Teledentistry: Are we closer to an alignment of views?

In our modern world with the ever-increasing expectation to increase productivity and efficiency, advances in technology are having a significant impact on many professions and industries, particularly the Healthcare sector.

One such polarising topic is the evolution of teledentistry (or “direct-to-consumer orthodontics”) and the impact this is having on the dental industry.

Teledentistry is growing with technology and is most commonly associated with periodontal monitoring and the provision of removable orthodontic aligners to address cosmetic dental issues such as misalignment or overcrowding.

A recent British Dental Journal article highlighted the advantages of teledentistry in modern practice, stating that it provides the opportunity for a cheaper and more readily available alternative to standard orthodontic treatment, arguably reducing barriers to treatment for a wider proportion of the population with the added benefit of it potentially assisting in reducing pressure on the vastly under resourced NHS dental services which is already at breaking point.  

However, the rise of teledentistry continues to face stiff opposition from established groups such as the British Orthodontic Society and indeed the General Dental Council involved itself in the debate by asserting in February 2020 that there is no replacement for face-to-face discussions and that for all dental interventions, face-to-face contact is an important interaction that should take place at the beginning of the patient consultation. The justification being that this enables the dental professional to carry out the assessments necessary for making clinical judgements that ensure the suitability of the proposed course of treatment and to address any underlying oral health problems.

The remote model, that is without direct/face-to-face input from a dentist, is predicated on the patient self-reporting whether they are a suitable candidate for treatment at the outset and raising any concerns during the course of treatment that can then be considered and, if appropriate, investigated further. Some patients can however be inaccurate reporters. 

Once such issue that we see in claims is asking a patient to confirm the state of their gum health before commencing orthodontic treatment, since some treatments are contraindicated if the patient has periodontal disease for example. However if we consider that over half the population of Great Britain have gingivitis (gum disease) and 53% of the public have not seen their dentist in the last year (Great British Oral Health Report 2021) – one can see why patients are unable to give an accurate report of their own dentition. This means that the clinician may be unable to accurately assess and inform the patient of tailored risks to them that the treatment may present. 

A key component of dental treatment is the overarching issue of consent and there are many dental cases, both in respect of claims and before the GDC, where informed consent (or more appropriately the lack of) has been central to the concerns raised. By now, we are all aware of the standard and informed consent required before a patient commences treatment; it should be an in-depth and personalised discussion pitched at the correct level where the patient has the opportunity to ask questions so that they may be satisfied that the course of treatment proposed is likely to meet their needs and expectations (this subjective assessment being a crucial factor in any aesthetic treatment). There are many quarters within the dental profession that loudly assert this crucial process cannot be replicated via an online or standardised consent form.  There is, however, growing support for a fully remote practice although this does, of course, depend upon the treatment being provided.  Telecommunication and digital technologies are key to the success of any fully remote approach.    

There is a growing trend of hybrid models of remote dentistry where the patient is seen by their dental practitioner on a face-to-face basis in the first instance, but then moves towards a remote model for ongoing monitoring using a combination of AI and patient ‘selfies’. Arguably, these steps would need to be overseen by a registered dentist  in order have the safeguards in place whereby arising concerns could be identified and treated, with the option of returning for face-to-face appointments when required/clinically indicated. It remains to be seen what view the GDC or Courts would take on this practice as the key consideration of having the initial face-to-face contact with a registrant authorised to provide direct services to patients is satisfied. Working alongside the patient’s treating dentist may also allow fully remote practice (for example for orthodontic treatment) whereby information is gathered from another professional to assist with the consultation findings potentially negating the need for a face-to-face appointment with the orthodontist.    

There have been a limited number of teledentistry cases before the GDC but the concerns raised all tend to focus on the lack of an in-person examination and the lack of a direct assessment of the patient’s mouth, together with no tailored or personalised discussion of the proposed treatment, including risks and benefits. The GDC has so far confirmed that these failures are serious and dental registrants involved in direct-to-consumer orthodontics can no longer assert they were unaware of the importance of these issues. However, where does the hybrid model of the initial face-to-face consultation with a dentist but then moving to remote reporting and observations or the fully remote consultation with input from the patient’s dentist fit on this spectrum? We suspect this will be a key area that will be tested in the coming years with the GDC under more pressure to release further guidance and publications to seek to define and clarify matters. However, as always, it is best to seek advice before embarking upon any technology driven advances, particularly as the registrant who puts their name to the treatment plan will be held ultimately responsible for it.

When considering the actions of the dentist from a claims point of view, we would be assessing whether the treatment they provided was in line with what a reasonable and responsible body of dental practitioners what have done and to review whether an in-person appointment would in fact have changed the scope of the treatment or outcome. Whilst this threshold does develop to account for new ways of working, at present it is likely that a dentist working in a hybrid model would still be held to the same standard as if they were treating a patient face-to-face so they need to assure themselves that this method is not inhibiting them from doing so.   

The Healthcare team at Clyde & Co are available to deal with any regulatory matters or clinical negligence claims in relation to teledentistry and please contact us if you would like our assistance in relation to a specific matter.