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Evaluating remote care by tele-dentistry Rodrigo Mariño Symposium Early Childhood Oral Health 28 September Evaluating remote care by tele-dentistry Rodrigo Mariño Symposium Early Childhood Oral Health 28 September 2016

e-Health “to encompass the rapidly evolving discipline of using computing, networking and communications methodology e-Health “to encompass the rapidly evolving discipline of using computing, networking and communications methodology and technology - to support the health related fields, such as medicine, nursing, pharmacy and dentistry" (WHO)

e-Health “products, systems and services that go beyond simply Internet-based applications. They include tools e-Health “products, systems and services that go beyond simply Internet-based applications. They include tools for both health authorities and professionals as well as personalised health systems for patients and citizens. ” (EU)

Major areas of tele-health applications Major areas of tele-health applications

Teledentistry “Body of knowledge that focuses on the organisation, management and distribution of information Teledentistry “Body of knowledge that focuses on the organisation, management and distribution of information in support of dental education, practice, research and administration”

Reasons for Teledentistry has the potential to benefit oral health care by: • enhancing Reasons for Teledentistry has the potential to benefit oral health care by: • enhancing early diagnosis, • facilitating timely treatment of oral diseases, • reducing isolation of practitioners through communication with peers and specialists, • reduce health care inequalities. For example access to specialists in rural (geographical or by resources) or underserved areas.

Applications of Teledentistry Applications of Teledentistry

Applications of Teledentistry Background • 1950’s dental education. • In use since the early Applications of Teledentistry Background • 1950’s dental education. • In use since the early 1960 s and covers a broad range of technologies. • The largest teledentistry undertaking in the world is being undertaken by the U. S. military. • Slow adoption of teledentistry.

Applications of Teledentistry ICT provides opportunities to supplement traditional methods for: Tele-consultation Tele-diagnosis Tele-treatment Applications of Teledentistry ICT provides opportunities to supplement traditional methods for: Tele-consultation Tele-diagnosis Tele-treatment Tele-education Tele-training

Inequalities in oral health Overcoming geographical barriers for community health Inequalities in oral health Overcoming geographical barriers for community health

Backgound • Face-to-face patient examinations are regarded as the most accurate method for correct Backgound • Face-to-face patient examinations are regarded as the most accurate method for correct oral health diagnosis. • However, members of specific groups of the community are less likely to have access to a dentist. • For example, the elderly (homebound or living in nursing homes).

Backgound Information from the Australian state of Victoria indicates that: • 11% percent of Backgound Information from the Australian state of Victoria indicates that: • 11% percent of residents have seen a dentist in the past 12 months, • few dentists are available to provide dental care for residents of aged care facilities, • half of Victoria’s dentists reported providing care to residents of RACFs, and • These spent on average only one hour per month providing care in this setting.

Inequalities in oral health Overcoming geographical barriers for community health Field testing of remote Inequalities in oral health Overcoming geographical barriers for community health Field testing of remote teledentistry technology Rodrigo Mariño, David Manton, Parul Marwaha, Richard Collmann, Andrew Stranieri, Matt Hopcraft, Michael Mc. Cullough, Ken Clarke

Inequalities in oral health Overcoming geographical barriers for community health High Definition 3 -D Inequalities in oral health Overcoming geographical barriers for community health High Definition 3 -D tele-medicine applications for the empowerment of patients in health care facilities and the home* *http: //www. hpc. unimelb. edu. au/~dirk/HD 3 D/hd 3 dtelemedicine/

Broadband 3 D tele-health applications Four proof-of-concept projects: • • Teledentistry, Teledentistry Teleoncology, Telepsychiatry, Broadband 3 D tele-health applications Four proof-of-concept projects: • • Teledentistry, Teledentistry Teleoncology, Telepsychiatry, and Telewound management

Objectives To assess the feasibility of using teledentistry to screen for oral diseases and Objectives To assess the feasibility of using teledentistry to screen for oral diseases and conditions and to develop treatment plans for older people living in Residential Aged Care Facilities (RACF).

Methods • Three nursing homes in Victoria • Two metropolitan • One rural. • Methods • Three nursing homes in Victoria • Two metropolitan • One rural. • Five registered nurses. • Fifty RACF’s residents.

Methods • RN Training involved: • 3 hours of direct contact, • a 66 Methods • RN Training involved: • 3 hours of direct contact, • a 66 -page training manual with contents organized in 6 modules. • • • Module Module 1: 2: 3: 4: 5: 6: Uses of teledentistry Oral health in older adults Oral and dental anatomy: practical issues How to conduct the intraoral teledental examination Use of the dental camera for teledentistry consultation Capturing and forwarding information from dental examination • up to 10 hours of practice examinations , and • compensation for their time.

Methods • Registered nurses performed a ‘virtual dental examination’ on a group of residents. Methods • Registered nurses performed a ‘virtual dental examination’ on a group of residents. examination • 10 residents (with no cognitive deterioration). 10 repeated face-face exams. • The information obtained from this examination was transmitted to a server. • Information was registered on a conventional chart for the generation of treatment plans by qualified clinicians at the Melbourne Dental School, University of Melbourne

The Implementation of teledentistry for Pediatric Patients Rodrigo Mariño, David Manton, Parul Marwaha, Kerrod The Implementation of teledentistry for Pediatric Patients Rodrigo Mariño, David Manton, Parul Marwaha, Kerrod Hallett, Ken Clarke, Matthew Hopcraft, Michael Mc. Cullough, Ann Borda

Objectives To assess: • the feasibility of using teledentistry for teleconsultation in children/adolescents living Objectives To assess: • the feasibility of using teledentistry for teleconsultation in children/adolescents living in rural/remote areas of the state of Victoria, • participants’ views about the structure, content and delivery of the program, • whether it could be implemented under current financial arrangements.

Methods • Sites for the project: - RCH (Main central site) - Shepparton • Methods • Sites for the project: - RCH (Main central site) - Shepparton • Urban • Rural - Frankston - Geelong c

Methods Three local general dental practitioners (GDP) were trained to manipulate an intra-oral camera Methods Three local general dental practitioners (GDP) were trained to manipulate an intra-oral camera and use ICT infrastructure to send the information for remote examinations. Teleconsultation specialists at the Royal Children’s Hospital of Melbourne/ Dental School, University of Melbourne

Methods 3 oral health conditions were selected: • Cleft lip and palate • Dental Methods 3 oral health conditions were selected: • Cleft lip and palate • Dental trauma • Orthodontics Patients from the RCH’s patient database who lived in the selected locations were recruited. Both, the community health centres and the Both RCH, operated within current financial arrangements.

Methods • Parents were given a questionnaire to assess his/her views on the teledentistry Methods • Parents were given a questionnaire to assess his/her views on the teledentistry approach. • GDPs self-completed a questionnaire to assess: • their overall experience with the approach, • the utility of the instructional training kit, and • other issues.

Results Oral condition Age (mean and s. d. ) Cleft lip and palate 7. Results Oral condition Age (mean and s. d. ) Cleft lip and palate 7. 2 (4. 3) Orthodontics Total 10. 9 (2. 6) 8. 6 (4. 2) Sex Male Female n (%) 18 (69. 2) 8 (30. 8) n (%) 8 (50. 0) n (%) 26 (61. 9) 16 (38. 1) Location Shepparton Geelong Rosebud 10 (38. 5) 13 (50. 0) 3 (11. 5) 7 (43. 8) - (0. 0) 9 (56. 2) 17 (40. 5) 13 (31. 0) 12 (28. 5) 26 16 42 Total

Results Oral condition Cleft lip and palate Outcome Review next 3 months Review at Results Oral condition Cleft lip and palate Outcome Review next 3 months Review at 6 months Review at 12 months Referral to CL&P/Ortho/RCH Referral local clinic Referral other c 3 (12. 0) 10 (40. 0) 8 (32. 0) 3 (12. 0) - (0. 0) 1 (4. 0) Orthodontics - (0. 0) 2 (12. 5) 4 (25. 0) 3 (18. 8) 7 (43. 7) Total 3 (7. 3) 10 (24. 4) 7 (17. 1) 3 (7. 3) 8 (19. 5)

Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia Costs to Patient Total Costs (cost per appt) RCH Model - RCH study population (n=367) Transport $61, 401. 60 ($167. 31) Accommodation Productivity Lost $27, 926. 42 ($76. 09) Paediatric Dentist $38, 202. 45 ($104. 09) Orthodontist Dental Assistant Costs to RCH $13, 569. 08 ($36. 97) $11, 415. 53 ($31. 10) $5, 771. 99 ($15. 73) Total RCH Costs to Patient Costs to RCH $55, 389. 97 ($150. 92) $158, 287. 07 ($431. 29) Teledental Model Transportation Productivity Lost Paediatric Dentist $18, 808. 40 ($51. 25) $13, 369. 34 (36. 43) $38, 202. 45 ($104. 09) Orthodontist Staff Training TD Equipment General Dental Practitioner $11, 415. 53 ($31. 10) $9, 738. 47 ($26. 54) $1, 751. 57 ($4. 77) $8, 970. 40 ($24. 44) Dental Assistant Costs to CDC $102, 897. 10 ($280. 37) $32, 177. 74 ($87. 68) $49, 617. 98 ($135. 19) $5, 771. 99 ($15. 73) $26, 232. 43 ($71. 48) Total TD Costs $108, 028. 15 ($294. 35) Total savings from TD $50, 258. 92 ($136. 94)

Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia Based on postcodes, the TD model :

Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia Cost-effectiveness analysis of implementing teledentistry for rural and regional paediatric patients in Victoria, Australia • 367 TD appropriate consultations were found in the dataset. • Average cost of a RCH consultation $431. 29 vs. $294. 35 for TD. • TD was more cost effective for those travelling greater distances. • 36. 7 days of clinic time may be freed up in the RCH clinic. • These results were robust when performing one-way sensitivity analysis.

Conclusions • The teledentistry approach proved to be feasible a viable solution, in terms Conclusions • The teledentistry approach proved to be feasible a viable solution, in terms of time, stress, and money saved for parents and children. • When taking a societal perspective, the implementation of TD is likely to be a costeffective alternative compared with the standard practice of face-to-face consultation at the RCH.

Conclusions • From the RCH perspective, the potential reduction of inappropriate referrals with the Conclusions • From the RCH perspective, the potential reduction of inappropriate referrals with the concomitant reduction of waiting lists for specialist consultation, are important advantages of teledentistry, which are clinically important and also have budgetary implications. • This reduction was achieved without increasing costs to the oral health provider.

Consumer medical and health information • Oral Health Promotion Multimedia Web Enhancement Oral Health Consumer medical and health information • Oral Health Promotion Multimedia Web Enhancement Oral Health Promotion Program for Older Adults Funded by BUPA Foundation

m. Health m. Health

Lab-on-a-smartphone • Personalised medicine approach in which consumers monitor their own health using devices Lab-on-a-smartphone • Personalised medicine approach in which consumers monitor their own health using devices attached to their smartphones. • These would comprise attachments that convert smartphones to optical microscopes and related instruments.

Dental Trauma Tracker Dental Trauma Tracker

Mobile Applications for the Prevention and Management of Early Childhood Carries (ECC) ECCAPP Mobile Applications for the Prevention and Management of Early Childhood Carries (ECC) ECCAPP

The solution To develop and validate a new mobile phone -based communication and monitoring The solution To develop and validate a new mobile phone -based communication and monitoring application, for the detection, prevention and management of early childhood caries. • The application is called ECCAPPS. • This application, will combine multimedia web and mobile technologies with personalized assistance as required.

Pukallus M, Plonka K, Kularatna S, Gordon L, Barnett AG, Walsh L, Seow WK. Pukallus M, Plonka K, Kularatna S, Gordon L, Barnett AG, Walsh L, Seow WK. Cost-effectiveness of a telephone-delivered education programme to prevent early childhood caries in a disadvantaged area: a cohort study. BMJ Open. 2013 May 14; 3(5). doi: pii: e 002579. 10. 1136/bmjopen-2013 -002579. Print 2013. Plonka KA, Pukallus ML, Holcombe TF, Barnett AG, Walsh LJ, Seow WK. Randomized controlled trial: a randomized controlled clinical trial comparing a remineralizing paste with an antibacterial gel to prevent early childhood caries. Pediatr Dent. 2013; 35(1): 8 -12. Plonka KA, Pukallus ML, Barnett AG, Holcombe TF, Walsh LJ, Seow WK. A longitudinal case-control study of caries development from birth to 36 months. Caries Res. 2013; 47(2): 117 -27. doi: 10. 1159/000345073. . Pukallus ML, Plonka KA, Barnett AG, Walsh LJ, Holcombe TF, Seow WK. A randomised, controlled clinical trial comparing chlorhexidine gel and low-dose fluoride toothpaste to prevent early childhood caries. Int J Paediatr Dent. 2013 May; 23(3): 21624. doi: 10. 1111/j. 1365 -263 X. 2012. 01248. x. Plonka KA, Pukallus ML, Barnett AG, Walsh LJ, Holcombe TF, Seow WK. A longitudinal study comparing mutans streptococci and lactobacilli colonisation in dentate children aged 6 to 24 months. Caries Res. 2012; 46(: 385 -93. doi: 10. 1159/000339089. . Plonka KA, Pukallus ML, Barnett AG, Walsh LJ, Holcombe TH, Seow WK. Mutans streptococci and lactobacilli colonization in predentate children from the neonatal period to seven months of age. Caries Res. 2012; 46: 213 -20. doi: 10. 1159/000337353. Epub 2012 Apr 19. Plonka KA, Pukallus ML, Barnett A, Holcombe TF, Walsh LJ, Seow WK. A controlled, longitudinal study of home visits compared to telephone contacts to prevent early childhood caries. Int J Paediatr Dent. 2013 Jan; 23(1): 23 -31. doi: 10. 1111/j. 1365 -263 X. 2011. 01219. x. Epub 2012 Jan 18. Onetto JE, Uribe S, Lira. Impacto en el índice ceo en población preescolar mediante aplicación de un modelo de intervención temprana. Proyecto FONIS SAO 4 I 2123. Informe final. 2008. Uribe S, Onetto JE, Lira P, Mariño R. Effectiveness of early diagnosis and intervention for early childhood caries. International Association of Dental Research. 86 th General Session. Toronto, Canada, July 2008 Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. The effects of chlorhexidine gel on Streptococcus mutans infection in 10 -month-old infants: a longitudinal, placebo-controlled, double-blind trial. Pediatr Dent. 2003; 25: 215 -22. Wan AK, Seow WK, Purdie DM, Bird PS, Walsh LJ, Tudehope DI. A longitudinal study of Streptococcus mutans colonization in infants after tooth eruption. J Dent Res. 2003 Jul; 82: 504 -8.

ECCAPPS will have three major components: • Information (using gamification) • Management • Clinical ECCAPPS will have three major components: • Information (using gamification) • Management • Clinical • The Information and Management Components will be on mobile devices • The Clinical component will be at a hospital or dental clinic.

The Information Component • Provides information about dental caries (ECC). • Oral health promotion The Information Component • Provides information about dental caries (ECC). • Oral health promotion • Allows the parents of children to take photographs for clinical assessment. • Gathers data and sends data back to the clinical facility where the risk and spread of carries can be analyzed and monitored.

The Management Component • Is used to implement a protocol for managing and reducing The Management Component • Is used to implement a protocol for managing and reducing the risk of ECC. • Sends reminders to parents when the prevention and treatment steps need to be performed • Guides parents through the steps required to reduce their children’s level of risk according to the protocol • Provides data back to clinicians for monitoring and, where necessary, intervention. • Reminds parents of dental visits.

The Clinical Component • Will reside at a Oral Healthcare Facility or Hospital. • The Clinical Component • Will reside at a Oral Healthcare Facility or Hospital. • Will allow the clinician to bring up patient records, see what has been done and what steps of the protocol have been followed. • Will allow the clinician to schedule appointments and send these directly with the parents’ mobile phone • Will allow the clinician to modify the treatment plan when necessary.

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