledentistry Room is available, check the "Telede" column on axiUm Ascend (last column on the right).

During the appointment

Starting the appointment

• In most situations, the dental assistant will start the appointment for the provider and ensure the patient is ready for the provider.
• Ensure the "teledentistry appointment in session" sign is posted on the outside of the room and close the door before beginning the appointment.
• Use the link in the email from the front desk or check the appoint in axiUm Ascend for the link to start the appointment.
• Do not talk to anyone off camera. This can be concerning for a patient and makes it difficult for them to trust the use of teledentistry.
• Double check that the patient has washed their hands.
• Once the patient is ready and you can see and hear them and they can see and hear you, it is time to get the provider.

Camera tips for the patient

• Whether using a device with a built in camera, or an external webcam, make sure the patient's camera is stable.
• Patients should not hold the phone or tablet in their hands. They should support it with something like a heavy book or against a wall.
• If they are using a laptop, they should not put it on their lap.
• If patients are using a smart phone or tablet, the screen can be vertical or horizontal.

Lighting tips for the patient

• Ensure patients do not have a window or bright light behind them.
• If possible, they should avoid having a light on just one side of their faces.
• It's best to have a light shining directly on the patient's face and behind their camera, or as an alternative have the light above them.

Positioning yourself and the patient

• Try not to be too close or too far from the camera.
• If possible, position yourself so the top of your head is at the top of screen.
• The image should capture just below your shoulders.
• If needed, move the camera or your body to fit yourself in the fame as seen in this picture.
• Ensure the patient follows these same recommendations. Give them suggestions for how to adjust their position so the provider will be able to see them clearly.

Commonly used buttons on Zoom

• If the patient can't hear you, try pressing the microphone button.
• If the patient can't see you, try pressing the camera button.
• If there is a red slash through the camera or microphone, it means that device is turned off.
• If you are still not able to be seen or heard, click this link to learn more about testing your video and audio.
• If you are unable to fix the video or audio issue, decide if you can simply talk on the phone with the patient or if you will have the patient come for an in-person visit.
• If someone is in the "Waiting Room," click the "Participants" button and then you can admit them. Additional information on waiting rooms can be found here.

Additional items to consider

• If you are unable to see or hear the patient and are unable to resolve the issue, please call them using a clinic phone to see if you can figure out what's going wrong.
• If problems can't get resolved, ask the provider if just talking to the patient on the phone will help, or if they need to reschedule for an in-person visit.
• For additional Zoom tips and tricks, go to the "Troubleshooting" section below.

After the appointment

• Ensure the appropriate codes were set complete. D9995 should always be used in conjunction with a direct to patient, live video conference, teledentistry visit.
• The providers will notify the front desk if any additional follow up visits are required, including in person or teledentistry visits.
• Remind patients to take the survey if they receive a link about their visit.

What is teledentistry?
In this video, dental staff can learn about teledentistry and how it is used to help connect patients to their oral health providers.

Preparing for a teledentistry visit
In this video, dental staff will be guided through the steps that will occur prior to the teledentistry visit.  

The teledentistry visit
In this video, dental staff will learn about how to conduct a teledentistry visit so that it is successful for both the provider and the patient. 

Teledentistry troubleshooting
In this video, dental staff will be given some troubleshooting tips should they run into any issues during the teledentistry visit.  

Here are some additional links that might be helpful for your teledentistry visit. These issues should not arise if you are working out of the teledentistry suite at ATSU-ASDOH. But if you are working from home, these links might come in handy.

• Securing your home network and mobile devices. By taking some simple steps to secure your home network and mobile device, you will decrease the chance of an unwanted person from accessing private information.
• Download Zoom. If you don't download Zoom, it will automatically download to your device when you click on the link for your appointment.
• Conducting a test of Zoom. You can initiate a "test meeting" to become more comfortable with Zoom.
• Frequently Asked Questions about Zoom
• Joining Zoom for a teledentistry appointment
• Testing video or audio
• My video/camera isn't working
• Configuring audio and video
• System requirements, including internet speed
• Using Waiting Rooms in Zoom
• Taking screen shots
• Running a speed test on your computer. Zoom only needs 3.8Mbps (up) and 3.0Mbps (down) for your teledentistry appointment. If you run a speed test on your device and it's less than this, please call us at 480.248.8107.
• Zoom troubleshooting (including video/camera not working, hearing an echo, and audio isn't working on mobile device)

There are three classes taught either in person or via Zoom to second- and third-year dental students.

In the first class (Introduction to Teledentistry), Dr. Howell teaches second-year dental students toward the end of the fall semester. In the first half of the class, Dr. Howell presents the general terms and concepts related to teledentistry and introduces students to diagnosing patients using digital records.

In the second half of the Introduction to Teledentistry class, the students are broken into groups to discuss a series of cases based on actual patients seen in the teledentistry program. This allows them to begin practicing identifying, diagnosing, and treatment planning cases using only digital records. After the students discuss the cases and questions in small groups, we come back as a class to discuss the answers. The focus of the second teledentistry class, which usually occurs in the spring of the second year, is about recognizing good digital records from bad digital records. Students are given a series of images from different teeth in the mouth and descriptions of what makes those photos good. This includes photos a patient may take of themselves. This class also has a guest speaker who provides students with some background information on the patients they will be working with in the juvenile detention center.

In the second half of the second teledentistry class, students work in groups to identify the problems with a series of digital images of teeth. They are not required to know how to fix those problems, yet, but will learn that in the intraoral camera lab in their third year. They use a Google Form to submit their answers to the instructor. We then come back as a class and students are called on to give their groups' answers.

In the third year, students are given an opportunity to explore the development of a teledentistry program in more detail. Dr. Howell has used a couple different methods to teach these concepts.

All ATSU-ASDOH students complete a Dentistry in the Community (DIC) course where they learn important public health concepts such as needs assessment, program development, and program evaluation. When the third-year teledentistry class was first designed it was done around this framework that they learned in their DIC class. Students were tasked with taking a population facing a unique barrier, identifying a solution to that barrier that involved teledentistry, and then coming up with some specifics for a teledentistry program. The barriers they were given are actual barriers that teledentistry programs around the country have faced.

As the ATSU-ASDOH program began surveying graduating fourth-year dental students on their readiness to use teledentistry after graduating there was a common theme: students didn't know if the states they would practice in or if their bosses would allow them to use teledentistry. To help them prepare to bring teledentistry to their communities, the third-year teledentistry class was modified to focus on advocacy skills. Each group of students is assigned a unique population for whom they could use teledentistry to help deliver oral health services. These groups include patients recently diagnosed with COVID-19, kids and adolescents in detention, and families living in rural communities, to name a few.

The students must develop a solution to delivering care to that population using teledentistry that could be turned into a legislative bill. Finally, they write a testimony that they could present to the state legislature advocating for the passage of their solution. In their testimony they must include data on health and social issues their community is facing and come up with concerns that both liberal and conservative lawmakers may have with their solution. Finally, they must include in their testimony why teledentistry is a viable solution to meet the oral health needs of their particular population. Students then present their testimony to the class and other groups are tasked with coming up with questions that a legislator may ask so as to recreate what a legislative committee meeting might look like.

In the third year, students get the opportunity to practice with intraoral cameras so that they can be better prepared to collect digital records when they go out to community sites as part of the teledentistry activities. In this lab, the students spend about two hours with Colleen Trombly reviewing how digital records are used for teledentistry-based exams. They then practice taking photos and videos on dental manikins.

After practicing, the students are required to complete an intraoral camera lab assessment. Photos are uploaded into the axiUm Ascend training environment and videos are emailed to Dr. Howell. The students then work with Dr. Howell to evaluate their photos and videos and discuss what went well and what needs to be improved. An important lesson during these discussions is specifically identifying how they would improve the photos (i.e. which way would they have to move their hand to make the photo ideal).

As part of their intraoral camera exercises, students get an opportunity to play a game where they have to identify the tooth they are looking at. The game is themed to different horror movies (one of Dr. Howell's favorite genres of movies). To add to the suspense, Dr. Howell will play horror music as the game is played. Students are only given 13 seconds per question to try to answer. All the answers are fill-in-the-blank (no multiple choice). When played in small groups, students write their answers on a piece of paper (or in an email if played virtually) and then Dr. Howell hand-checks the answers. Partial credit can be given when the game is played this way. When played in large groups, Dr. Howell uses Google Forms, which can automatically check the answers but there is no partial credit awarded. The exact games are not available to the public but Dr. Howell has created a Kahoot online game where you can test your own skills at guessing "Which Tooth Is It?"

To play the Kahoot, please go here. Then click "Classic" or "Team Mode." Open a second browser window or use a second device and go to kahoot.it. In this second window/device enter the pin that you see on the first window/device. Enter your name or your team name. Now use the first window/device to advance through the game and the second window/device to play the game. The first few slides in the game are educational slides and the first question starts on slide 9.

If you would like to discuss teledentistry curriculum with Dr. Howell, please email him at showell@atsu.edu. 

There are a number of excellent resources available that discuss the various concepts related to teledentistry. These are only a handful but they provide a robust review of the general concepts.

• In 2020, the American Dental Association updated its policy on teledentistry.
• Dr. Howell worked with the Association of State and Territorial Dental Directors to develop a white paper on teledentistry. This white paper discusses the general problem that teledentistry is addressing and provides several examples.
• Dr. Paul Glassman wrote a white paper for the CareQuest Institute (formerly the DentaQuest Partnership). This white paper discusses a variety of topics from the basics of teledentistry, to policy, to the Virtual Dental Home.
• Dr. Nathan Suter runs a teledentistry consulting business, Access Teledentistry that will be of particular interest for those working in private practice and community health centers as Dr. Suter has developed teledentistry programs in both settings.
• A little bit older, but this document from the Oral Health Workforce Research Center provides six different case studies on teledentistry.
• The Arcora Foundation put together a document on the ins and outs of teledentistry including several scenarios in which teledentistry can be used.
• The Southwest Telehealth Resource Center is full of information that can come in handy. It has a telemedicine focus but much of what can be found here can be applied to teledentistry.
• The National Network for Oral Health Access has promising practice documents that highlight how two FQHCs, Ravenswood Family Health Centers in East Palo Alto, CA and Petaluma Health Center in Petaluma, CA, have used teledentistry within their clinics. Additional promising practice documents on other topics that focus on access to care can be found on the NNOHA website.

The legal and policy landscape around teledentistry changes on a regular basis. These sites can become outdated as soon as they are posted. Please be sure to check state legislative and state dental board websites before you begin using teledentistry.

• Dr. Thomas Poleman put together a document reviewing the nationwide teledentistry regulations. This is current as of April 2020.
• The Center for Connected Health Policy updates its site regularly on the various legislation that is adopted across the country on telemedicine and teledentistry. The CCHP laws and reimbursement policies report is probably the most comprehensive document available when it comes to this topic.
• As teledentistry is still developing around the country (and the world), it's important to know how to advocate for it to a clinic director, the state legislature, Medicaid directors, insurance companies, etc. This website, from the Chronic Disease Coalition, offers a good list of tips for when you are getting ready to advocate for a particular issue.

For those practicing in Arizona:

• Learn more about affiliated practice dental hygiene or go to the board website for the proper paperwork.
• Arizona state laws on teledentistry.
• For the AHCCCS policy on teledentistry, go here and here, and for approved codes go here.

Billing and coding will be very specific from state to state and from insurance carrier to insurance carrier. While these documents can be used for reference, it's very important to check with your local insurance carriers, Medicaid programs, and state rules and regulations regarding the use of teledentistry.

• One of the first documents to be developed by the American Dental Association on teledentistry, this document on the teledentistry codes (D9995 and D9996) provides several scenarios for how these codes should be used.
• The American Dental Association has also developed a coding and billing guide that is primarily relevant to COVID but may be applicable post-COVID depending on your state rules and regulations and depending on the insurance plans you take.
• The American Dental Association developed a few new codes that are applicable to teledentistry and the taking of images. This document walks people through how these codes should be used. These "image capture only" codes are not only applicable to teledentistry but also to imaging centers where an individual may go to take a CBCT, for example.

Technology is constantly changing. There is no one item that the ATSU-ASDOH teledentistry team can recommend. They encourage providers and clinics to explore the various technologies.

• Dr. McAllister Castelaz put together a comprehensive spreadsheet on the various technologies available for communicating with patients. From video conferencing to simple text messaging, this covers a lot of the existing technology.

Knowing how to use teledentistry with patients is crucial to a successful teledentistry visit. Here are some items that might be helpful for working with patients.

• Guidance document for patient assessment via synchronous teledentistry, developed by Dr. Howell in conjunction with MouthWatch. There is also a webinar that goes along with this document. You will need to create a free account to watch this webinar.
• The National Network for Oral Health Access has created a sample workflow for teledentistry visits that are conducted using a video conference platform.
• The Southwest Telehealth Resource Center has wealth of information. If you are looking for patient or provider satisfaction forms scroll to the bottom of this page. These are aimed at telemedicine but could be modified to fit a dental clinic.
• The San Francisco Department of Public Health has created a video going through motivational interviewing, which is a great way to better understand our patients and help them achieve their health goals. Teledentistry can easily be used in conjunction with motivational interviewing.
• Cavity Free San Francisco has some videos on teledentistry (plus additional patient education videos) that can be shared with parents or guardians to prepare them for a teledentistry visit and to help guide them in taking pictures of their children's teeth.