GENERAL DENTISTRY

Delivering dental care as we emerge from the initial phase

of the COVID-19 pandemic: teledentistry and face-to-face
consultations in a new clinical world
Pascaline Kengne Talla, DMD, PhD/Liran Levin, DMD, FRCD(C)/Michael Glogauer, DDS, PhD/
Cheryl Cable, DDS, MBA, FRCD(C)/Paul J. Allison, BDS, FDSRCS(Eng), MSc, PhD, FCAHS

At a time when access to health care and services for the global
population is a concern due to the COVID-19 pandemic, health
professionals and their teams are struggling to find a way to adapt
their practices. Dental professional organizations and deci-
sion-makers are required to provide guidance in a rapidly evolving
environment based on the current data, available research, and
existing knowledge. Continuous progress in the information com-
munication technology field and universal access to social com-
munication platforms have allowed clinicians to creatively tran-
scend some of the existing traditional barriers in clinical and
technological workflows. The aim of this paper is to provide in-
sight and propose future directions concerning the use of teleden-
tistry for dental care in crisis situations such as the COVID-19 pan-
demic as well as the continuous implementation of teledentistry
in noncrisis scenarios. This paper provides information to support
the use of teledentistry as a promising avenue for dental profes-
sionals when possible, during and possibly beyond the outbreak.
(Quintessence Int 2020;51:672–677; doi: 10.3290/j.qi.a44920)

Key words: crisis management, dental trauma, emergency, evidence-based practice, telehealth

The world is facing an unprecedented situation due to the
COVID-19 pandemic. There are millions of cases and thousands
of deaths related to this disease worldwide to date.1,2 People are
instructed to stay at home in order to “flatten the curve” (reduce
or limit the propagation of the pandemic and spread out the
volume of patients in hospitals that would otherwise become
overwhelmed) and to reduce the risk of cross-contamination
caused by close contact. At a time when access to health care
and services for the entire population is a concern, many health
professionals and their teams struggle to find ways to adapt
their practices accordingly. Dental professional organizations
and decision-makers are required to provide guidance in a rap-
idly evolving environment, based on continually evolving data,
research, and knowledge. Many dental regulatory bodies have
recommended limiting services to emergency and/or urgent
visits during this early phase of the pandemic.3-6 There is a new
requirement for stricter implementation of infection preven-
tion and control measures in dental practice because of COVID-
19.7 However, continuous progress in the information techno-
logy field has allowed clinicians to transcend some of the
existing barriers in clinical and technological workflows.8
From mid-March 2020, as dental offices across the world
closed down, dental regulatory authorities provided guidance
on the use of teledentistry5,9-12 for managing emergency and
urgent dental problems. As the leadership of dental professions
across the world plan returning to dental care beyond emer-
gency and urgent problems, and consider how best to guide
dental care providers in their return to work following the initial
acute phase of the COVID-19 pandemic in the next months,
there is an excellent and beneficial opportunity to incorporate
teledentistry in routine dental care. Used in an appropriate, evi-
dence-informed manner, teledentistry has the potential to help
dental professionals and staff manage their patients’ health
problems while addressing access-to-care issues. Several sys-

672 QUINTESSENCE INTERNATIONAL | volume 51 • number 8 • September 2020


tematic reviews have shown that teledentistry may provide
many new opportunities for general and speciality dental prac-
tices,13-15 as well as teleradiography.8 Moreover, a systematic
review reported that patients and dental professionals were
satisfied by this approach.14 Some studies regarding dentistry
in crisis situations16,17 reported on the importance of teleden-
tistry, while others report that it may provide a promising alter-
native for remote assessment, screening, advice, monitoring,
referrals, or prescriptions to patients for dental problems.14,18
That said, while teledentistry shows much promise for certain
forms of care, it remains a field that needs more research to
demonstrate where it is and is not effective and efficient.13-15
This paper aims to i) briefly review the state of knowledge
of the use of teledentistry prior to the pandemic; ii) apply this
information to discuss how teledentistry can be used during
and as we emerge from the pandemic; and iii) highlight import-
ant areas of research needed to demonstrate the interventions
for which teledentistry is and is not effective and cost-effective.
Teledentistry
Teledentistry is the use of information technology and telecom-
munications for dental care to deliver and support certain re-
mote services. It is a virtual encounter of communication be-
tween a dental professional and a patient and/or another
health professional. Teledentistry is a delivery modality that can
be used in rural and urban settings to improve the accessibility
and the availability of dental care.13-15 It has proven especially
useful in remote areas where patients must travel long distances
to meet health care providers. Dental emergencies can happen
in remote environments with specific concerns such as: limited
access to care, lack of equipment, and often a scarcity of care
workers. Dental emergencies can also happen within various
contexts such as natural or manmade disasters. In an emergency
situation like the COVID-19 pandemic, teledentistry can act as a
promising method of delivery for maintaining patient contact
and some elements of dental care, including for screening, triage,
pharmacotherapy, referrals, education, and research.19,20
Platforms for teledentistry
Many platforms can be used for teledentistry. Some of these
include telephone, text, or email for initial patient contacts, or
videoconference solutions such as Zoom Pro, Microsoft Teams, or
Webex.
There are three primary ways that teledentistry can be used
as a service modality.21,22 These include:
QUINTESSENCE INTERNATIONAL | volume 51 • number 8 • September 2020
Talla et al
■ consultations between clinicians: for example, a general and
a specialty dental practitioner share images and records
obtained from the patient followed by a review and treat-
ment planning discussion
■ a face-to-face consultation in real time by video conference
between a general dental practitioner or a specialist and a
patient or a member of his or her family located in a sepa-
rate, distant location
■ remote monitoring of patients, where data is collected in
real time, transmitted to dental professionals at a distant
location for review, and action as needed.
Teledentistry as an adjunct to standard
care for patients with access-to-care issues
Teledentistry can be utilized as an adjunct to standard care for
patients with access-to-care issues such as immunocompro-
mised patients, elderly patients, patients in remote locations,
and disabled or disadvantaged individuals. Vulnerable patients
may need adapted care for continuity of treatment. Patients
who cannot afford travel, stays in remote housing, or are not
comfortable leaving their communities due to social, cultural,
or mental health challenges need to be acknowledged and
empowered. People in pain and those in palliative care may be
disinclined to leave their place of security and comfort for a
quick “check-up” appointment. The practice in dentistry has vir-
tually always been for patients to come to clinics. Teledentistry
affords the opportunity for certain patients with certain condi-
tions not to have to visit the dental clinic.
Communication with dental patients, regardless of whether
the appointment is an emergency exam, a follow-up post-ex-
traction appointment, or other, might better be performed
using teledentistry. It can be used to assess progressing symp-
toms and pain management, to discuss further treatment
options, or to complete a video visit as an initial consultation to
gather more information about the patient’s dental concerns
and desires. The dental professional can discuss over the phone
a potential diagnosis and determine if a clinic appointment is
necessary. Patient triage at this time can expedite data collec-
tion or allow for the patient to be referred to an appropriate
clinician where necessary treatment can be provided.
Today, dentistry, along with every other profession, is
adapting to the rapidly changing environment. Teledentistry
modalities are imperative tools for every dental clinic whether in
hospital or private practice. Outside of a “true emergency” situa-
tion, teledentistry can be incorporated into routine care even
during dental clinic shutdowns and upon reopening in stages
673
 GENERAL DENTISTRY
as mandated by governing bodies or supply chain manage-
ment limitations.
Teledentistry has the opportunity to improve patients’ oral
health outcomes, including reinforcing self-care, patients’ edu-
cation, and empowerment, and reducing psychologic anxiety.
Teledentistry can also be a tool for improving the general health
of patients, reducing dental professionals’ and their staffs’ expo-
sure to possible contamination and the use of consumable per-
sonal protective equipment (PPE), while also enabling contin-
ued dental care delivery, removing or reducing transportation
barriers, reducing patients’ risk for contamination, monitoring
of treatment prescribed, and providing and encouraging access
to a wider range of specialist advice and services.
Challenges to teledentistry
Challenges to teledentistry are diverse14,18 and complex. There is
an initial need for willingness of dental practitioners and their
team to accept teledentistry. Not all providers and patients are
familiar with and/or equipped to use current technologies. Train-
ing and continuing education efforts will be needed to make the
field more accessible and endorsable by the dental community.
The effectiveness of teledentistry services is predicated on signif-
f efits of teledentistry and its limits for clinical diagnosis/man-
icant preliminary planning processes and focused training for
dental professionals prior to implementation of a teledentistry
program. Infrastructure requirements vary by location, but cer-
tain basic technology is essential to provide high-quality services.
Another aspect that needs to be considered is patient
record acquisition, management, sharing, and storage of per-
sonal information. Privacy and security of patient health infor-
mation across delivery systems should be assured to the patient
and be constantly updated. Consent of the patient to utilize
potentially unsecure teledentistry modalities must be obtained.
Teledentistry services must also be recognized by the dental
regulatory bodies as well as the insurers in order to encourage
dental professionals to utilize the delivery of dental care and to
increase the accessibility for the patients.23 Increased clinical
efficiencies, expediting care, and reducing long specialist wait-
ing lists would save patients, clinicians, and insurance compa-
nies in the long term, with the common goal of providing the
most appropriate care for patients in need in a timely manner.
Remuneration can be a significant disincentive to involving
dental professionals in teledentistry. Time and other unique
considerations related to technology and delivery of telecare
will need to be considered for appropriate remuneration of
teledentistry consultations. Temporary codes from regulatory
dental authorities may be an appropriate way of dealing with
674 QUINTESSENCE INTERNATIONAL | volume 51 • number 8 • September 2020
dental emergencies during the COVID-19 pandemic or other
scenarios,24,25 but there is an opportunity to extend the code
and practice of telehealth beyond emergency provision only,
so as to become an accepted standard of care.
Guidance for the use of teledentistry must be used in con-
junction with all applicable organizational standards, proto-
cols, policies, and procedures for dental care service provision.
Clinical standards and outcomes
Teledentistry services follow the same principles as face-to-face
dental care. Dental professionals should give the patients ade-
quate, current, and ongoing dental care information. If in-per-
son consultations require the use of interpreters or the pres-
ence of family members or care providers, those same supports
should be arranged for teledentistry services. Recording a
teledentistry session is not typically performed due to the unse-
cure nature of most platforms. If recordings are retained as part
of patient care records, then patient consent must be obtained.
Dental professionals must recognize the limits of teleden-
tistry (eg, the lack of ability to directly examine a patient) and
must explain to the patients the potential challenges and ben-
agement. Reasonable expectations on diagnostic abilities must
be vocalized. Communication must be clear and expectations
realistic. This is both for the patient and the dental professional.
Lack of facial, vocal, or physical cues can lead to misunder-
standings and misdirection.
Dental professionals must also follow protocols and pro-
cedures related to informed consent (verbal or written) as well
as privacy and confidentiality about personal information, per-
sonal communications, and the consulting space. Having a
strategy for confirming patient identity is necessary to avoid
the risk of misidentification and exposure to inappropriate
interventions for a patient with whom one is communicating.
Failure to correctly identify patients may result in a range of
adverse events such as the patient receiving information meant
for a different person. As always, documentation is an import-
ant aspect of the patient records and ongoing treatment.
The same ethical principles that apply in any face-to-face
patient interaction apply to teledentistry encounters (integrity
of services, standards of quality, practice standards). It is essen-
tial to pay special attention to the elements that characterize
the patient-clinician relationship, such as communication, the
dental practitioner’s behavior (degree of empathy, profession-
alism), clinical services (assessment, diagnosis, prescriptions,
treatment, etc), the relationship of trust between the clinician

Figs 1 Teledentistry could be used for discussion among experts on a treatment plan for a patient. Multiple disciplines could be involved in a
conference call presenting clinical and radiographic findings to add to the discussion.
and patient, and measures for ensuring confidentiality and pri-
vacy.26 Identify immediately every person who is present for the
teledentistry session on each side of communication. Respect.
Listen. Document. Empower.
Research needs going forward
Having briefly reviewed the literature on teledentistry and
made suggestions on how it could be used going forward
beyond the acute phase of the COVID-19 pandemic, it is import-
ant to recognize the limitations of the evidence supporting its
use in dental care. In short, what can, and very importantly what
cannot be done effectively and cost-effectively using teleden-
tistry needs to be documented. The care that can be performed,
the communication approaches that can be used, and the effi-
ciencies that can be gained using teledentistry need to be iden-
tified. For instance, well-designed research is needed to demon-
strate whether teledentistry can be used as a screening tool,
investigating, just as is done with other screening tools, the
sensitivity and specificity of the approach for different condi-
tions. On top of this, can teledentistry be used, for instance, by
QUINTESSENCE INTERNATIONAL | volume 51 • number 8 • September 2020
Talla et al
a specialist to guide a general dental practitioner in a remote
region to perform certain forms of care? And linked to this,
does having teledentistry consultations with patients in rural
and remote settings really save transport costs or does it result
in missed disease or wasted appointments for un-needed care?
The limits of teledentistry as a communication tool with differ-
ent sectors of the population, particularly more vulnerable
groups, needs to be explored. For instance, teledentistry could
potentially be an excellent tool to screen for oral health prob-
lems among residents of centers for elderly patients, but it is
important to ensure that patients in such centers understand
teledentistry communication. Furthermore, it may be an excel-
lent form of “outreach” care for younger, marginalized groups,
but it must be ensured that care needs identified through
teledentistry are followed up. And does having a “tele-dental-
clinic” interspersed with in-person care enable efficiencies and
cost savings for both dental practitioners and patients? These
and many other research questions need to be answered
urgently as the dental profession explores expanding the use
of teledentistry. We need to look to our colleagues in other
health professions who have been using telemedicine/tele-
675
 GENERAL DENTISTRY

health approaches with success for many years. These pro-
grams have many lessons that we can learn from immediately
as we explore teledentistry.
Conclusions
Teledentistry is an evolving, innovative approach to delivery of
dental care and access issues, which does not require close con-
tact with the dental professional. Dentistry has been slow in the
adoption of communication and information technologies for
dental care, in comparison to others health care domains. The
dental profession’s rapid turn to teledentistry in the acute phase
of the COVID-19 pandemic provides an excellent opportunity to
explore how teledentistry can be adopted in dental care in the
long, as well as the short term. Teledentistry has the potential to
help dental professionals begin to address some of the lon-
ger-term problems of access to dental care, as well as providing
safe and secure means to provide quality care while reducing the
risk of contagion. During a crisis like the pandemic COVID-19,
dental professionals can use teledentistry to provide advice,
screening, and treatment for emergent and urgent dental issues.
However, teledentistry may lead to a transformation of standard
dental practices and requires organizational, clinical, technolog-
ical, and ethical standards. A fee-for-service remuneration for
dental practitioners and their team must be recognized by den-
tal regulatory bodies and employers/insurance companies out-
side of emergency situations. Infrastructures, appropriate equip-
ment, and accessories are important to ensure a quality practice
environment and the quality of dental services. Teledentistry
highlights the potential to offer additional dental care beyond
dental emergencies, during and post COVID-19. Recognition of
access-to-care limitations and empowerment of those who need
help the most must not be lost in future conversations. With the
rapid evolution of communication and information technologies
and their use in our lives, dentistry must change in response.
Declaration
The authors declare there are no conflicts of interest associated
with this manuscript.

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Pascaline Kengne Talla Pascaline Kengne Talla Assitant Professor, Faculty of Dentistry,
Laval University, Quebec, Canada
Liran Levin Professor, Faculty of Medicine and Dentistry, Univer-
sity of Alberta, Alberta, Canada
Michael Glogauer Professor, Faculty of Dentistry, University of
Toronto, Ontario, Canada
Cheryl Cable Associate Professor, Faculty of Medicine and Den-
tistry, University of Alberta, Alberta, Canada
Paul J. Allison Professor, Faculty of Dentistry, McGill University,
Quebec, Canada

Correspondence: Prof Liran Levin, University of Alberta, Faculty of Medicine & Dentistry, 5-468 Edmonton Clinic Health Academy, 11405
87 Avenue NW, 5th Floor, Edmonton AB, T6G 1C9, Canada. Email: liran@ualberta.ca

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