Dentistry, Faculty of
DSpace
UBCV
Amaniampong, Kevin
Master of Science - MSc
University of British Columbia
Objectives: Our primary objective was to determine if differences exist between the estimated and actual numbers of teeth requiring treatment and the time required under general anesthesia for dental treatment in virtual and in-person dental consultations. Secondarily, we assessed the distance from the primary residence to BC Children's Hospital (BCCH) for families using consultations. Methods: A retrospective chart review was conducted for patients meeting the criteria. Data were collected for both types of consultations, including patient demographics, estimated treatment information (predicted treatment time and number of teeth planned for treatment), presence of caregiver-obtained pretreatment photographs, and actual treatment outcomes. The average percent difference was calculated by determining the difference between measured and predicted values and expressing this difference as a percentage of the measured value. Based on photograph presence and quality, the virtual consultation group was further split into no, poor, fair or excellent pretreatment photographs. One-way ANOVA with Tukey’s post hoc testing and unpaired T-tests were performed using Prism V10.0. Human ethics # H21-02433. Results: A total of 321 patients [Mean Age = 76.277± 49.4 months] were included. There were 183 (57%) in-person and 138 (43%) virtual consultations. Out of the virtual consultations, 97 (70%) included pretreatment photographs, while 41 (30%) did not include pretreatment photographs. The average difference in the predicted versus the actual time needed for treatment was significantly higher in virtual health consultations with poor pretreatment photographs (105.2%, p= 0.0003) compared to in-person consultations (35.3%). The remaining groups showed no significant differences. No significant differences were also found in the percentage difference in teeth treated between the consultation types. Significant differences (p = 0.003) were observed between the average distance traveled to the hospital between all virtual (138km) and in-person (60.8km) patient consultations. Conclusions: Our findings suggest that virtual dental consultations can be effective for planning dental treatment under general anesthesia, especially for families who live farther away. Our study highlights that photographs may not be essential in treatment planning for virtual patients, making it feasible for more widespread adoption of virtual consultations for pediatric dental treatment under general anesthesia.
A COMPARISON OF IN-PERSON VERSUS VIRTUAL HEALTH CONSULTATIONS FOR FULL MOUTH REHABILITATION IN PEDIATRIC DENTAL PATIENTS by Kevin Amaniampong D.D.S., The University of Alberta, 2019 B.Sc., The University of Calgary, 2015 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Craniofacial Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) June 2024 © Kevin Amaniampong, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: A comparison of in-person versus virtual health consultations for full mouth rehabilitation in pediatric dental patients submitted by Kevin Amaniampong in partial fulfillment of the requirements for the degree of Master of Science in Craniofacial Science Examining Committee: Joy M. Richman, Professor, Dentistry, UBC Supervisor Ahmed Hieawy, Associate Professor, Dentistry, UBC Supervisory Committee Member Jennifer Park, Clinical Assistant Professor, Dentistry, UBC Supervisory Committee Member Nicholas Tong, Assistant Professor of Teaching, Dentistry, UBC Additional Examiner Additional Supervisory Committee Members: Brenden Hursh, Clinical Assistant Professor, Medicine, UBC Supervisory Committee Member iii Abstract Objectives: Our primary objective was to determine if differences exist between the estimated and actual numbers of teeth requiring treatment and the time required under general anesthesia for dental treatment in virtual and in-person dental consultations. Secondarily, we assessed the distance from the primary residence to BC Children's Hospital (BCCH) for families using consultations. Methods: A retrospective chart review was conducted for patients meeting the criteria. Data were collected for both types of consultations, including patient demographics, estimated treatment information (predicted treatment time and number of teeth planned for treatment), presence of caregiver-obtained pretreatment photographs, and actual treatment outcomes. The average percent difference was calculated by determining the difference between measured and predicted values and expressing this difference as a percentage of the measured value. Based on photograph presence and quality, the virtual consultation group was further split into no, poor, fair or excellent pretreatment photographs. One-way ANOVA with Tukey’s post hoc testing and unpaired T-tests were performed using Prism V10.0. Human ethics # H21-02433. Results: A total of 321 patients [Mean Age = 76.277± 49.4 months] were included. There were 183 (57%) in-person and 138 (43%) virtual consultations. Out of the virtual consultations, 97 (70%) included pretreatment photographs, while 41 (30%) did not include pretreatment photographs. The average difference in the predicted versus the actual time needed for treatment was significantly higher in virtual health consultations with poor pretreatment photographs (105.2%, p= 0.0003) iv compared to in-person consultations (35.3%). The remaining groups showed no significant differences. No significant differences were also found in the percentage difference in teeth treated between the consultation types. Significant differences (p = 0.003) were observed between the average distance traveled to the hospital between all virtual (138km) and in-person (60.8km) patient consultations. Conclusions: Our findings suggest that virtual dental consultations can be effective for planning dental treatment under general anesthesia, especially for families who live farther away. Our study highlights that photographs may not be essential in treatment planning for virtual patients, making it feasible for more widespread adoption of virtual consultations for pediatric dental treatment under general anesthesia. v Lay Summary Our study evaluated whether differences existed in the accuracy of virtual and in-person dental consultations in predicting the number of teeth requiring treatment and the treatment time required under general anesthesia. Patient charts from BC Children’s Hospital (BCCH) showed that virtual dental consultations with poor quality pretreatment photographs led to a larger difference in the predicted vs. actual time needed for treatment when compared to in-person consultations. Virtual consultations with pretreatment photos that were excellent, fair, or not present led to similar levels of accuracy as in person consultations. No significant differences were found in the percentage difference in teeth treated between the different consult types. Families who chose to complete virtual dental consultations often lived further from BCCH than those who chose in-person consultations. Our findings suggest that pediatric dental virtual consultations can be effective, especially for those patients who may live farther away. vi Preface This thesis is an original, unpublished, and independent work by Dr. Kevin Amaniampong, hereby referred to as “the author”. The identification and the design of this project were by the author under the direction of their research supervisor, Dr. Joy Richman. The collection of data was completed by the author with the assistance of research Co-op students hired by the Office of Pediatric Surgical Evaluation and Innovation (OPSEI). Data analysis was conducted by the author with the guidance of Dr. Richman and statistical consultants. Regular committee meetings were held with the supervisory committee, consisting of Drs. Joy Richman, Jennifer Park, Brenden Hursh. Ethics approval for the study was granted by the UBC Children’s & Women’s Clinical Research Ethics Board [H21-02433]. The author successfully completed the Course on Research Ethics based on the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans Course (TCPS 2: CORE 2022) on March 29th, 2021. vii Table of Contents Abstract ............................................................................................................................. iii Lay Summary .....................................................................................................................v Preface ............................................................................................................................... vi Table of Contents ............................................................................................................ vii List of Tables .................................................................................................................... ix List of Figures .....................................................................................................................x List of Abbreviations ....................................................................................................... xi Acknowledgments ........................................................................................................... xii Chapter 1: Introduction ................................................................................................... 1 1.1 Dental Caries ...................................................................................................2 1.2 BC Children’s Hospital Dental Clinic .............................................................2 1.2.1 BC Children’s Hospital Dental Clinic Treatment Consultation ................. 3 1.2.2 BC Children’s Hospital Dental Clinic General Anesthesia Treatment ....... 4 1.3 Virtual health dental visits or teledentistry at BCCH ......................................5 1.4 Telehealth or virtual health and its use in dentistry .........................................6 1.4.1 Teledentistry during the COVID-19 pandemic ........................................... 7 Chapter 2: Aim and Objectives ..................................................................................... 11 2.1 Primary ..........................................................................................................11 2.2 Secondary ......................................................................................................11 2.3 Null Hypothesis .............................................................................................11 Chapter 3: Methods ....................................................................................................... 12 viii 3.1 Sample ...........................................................................................................12 3.2 Study Procedures ...........................................................................................13 3.3 Data Collection ..............................................................................................13 3.3.1 Medical History ........................................................................................ 15 3.3.2 American Society of Anesthesiologists’ Physical Status Classification ... 16 3.3.3 Distance Between Primary Residence and BC Children’s Hospital ......... 16 3.3.4 Quality of Photographs ............................................................................. 17 3.3.5 Early Childhood Caries ............................................................................. 18 3.3.6 Errors of Predicted vs. Actual Skin to Skin Time ..................................... 19 3.3.7 Errors of Predicted vs. Actual Number of Teeth Treated ......................... 20 3.4 Data Security .................................................................................................22 Chapter 4: Results ......................................................................................................... 23 4.1 Patient characteristics ....................................................................................23 4.2 Analysis of the accuracy of predictions .........................................................26 4.3 Disposition of patients following GA at BCCH - Dental home ....................30 Chapter 5: Discussion ................................................................................................... 32 5.1 Virtual Health Helps Equalize Pediatric Dental Access ................................38 5.2 Study Strengths and Limitations ....................................................................38 5.3 Future Research .............................................................................................41 Chapter 6: Conclusion ................................................................................................... 43 Bibliography .....................................................................................................................45 ix List of Tables Table 4.1 Patient demographics ........................................................................................ 24 Table 4.2 Virtual Health Consultation Photo Characteristics ........................................... 26 Table 4.3 Predicted Vs. Actual Skin-to-Skin Time .......................................................... 27 Table 4.4 Predicted Vs Actual Number of Teeth Treated ................................................ 29 Table 4.5 Follow-up dental care location ......................................................................... 31 x List of Figures Figure 3.1 Virtual Health Consultation Photo Quality Definition .....................................18 Figure 4.1 Distance between home forward sortation area and BCCH .............................25 Figure 4.2 Effect of consult type on % error in predicted versus actual time ...................28 Figure 4.3 Effect of consult type on % error in predicted versus actual teeth treated .......30 xi List of Abbreviations AAPD – American Academy of Pediatric Dentistry ASA – American Society of Anesthesiologists BC – British Columbia BCCH – BC Children’s Hospital BCCH-DC – BC Children’s Hospital Dental Clinic COVID-19 - Coronavirus Disease 2019 DMFT – Decayed, Missing, and Filled, Permanent Teeth DFT – Decayed and Filled Teeth ICDAS - International Caries Detection and Assessment System IP – In Person ECC – Early Childhood Caries FSA – Forward Sortation Area GA – General Anesthesia MAE – Mean Absolute Error MAPE – Mean Absolute Percentage Error OPSEI - Office of Pediatric Surgical Evaluation and Innovation PHSA - Provincial Health Services Authority PPE – Personal Protective Equipment REB – Research Ethics Board REDCap - Research Electronic Data Capture VH – Virtual Health xii Acknowledgments I would like to extend my sincere appreciation to my supervisor Dr. Joy Richman. I am thankful for your expertise, support, and guidance throughout my research journey. I am grateful to you for playing such a fundamental role in my academic success and my thesis. To my committee members, Dr. Jennifer Park, Dr. Brenden Hursh, and Dr. Ahmed Hieawy. Thank you for your patience, insightful feedback, and your belief in me. My discussions with each of you have helped me through challenging times. To my batch mates, Drs. Mayhay Ho, Michael Wong, and Smita Kumar. I thank you for our camaraderie, your friendship, and your support throughout our time together. I am so lucky to have gone through this journey with each of you. Lastly, to my family, loved ones, and educators. Thank you for all your support over the years. I would not be the person I am today if it weren’t for you, and I am appreciative and thankful. 1 Chapter 1: Introduction The Coronavirus Disease 2019 (COVID-19) pandemic has and continues to challenge and shape the way healthcare is provided worldwide (Filip et al. 2022). We are now certain that the mode of human-to-human transmission occurs through respiratory droplets released by pre-symptomatic, symptomatic, or post-symptomatic individuals (Sharma et al. 2021). Therefore, dental providers who are involved in direct patient care are at risk of this transmission (Innes et al. 2021). Dental examinations traditionally have required a close, in-person inspection of the teeth and oral cavity to make accurate diagnoses and assessments of patient treatment needs (Mettes et al. 2007). Consequently, in March 2020, during the initial wave of the pandemic, dentistry throughout the world came to a stop because the risk of acquiring COVID-19 from the typical aerosol-generating dental procedures was thought to be unacceptably high (Izzetti et al. 2020; Meng et al. 2020). To help contain and limit the spread of COVID-19, clinic closures were imposed, including the suspension of all elective and non-emergency dental services. Variations existed as to when dental clinics could reopen around the world. New developments in COVID-19 information and limited availability of high-quality personal protective equipment (PPE) led to dental practitioners continuing to cease operations until they could appropriately secure a fit-tested mask and visor. At one point early in the pandemic, even donning of face respirators were being advocated (Arellano-Cotrina et al. 2021). However, these turned out to be unnecessary (Alkhalaf et al. 2023). Recognizing the crucial and essential role hospitals in Canada play in providing care to the entire community, PPE was readily available in hospitals paired with the eventual early access to testing and vaccination once available (McNamara et al. 2022). BC Children’s Hospital Dental Clinic (BCCH-DC) continued to provide urgent and emergency dental services to pediatric patients across British Columbia (B.C) and was one of the first dental clinics to open after complete 2 shutdown with measures added to keep patients and staff safe. One of these measures, the implementation of virtual health (VH) dental visits, is the subject of this thesis. 1.1 Dental Caries Dental caries is both the process and result of localized destruction of hard dental tissue (Kidd 2010). Commonly referred to as tooth decay, it continues to remain the most common health condition worldwide (Wen et al. 2022). The presence and manifestation of dental caries in children is referred to as Early Childhood Caries (Ismail and Sohn 1999). Dental caries can have a pronounced effect on individuals with special healthcare needs, as they have been found to have a higher prevalence of poor oral hygiene and caries prevalence (Patidar et al. 2022). The localized destruction of dental hard tissue is due to an increase in fermentable carbohydrates in the oral cavity which are metabolized by cariogenic and acidogenic bacteria, leading to an increased production of acids and demineralized tooth structure (Zero 1999). Untreated dental caries has been associated with pain, difficulty eating and sleeping, dental infection and swelling, and negatively impacting the physical, social, emotional and psychological aspects of an adolescent’s quality of life (Akesson et al. 2016; Kastenbom et al. 2019; Matos et al. 2022; Souza et al. 2018). These needs were still present during the pandemic, and it was essential to find an alternative means to consult with parents and children. 1.2 BC Children’s Hospital Dental Clinic BC Children’s Hospital is not only the provincial leader involved in providing pediatric healthcare services but is Western Canada’s leading research and training setting for pediatric health. It aims to offer care for the most critically ill or injured children across British Columbia ((PHSA) 2023). 3 The dental clinic located within BC Children’s Hospital aims to provide comprehensive dental care for children in British Columbia who cannot be treated in private dental practices in the community. With a three-chair dental clinic in the Ambulatory Care Building and two dedicated operating rooms, treatment for children can be completed with a variety of behavioral guidance techniques. Eligibility includes children under the age of four with dental decay, children/adolescents under the age of seventeen with significant compromising medical conditions or behavioral management issues, and children requiring emergency dental care ((PHSA) 2023). A referral is required from a physician, nurse practitioner, or dentist to be seen at BCCH-DC. The standard referral form is organized into three parts. The first part includes patient demographic information. The second part includes information regarding the referring professional. The final part involves medical/dental information. This portion of the referral form varies in the amount of detail provided ((PHSA) 2023). Often, dentist referrals tend to include more information regarding dental pathology and findings, while physician and nurse practitioner referrals are inclined focus more broadly on the overall health of the child. Dental care is not a free service at BC Children’s hospital and dentistry specialty fees are charged based on the British Columbia Dental Association fee guide. Dental care is provided by pediatric dentists, oral surgeons, orthodontists, endodontists, certified dental assistants, dental hygienists, periodontists, prosthodontists and pediatric dentistry graduate student ((PHSA) 2023). 1.2.1 BC Children’s Hospital Dental Clinic Treatment Consultation The children that are seen at BCCH-DC have various intellectual, emotional, and physical developments, temperaments, and a wide range of medical diagnoses. There are three main behavioural guidance approaches that are used at BCCH-DC to provide dental treatment safely for these children. The first approach is communicative management which involves effective 4 communication and guidance to help the patient cooperate. The second, commonly referred to as “laughing gas”, is nitrous oxide/oxygen inhalation. This is a safe and effective adjunct that is used in a conscious patient to help improve communication and decrease anxiety during dental treatment. Should these techniques prove ineffective or unsafe for patients due to different challenges, advanced methods such as general anesthesia are used. Provided by an anesthesiologist, general anesthesia involves treating the child while completely unconscious and unable to react to commands or to physical touch. Several indications include patients who cannot communicate or cooperate due to young age or behavioural conditions, extremely uncooperative patients, and reducing medical risk in high-risk patients AAPD (2023a). There are crucial steps that are involved in the general anesthesia planning and consultation at the BCCH-DC to help ensure safe, effective and successful treatment for patients. Consultations are completed by a pediatric dentistry graduate student and supervising attending pediatric dentist. Should dental treatment under general anesthesia (GA) be deemed appropriate and necessary, a full dental treatment plan is provided. Additional information that can be collected from the consultation visits includes: 1. The estimated skin-to-skin time required for dental treatment exclusively. 2. The number of teeth requiring treatment and the type of treatment required for each tooth. 1.2.2 BC Children’s Hospital Dental Clinic General Anesthesia Treatment Once the patient is safely under the care of the hospital anesthesiologist on the day of the general anesthesia, dental treatment is completed by a pediatric dentistry graduate student and supervising attending pediatric dentist. Dental rehabilitation on this day consists of: 5 • Review of chief complaint • Identifying medical history changes • Receiving informed consent • Full clinical assessment • Full radiographic assessment • Completion of appropriate treatment • Providing post-operative care • Identifying anticipated follow-up Once the dental treatment under general anesthesia is completed, additional information collected includes: 1. The actual number of teeth treated and the type of treatment required for each tooth. 2. The actual skin-to-skin time required for dental treatment exclusively. This information from the dental treatment under general anesthesia can give an opportunity to assess the accuracy of the plan made at the initial consultation appointment. 1.3 Virtual health dental visits or teledentistry at BCCH To address the large group of children left without medical or dental care in BC during the COVID-19 pandemic, BC Children’s Hospital (BCCH) introduced virtual health (VH) throughout the hospital in April of 2020. The hospital provided secure, private Zoom links for video consultations with caregivers and their children. The Dentistry department at BCCH took this protocol and modified it to obtain as much information about the teeth as possible. Virtual dental visits gave all caregivers of children referred to BCCH for treatment a chance to consult with a specialist without the increased risk of being around other people in the clinic. Appropriate modifications, including the provision of photographs by the caregiver, allowed synchronous 6 virtual dental consultations to continue to plan dental rehabilitation under general anesthesia. The caregiver was emailed the forms for consent and medical history, and these were sent back to the clinic ahead of the visit. Families that could not participate in a Zoom consultation were given in-person appointments. The photographs were introduced in May 2020, and an ~100-second video explaining how to take pictures of their child’s teeth using any smartphone of their choice and soup spoons was sent to caregivers. This helped to improve quality anecdotally. Virtual health consultations effectively replaced what would have been traditional in-person consultations for these patients, and dental treatment under general anesthesia was successfully completed based on the information gathered at the VH visit. Virtual health consultations continued through the pandemic and occur to this day. Priority is now given to patients who live farther away from BCCH-DC, those with severe behavioural conditions who otherwise would be uncooperative for in person consultations, and those with diagnostic pre-consultation radiographs. At the time, there was no previous research on teledentistry or virtual health dentistry using our format, no literature exploring the use of virtual health consultations in the planning of dental rehabilitation, or comparisons to the current standard, in-person consultations. With an already significant level of unmet dental treatment needs in Vancouver school-aged children (Samim et al. 2013) and a history of poorer oral health and barriers to care in children with special healthcare needs (Alamri 2022; Ningrum et al. 2020; Obeidat et al. 2022), the closure of dental offices left children in precarious dental health. 1.4 Telehealth or virtual health and its use in dentistry Telehealth involves the use of technology for not only clinical but also structural and administrative purposes (Bouabida et al. 2022). These uses can occur locally and/or remotely at a distance. The COVID-19 pandemic created an avenue for wider adoption of telehealth systems, 7 and the understanding and use of telehealth in the context of BCCH-DC is vital for our purpose. The global implementation of various telemedicine approaches is recognized by the World Health Organization as a complementary way to improve access to care. The World Health Organization's definition of telemedicine is “The use of information and communication technologies to improve patient outcomes by increasing access to care and medical information.” (Hyder and Razzak 2020). Telemedicine has a long history of use in North America, with early uses including the monitoring of astronauts by healthcare professionals by the National Aeronautics and Space Association (NASA) in the 1960s (Alkhalaf et al. 2023). Over the years, two main types of telemedicine have evolved and been utilized by healthcare providers. The conferencing method involves real-time teleconsultation between patients and their healthcare providers in a hospital or clinic setting, as well as between healthcare providers using a variety of communication methods (i.e., video or internet chat, phone, email, etc.) (Deldar et al. 2016). The other method is asynchronous. The patient or healthcare provider collects information, stores it and forwards the files to another location for further response and next steps (Bradley 2008; Feroz et al. 2020; Thrall 2007; Warshaw et al. 2011). 1.4.1 Teledentistry during the COVID-19 pandemic Like telemedicine, teledentistry is a branch of telehealth. The use of teledentistry can be dated back to the U.S. Army’s Total Dental Access Project in 1994, aiming to improve communication around dental care (Rocca et al. 1999). Cook, in 1997, has been attributed to first defining teledentistry as: “the practice of diagnosing and providing treatment advice over a distance using video-conferencing technology”(Islam et al. 2022). There are now several meta-analyses (Gurgel-Juarez et al. 2022), systematic reviews (Fernandez et al. 2021; Priyank et al. 8 2023) and scoping reviews of the teledentistry literature (Hung et al. 2022). Here, we will focus on primary research studies that attempted to measure the accuracy of diagnosis using teledentistry in children using photographs. Our aim is to determine the methods that have been tested most thoroughly and to identify gaps in knowledge. In a recent study from Saudi Arabia, the study design included a calibrated dentist and two teachers using smartphones (AlShaya et al. 2022). The teachers were non-experts and were representing caregivers. A total of 95 children were enrolled in the study between 5-10 years of age, indicating that the majority of children were in mixed dentition (77/95). The decayed, missing, and filled, permanent teeth (DMFT) score was determined from 5 photographs of the mouth and further compared to the standard of care, an in-person examination carried out by a dentist. In this study, the teachers had received extensive training on how to take intra oral photographs. The teachers worked as pairs, with one acting as the assistant and retracting the cheeks while the other took the photographs. The photographs were taken in the dental chair with optimal lighting and patient positioning. Standardization was such that the same smartphone (iPhone X) was used by everyone. The 3 sets of photos taken by 2 non-professional teachers and the dentist were evaluated blind. Under these extremely controlled conditions, the DMFT scores were very accurate. The only comparison that was significant was the comparison of teacher images with the clinical exam by the dentist. In this case, the accuracy was greater for the dentist. Otherwise, the specificity (ability to detect a truly sound tooth) and sensitivity (ability to detect caries when it is indeed present) were greater than 90% for all comparisons in primary teeth, with a slightly lower ability to diagnose caries in permanent teeth for everyone, including the dentist. This study was highly optimized and shows excellent agreement between virtual exams and clinical exams. 9 Two recent studies carried out in Australia looked at the accuracy of caries diagnosis in children made from photographs (Azimi et al. 2023; Estai et al. 2022). A teledentistry study was carried out on 42 children under 4 years of age (Azimi et al. 2023). Here, the parents were trained to take photos with a smartphone that was provided to them. The parents were encouraged to take up to a maximum of 12 photos of their child and were provided with hands-on training by dental professionals. The photos were taken while a dental therapist watched. After the photos were taken, the same children were examined by a pediatric dentist using the knee-to-knee method. The photos were separately evaluated by 2 oral health care professionals and each of the assessors assigned a quality score for the photos. The teeth were scored for caries with the International Caries Detection and Assessment System II (ICDAS-II) system; however, they did not attempt to include smooth surface decalcification. The specificity was high (ability to detect sound teeth); however, sensitivity (ability to detect caries) was variable depending on which quadrant was being examined. In the second study (Estai et al. 2022), the photos were taken by trained dental personnel after 6 hours of training. Extra lighting was provided as well for the clinical photography. In this instance, the clinical exams were carried out by the dental therapists. The DFT/dft method of scoring caries was used, which does not include the affected surfaces. In the end, the ability to correctly identify carious teeth varied between 58-80%. In contrast, sound teeth could be identified with great certainty (98-99%). Thus, a similar conclusion was reached that the ability to detect caries was better with a clinical exam. Also, photos of children in primary dentition were easier to score, and thus, sensitivity was higher, as reported previously using an SLR camera with optimal lighting (Boye et al. 2013). Taken together, there are very few studies that ask caregivers to take the photos. In those that do, the real-life context of obtaining photos at home with no extra lighting and minimal help with cheek retraction is not captured (Azimi et al. 2023). 10 Our study design intentionally examined the validity of teledentistry or virtual dental visits to treatment plan full-mouth rehabilitations. None of the other studies tested the use of synchronous teledentistry with caregivers to generate a full treatment plan for their child. With the pandemic, it was not possible to train parents directly in the clinic, nor was it realistic to standardize the smartphones, or to optimize lighting conditions in the home. We put virtual dentistry to the test in this study to find out how successful this method that was initially started out of necessity truly was. 11 Chapter 2: Aim and Objectives The aim is to compare the standard of care, which was in-person consultations for full mouth rehabilitation, to the virtual health format, which was introduced as a result of the COVID-19 pandemic. The review would include patients who required a general anesthesia consultation (and subsequent treatment) irrespective of consultation format in these months: July 2020, November 2020, March 2021, and June 2021. This encompasses different waves of the pandemic and different times of the year to account for any seasonal differences. The study also captured the evolution of virtual health visits from shortly after they were implemented, July 2020, until June 2021; a full year after they had been established. 2.1 Primary 1. To determine the accuracy of the estimated skin-to-skin time made in virtual or in-person dental consultations. 2. To determine the accuracy of the estimated number of teeth planned for treatment made in virtual or in-person dental consultations. 2.2 Secondary 1. To determine the difference between the distance from primary residence to BC Children’s Hospital of families who used virtual or in-person consultations. 2.3 Null Hypothesis The null hypothesis is that there will be no difference in the accuracy of planning comprehensive care for patients, whether examined virtually or in-person. 12 Chapter 3: Methods This retrospective chart review was approved by the University of British Columbia Research Ethics Board (REB PROTOCOL H21-02433) and renewed in 2023. In addition, this project has been vetted by the Director of the Pediatric Dentistry Graduate Program at the University of British Columbia, as well as the Chief of Dentistry at BC Children’s Hospital. As this was a chart review of low-risk, specific patient consent was not required. No patients (or guardians/caregivers) were approached for this retrospective chart review. 3.1 Sample All patients who completed synchronous general anesthesia consultations at the British Columbia Children’s Hospital Dental Clinic in the months of July 2020, November 2020, March 2021, and June 2021 were identified. Though introduced in May 2020, by July 2020, the format of the virtual health visit was established and did not change or evolve after that time. Once the records of these patients were examined, those with the following inclusion criteria were included in the study: 1. Completion of general anesthesia consultation at BC Children's Hospital. Patients’ records were excluded if: 1. Full-mouth dental rehabilitation under general anesthesia was not completed at BC Children’s Hospital. 2. Predicted time for treatment was “< 60 minutes” or “>120 minutes” 3. Photography was obtained by oral health professionals. Cases that did not complete full mouth dental rehabilitation under general anesthesia at BC Children’s Hospital were excluded as this did not allow for pretreatment and posttreatment 13 comparisons. Reasons why cases were not completed at BCCH included treatment completed at another facility, cancellation (due to parental decision, or health and COVID-19 concerns) or completion of dental treatment with other methods of behavioural guidance. Cases with predicted times for treatment as “<60 minutes” or “>120 minutes” were excluded because these were not always presented as continuous values and would be presented at categorical values at times in the chart review. In addition, most dental cases at BC Children’s Hospital that were labeled for “<60 minutes” were coordinated dental exams under anesthesia on another surgical services operating room slate. These are examinations only and do not have predicted treatment. Furthermore, cases labeled for “>120 minutes” often included coordination with another specialist and operating times may not reflect the amount of dental treatment time exclusively. Cases with photographs obtained by oral health care professionals were excluded because the aim of this study was specifically assessing photographs obtained by caregivers. 3.2 Study Procedures All general anesthesia consultations and treatment were completed by certified pediatric dental attendings with or without a pediatric dentistry graduate student at BCCH-DC. 3.3 Data Collection The primary investigator for the study (KA) completed data collection for patient records who met the inclusion and exclusion criteria. Each Cleardent® dental record number was assigned a unique subject ID to protect patient identity. Moreover, the Cleardent record ID and subject ID were placed into an encrypted, password-protected Microsoft® Excel Spreadsheet. No patient names were captured in the master tracking log. Information extracted based on chart entries in ClearDent® were entered into Research Electronic Data Capture (REDCap). All inputs were 14 assigned variables to aid in analyses. One-way ANOVA with Tukey’s post hoc testing and unpaired T-tests were performed using Prism V10.0 and was used to assess the strength of association between variables. A p-value of < 0.05 was used determine statistical significance. The information collected included these variables: 1. Patient demographics a. Age at both the consultation and treatment visit dates. b. Sex assigned at birth – male or female c. Forward sortation area - first three characters of the postal code d. Dental insurance coverage - private, government, no insurance e. Dental home - yes or no f. Medical diagnosis from the health history, not coded g. American Society of Anesthesiologists’ Physical Status Classification h. Referral source to BCCH-DC – Dentist, Physician, Dentist + Physician, BCCH Patient, Other 2. Pretreatment information a. Date of consultation b. Type of consultation – in person or virtual consultation c. Presence of early childhood caries d. Pediatric Canadian Access Target (PCAT) code for surgery e. Presence and quality of pictures obtained by caregiver f. Presence of any type of dental radiograph provided by referring dentist g. Number of teeth requiring treatment h. Estimated time required for treatment 15 3. Treatment information a. Date of treatment b. Actual time required for treatment c. Number of teeth treated (filled, crowned, or extracted) d. Number of teeth disked e. Follow-up visit location (BCCH, General Dentist or Pediatric Dentist) 3.3.1 Medical History Medical histories were collected by reviewing the available medical history information present in Cleardent® chart (information was obtained from the medical record and updated with the legal guardian) and identifying the type and number of co-conditions for each patient. Categories were as follows: 1. Healthy and under the age of 4 years 2. Autism spectrum disorder 3. Developmental delay 4. High BMI 5. Cancer diagnosis 6. Cardiac diagnosis 7. Syndromic 8. Organ transplant 9. Respiratory 10. Endocrine & Metabolic 11. Psychiatric 12. Other 16 3.3.2 American Society of Anesthesiologists’ Physical Status Classification The American Society of Anesthesiologists’ (ASA) Physical Status Classification was determined through consultation of “ASA Physical Status Classification System” Standards and Practice Parameters developed by the American Society of Anesthesiologists Committee on Economics (Anesthesiologists 2020). This is the recommended proxy to be used in the assessment of perioperative risk by the American Academy of Pediatric Dentistry (AAPD 2023c). 3.3.3 Distance Between Primary Residence and BC Children’s Hospital Due to patient confidentiality, exact addresses and postal codes could not be utilized to determine the exact distances between primary residence and BC Children’s Hospital. Forward sortation area (FSA) was used as a proxy for primary residence. The forward sortation area makes up the first three-character segment of a postal code. The first character in the segment helps to identify one of Canada’s major geographic areas, districts, or provinces. The first character of the FSA for the geographic area of British Columbia is V. The second character of the FSA segment helps to identify either an urban postal code (numbers 1 to 9) or a rural postal code (number 0). Finally, the third character of the FSA segment, in combination with the first two characters, describes an exact area of a city, town, or geographic area (https://www.canadapost-postescanada.ca/cpc/en/support/articles/addressing-guidelines/postal-codes.page). For rural and urban residences, FSA is well suited and has been used in previous Canadian studies (Meyer 2012; Perlman et al. 2018). The FSA for each patient was placed in Google Maps, and the centroid was used to determine the distance from the primary residence to BCCH-DC. This method was used in a recent study observing the impact of telemedicine on care for rare cancers (Smrke et al. 2020). Each 17 distance was obtained using the same pre-set date and time for each FSA. The shortest land and water distance was used for each FSA. Air travel was not used. 3.3.4 Quality of Photographs When evaluating intra-oral photography obtained by the caregivers, a set of criteria were established to classify the quality of the photographs. A current standard in the evaluation of caregiver-obtained intra-oral photography is not available. Factors used in determining image quality included: 1. Image focus 2. Visible teeth Photograph quality was deemed excellent if the images were in focus and teeth were visible; fair if the images were out of focus or if only some teeth were visible; and poor if no teeth or only the chief complaint was visible (Fig. 3.1). 18 3.3.5 Early Childhood Caries Early childhood caries, as defined by the AAPD, was used to identify which patients suffered from this condition (AAPD 2023c). Their definition includes: Figure 3.1 Virtual Health Consultation Photo Quality Definition A,A’) patient with almost no teeth visible, B-B’’) Patient with incisors, lower quadrants and the upper right quadrant partially visible. There is no view of the upper left quadrant. C-C’’’) Good views of all 4 quadrants. 19 “the presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six”. 3.3.6 Errors of Predicted vs. Actual Skin to Skin Time The predicted time for dental treatment and actual skin-to-skin time required for dental treatment was recorded from the dental operating room daily status reports paper records. For each consultation, the case is given an estimated number of minutes required to treat the case. There are factors that are considered when estimating the time needed. These include the number of teeth affected, whether there are teeth requiring pulp therapy, restorability of primary and the presence of permanent teeth with caries. Depending on the level of treatment required, a dental treatment time length will be estimated for booking. Cases are generally booked in 15-minute units of time, and all the cases included in this study were estimated to take either 60, 75, 90, 105, or 120 minutes. A 75-minute case typically involves the primary or early mixed dentition with 4 quadrants of posterior restorations and/or extractions without nerve treatment. A 90-minute case typically involves the primary or early mixed dentition with 4 quadrants of posterior restorations and/or extractions with nerve treatment. A 105-minute case often involves primary or mixed dentition with 4 quadrants of posterior restorations and/or extractions and nerve treatment in addition to anterior restorations. Finally, a 120-minute case will usually involve mixed or permanent dentition requiring multiple restorations and/or extractions of primary and permanent molars, in addition to possible anterior restorations. The time required for induction under anesthesia was not considered in the predicted or actual skin-to-skin time required for dental treatment. The estimated skin-to-skin time was subtracted from the actual dental skin-to-skin time to generate the time variance. This method has been used previously in the generation of overrun times at Seattle Children’s Hospital (Forsyth et 20 al. 2012). Negative values in that study indicated cases that were shorter than expected, and positive values indicate cases that were longer than expected. Mean absolute error (Chen et al. 2017) was found by calculating the arithmetic mean of the absolute time variances: Mean absolute error (𝑀𝐴𝐸) = 1𝑛5|𝑡𝑖𝑣!"!#$ | Prediction error was determined by dividing the time variance by the actual dental skin-to-skin time (Wu et al. 1995). This was multiplied by 100% to determine the percentage prediction error. Mean absolute percentage error was found by calculating the arithmetic mean of the absolute percentage prediction errors. Mean absolute percentage error (𝑀𝐴𝑃𝐸)= 1𝑛5|measured value − predicted valuemeasured value x 100%"!#$ ! | 3.3.7 Errors of Predicted vs. Actual Number of Teeth Treated The predicted number of teeth requiring treatment and actual number of teeth treated were recorded from the patient’s electronic ClearDent® chart. Charts that did not clearly indicate the number of teeth predicted for treatment were not included in this portion of the analysis. There are variables that are considered when assessing caries risk and estimating the number of teeth that will require treatment (AAPD 2023b). These include indicators of disease such as visible caries, noncavitated caries, missing teeth due to caries, and recent dental restorations. Risk factors include primary caregivers with active caries or low health literacy, frequent between meal or nighttime exposures of sugars, special health care needs, visible plaque on teeth or enamel defects, low 21 salivary flow, and defective restorations. Protective factors include optimal water fluoridation or fluoride supplementation, use of fluoride toothpaste and excellent oral hygiene, establishment of a dental home and regular dental care (AAPD 2023b). Depending on the mode of consult, information from referral, availability of clinical photographs, dental history, age and behaviour of the child were variables which were used (as appropriate) to determine the predicted dental treatment, and such, the number of teeth planned for treatment. The predicted number of teeth requiring treatment was subtracted from the actual number of teeth treated to generate the treatment variance. Negative values indicate cases that required less treatment than expected, and positive values indicate cases that required more treatment than expected. Mean absolute error was found by calculating the arithmetic mean of the absolute treatment variances: Mean absolute error (𝑀𝐴𝐸) = 1𝑛5|𝑡𝑟𝑣!"!#$ | Prediction error was determined by dividing the treatment variance by the actual number of teeth treated. For this analysis, only patients who had at least 1 tooth treated were included. This was multiplied by 100% to determine the percentage prediction error. Mean absolute percentage error was found by calculating the arithmetic mean of the absolute percentage prediction errors. Mean absolute percentage error (𝑀𝐴𝑃𝐸)= 1𝑛5|measured value − predicted valuemeasured value x 100%"!#$ ! | 22 3.4 Data Security Dental records are housed within ClearDent® dental software stored within the local network at BCCH. The data is backed up at the Kelowna data storage centre. ClearDent® puts all patient data into an encrypted database. In addition, enhanced encryption exists as ClearDent® resides on the Provincial Health Services Authority (PHSA) servers. Access is managed via a username and password for each user. There is a full audit trail of logins and actions available to search if need be. REDCap is a secure data-capturing collection application used to collect and store data for research studies. 23 Chapter 4: Results 4.1 Patient characteristics In the 4 months included in this study, a total of 684 patient had completed general anesthesia consultations at BCCH-DC. Of those, 321 patients met the inclusion criteria and were included in the following results after excluding 363 patients who met the exclusion criteria. Of the 321 included, there were a similar number of patients seen in each of the 4 study periods: 84 (26%) for July 2020, 70 (22%) for November 2020, 99 (31%) for March 2021, and 68 (21%) for June 2021 (Table 4.1). A total of 194 males (60%) and 127 females (40%) were included in this study. There were 183 in-person visits and 138 virtual health visits included in the study (Table 4.1). The mean time from the date of general anesthesia consultation to the date of treatment under general anesthesia was 4.3 months. The proportions of IP versus VH consultations were similar (IP, n=183/321, 57%; VH, n=138/321, 43%). Nearly half of the patients presented with 1 or 2 medical diagnoses (n=158/321, 49%) or more than 2 conditions (n=65/321, 20%). Autism (n=114/321, 36%), healthy under the age of four (n=99/321, 31%) and developmental delay (n=66/321, 21%) were the most common conditions occurring in this patient population. A category of “other” (31%) included all other coexisting conditions that did not fit into the other categories. The American Society of Anesthesiologists (ASA) classification I is used for normal healthy patients (Anesthesiologists 2020) and there were overall 33% treated children with ASA I status. Those with an ASA classification of II made up the majority of patients (n=152/321, 47%). More advanced ASA status was less common (ASA III, n=60/321, 19%; ASA IV, n=2/321, 1%). 24 Table 4.1 Patient demographics Contingency analysis with Fisher’s exact test was used to test for statistical differences between observed and expected values. Overall N = 321 In-Person N = 183 Virtual Health N = 138 Significance Sex n (%) Female 127 (40) 64 (35) 63 (46) ns Male 194 (60) 119 (65) 75 (54) Mean age in years (months) At consult 6.4 (76.3) 6.0 (72.1) 6.8 (81.8) ns At treatment 6.7 (80.6) 6.4 (76.3) 7.2 (86.2) Age in years at consult n (%) < 6 188 (59) 114 (62) 74 (54) ns 6 – 12 97 (30) 53 (29) 44 (32) > 12 36 (11) 16 (9) 20 (15) Medical History n (%) Healthy under 4 98 (31) 59 (32) 39 (28) ns 1 or 2 co-conditions 158 (49) 89 (49) 69 (50) 3 or more co-conditions 65 (20) 35 (19) 30 (22) ASA classification n (%) I 107 (33) 62 (34) 45 (33) ns II 152 (47) 88 (48) 64 (46) III 60 (19) 32 (17) 28 (20) IV 2 (1) 1 (<1) 1(<1) Consult Month n (%) July 2020 84 (26) 51 (28) 33 (24) ns November 2020 70 (22) 39 (21) 31 (22) March 2021 99 (31) 59 (32) 40 (29) July 2021 68 (21) 34 (19) 34 (25) Most patients (188/321; 59%) were 71 months of age or younger at the time of consultation. The proportion of children 71 months or younger in the virtual health group was 74/138 (54%) and 114/183 (62%) in the in-person consultation group. The patients less than 71 months had a high prevalence of early childhood caries (72 or 97% virtual; 111 or 97% for in-person consultations). 25 Children who utilized virtual health consultations had a significantly farther mean distance between primary residence and BC Children's Hospital (138.9 km; 95% C.I equals 89.3 km to 188.5 km) than those who used in-person consultations (60.8 km; 95% C.I equals 36.8 km to 84.9 km)(Fig. 4.1; unpaired T-test, p = 0.003). Photographs became an important adjunct to virtual health consultations during the pandemic. Of the 138 patients who utilized virtual consultations, 41 (29.7%) did not provide photographs while 97 (70.3%) patients did. The quality of the photographs was variable and were placed into 3 categories. The first category (poor) consisted of 12 patients (8.7%) with photos that did not show the teeth or only the chief complaint (Table 4.2). The second category (fair) contained 45 patients (32.6%) whose photographs were out of focus or had a partial view of the teeth. Figure 4.1 Distance between home forward sortation area and BCCH The distance was significantly greater for patients that attended virtual health visits (VH) compared to in-person consultations (IP). T-test, P = 0.003. Mean with 95% CI shown. 26 Category three (excellent) contained 40 patients (29.0%), and these photos had the majority of teeth visible in all quadrants, and images were in focus. There were also radiographs provided for 56/183 in-person consultations (30.6%) and 50/138 (37%). There was no statistical difference in the proportion of patients that had radiographs in the two groups. The quality of the radiographs was not assessed in this study. Table 4.2 Virtual Health Consultation Photo Characteristics Photographs available out of total VH patient pool (N = 138) N = 97 70.3% VHP0 - No photos available 41 29.7% Photograph Quality and category VHP1 - Teeth not Visible 12 8.7 VHP2 - Out of Focus or Some Teeth Visible 45 32.6 VHP3 - In Focus, Teeth Visible 40 29.0 4.2 Analysis of the accuracy of predictions We analyzed the accuracy in four different ways. The first was the minute difference in time for each case between the predicted and actual skin-to-skin time, or time variance. The average predicted case duration for in-person consult patients was 87 minutes, for virtual health patients with photographs, it was 85 minutes, and for virtual health patients without photographs, it was 85 minutes. The average final skin-to-skin time for in-person consult patients was 72 minutes, for virtual health patients with photographs 74 minutes, and for virtual health patients without photographs 70 minutes. No significant differences in the minutes between estimated and actual times were found between these conditions (Table 4.3). 27 Table 4.3 Predicted Vs. Actual Skin-to-Skin Time Overall N = 321 Average Predicted Skin-to-Skin (min) Average Final Skin-to-Skin (min) Average Time Variance (min) Consult type IP 183 87 72 -15 VHP (total) 97 85 74 -11 VHP0 41 85 70 -15 VHP1 12 85 69 -16 VHP2 45 85 77 -8 VHP3 40 86 73 -13 The second way we analyzed accuracy was to calculate the percentage error between estimated and actual treatment time. We found no statistically significant difference in the percentage error between virtual health consultations with pretreatment photographs (37.5%, p= 0.95) and virtual health consultations without pretreatment photographs (55.7%, p = 0.09) compared to in-person (35.3%). There were, however, significant differences found between taking poor-quality photographs and an in-person visit (Fig. 4.2). The error percentage was significantly higher in virtual health consultations with poor-quality pretreatment photographs (VHP1, 105.2%) compared to in-person (IP, 35.3%; p= 0.0003) and virtual health consultation with highest quality pretreatment photographs (VHP3, 31.0%; p=0.0005). Compared to in-person consults (IP), the error percentage was not significantly different in virtual health consultations with pretreatment photographs that were in focus with the teeth visible (VHP3, 31.0%, p = 0.99), out of focus or had some teeth visible (VP2, 25.1%, p=0.80) or had no pretreatment photographs (VP0, 55.69%, p=0.20) (Fig. 4.2). 28 We also grouped all patients that had photographs together regardless of quality and those without photographs in a second group. Again, there was no statistical significant difference in the percentage error. Finally, we asked whether there are differences in the accuracy of photographs taken of children in primary dentition compared to those with permanent molars erupted. There was no significant difference in accuracy. The third way we analyzed accuracy was by assessing the mean error in the number of predicted and actually treated teeth, comparing the preoperative treatment plan to the completed Figure 4.2 Effect of consult type on % error in predicted versus actual time The poorest quality images, VHP1 had significantly more variability than the in person visits as well as the VPH3 which were the highest quality images. Having any images that were of fair or excellent quality gave similar accuracy to the in-person visits. 1-way ANOVA 29 treatment. The average predicted number of teeth needing treatment for in-person consult patients was 8.5 teeth, for virtual health patients with pre-treatment photographs 9.1 teeth, and for virtual health patients with no pre-treatment photographs 6.4 teeth (Table 4.4). The average final number of teeth treated for both in-person patients and virtual health patients with pre-treatment photographs were 8.8 teeth, while the average for virtual health patients without photographs were 6.8 teeth. There were no significant differences in treatment variances between any of the conditions. Table 4.4 Predicted Vs Actual Number of Teeth Treated Overall N = 315 Mean Predicted Number of Teeth Requiring Treatment Mean Final Number of Teeth Treated Mean # of teeth that varied from predicted Consult type IP 179 8.5 8.8 0.3 VHP (total) 96 9.1 8.8 -0.3 VHP0 40 6.4 6.8 0.4 VHP1 12 5.5 7.1 1.6 VHP2 44 9.5 8.9 -0.6 VHP3 40 9.6 9.4 -0.2 The final way that accuracy was assessed was by percentage error in the number of teeth estimated for treatment vs. the actual number of teeth treated. When comparing in-person consultations to all four virtual consultation conditions, no significant difference in error percentage was found between conditions (Fig 4.3). 30 4.3 Disposition of patients following GA at BCCH - Dental home Once dental treatment had been completed, all patients were encouraged to seek follow-up dental care with a dental provider. Most patients who were healthy under the age of four were followed by a community pediatric dentist (n = 71/98, 72%) or general dentist (n = 27/98, 27%). For patients who presented with 1 or 2 co-conditions, 26% (n= 41/158) of patients were followed by BCCH Dentistry, 62% (n= 98/158) of patients were followed by a community pediatric dentist, with 12% (n=19/158) following up with a general dentist. Not surprisingly, patients who presented with 3 or more co-conditions were nearly all followed at BCCH Dentistry (40%; n= 26/65) or by a specialist in the community (54%; n= 35/65). A minority (6%; n=4/65) went back to a general dentist for routine care (Table 4.5). Figure 4.3 Effect of consult type on % error in predicted versus actual teeth treated. There were no statistical differences between the groups, 1-way ANOVA 31 Table 4.5 Follow-up dental care location Overall N = 321 BC Children’s Hospital Community Pediatric Dentist Community General Dentist Medical History n (%) Healthy under 4 98 (31%) 0 71 (72%) 27 (28%) 1 or 2 co-conditions 158 (49%) 41 (26%) 98 (62%) 19 (12%) 3 or more co-conditions 65 (20%) 26 (40%) 35 (54%) 4 (6%) In summary, the accuracy of treatment needs was similar whether the consultation was done virtually or in person. The provision of high-quality photographs was not essential to the predicted time for the case, nor were photos necessary to know how many teeth needed treatment. 32 Chapter 5: Discussion Our study is the first to compare the use of caregiver, smartphone-obtained intraoral photographs in virtual, synchronous dental consultations to traditional in-person consultations. We were comparing similar types of cases where full-mouth rehabilitation was required under general anesthesia. Both types of consultation requires detailed discussions with the parents about all the treatment options, e.g., types of materials, which teeth to keep and which to extract, alternative plans if the radiographs show that a tooth has become necrotic, alternative treatment if a teeth become unrestorable, and many other possibilities. The caries risk for each patient is also considered and a detailed reflection on the dental history can affect the final treatment plan. The parent's input is considered in the plan, and together, the dentist and parent arrive at a consensus. In a related study currently underway at BCCH, the satisfaction of the caregivers with the virtual versus in-person discussions is being evaluated. In our study, a greater trend of patients who were seen for dental treatment under general anesthesia were males. Though not statistically significant, this disproportion has also been found in similar studies (Ciftci and Yazicioglu 2020; Hsiao et al. 2021; Kasemkhun et al. 2022; Mallineni and Yiu 2018). However, these studies have not explained the reasons why males consistently outnumber females in relation to dental treatment under general anesthesia. The present study is unique in that we used the estimated time for dental treatment under general anesthesia to measure the accuracy of a virtual health dental consultation. The other studies used individual caries scores (DMF, DMFS, ICDAS-II) to measure sensitivity (false negatives) and specificity (false positives) (AlShaya et al. 2022; Azimi et al. 2023; Estai et al. 2022). Our study could not assess DMF or ICDAS since 30% of the time photographs were not provided in the virtual health dental visits. In addition, out of the 70% that did send photos, only 29% were of 33 excellent quality. Full intraoral photographs taken in a standardized manner are required for accurate scoring of caries in research studies (Crowder 2022). Another method we could have used to analyze accuracy was to measure the deviation from the original behavioural guidance plan. In addition to accuracy of restorative treatment plans, one study has used teledentistry to predict the type of behaviour guidance methods needed for restorative treatment (McLaren et al. 2017). These authors however did not analyze the change in behaviour guidance methods using non-parametric statistics. We also do not know whether the patients in this study had differences in restorative dentistry treatment planning. We were able to show that, on average, the estimated dental general anesthesia skin-to-skin times made in virtual general anesthesia consultations without pretreatment photographs (VP0), as well as those with fair (VP2) or excellent (VHP3) quality pretreatment photographs were just as accurate as those made in in-person general anesthesia consultations (IP). In addition, each form of virtual consultation yielded an average estimation of the number of teeth required for treatment, which was statistically as accurate as those made in in-person general anesthesia consultations. One possible reason for the lack of statistical significance is a high variability in the accuracy of in-person visits. Indeed, frequently the in-person consultations are carried out on behaviorally challenged children who cannot tolerate intra-oral examinations in the dental chair. Exclusion of this group of patients may have decreased the variation, leading to a significant difference in accuracy of treatment planning. On average, the time variances found in our study indicate a general tendency to finish faster than the required time during dental treatment. This was the case with every form of consult and has been a consistent trend reported in the literature (Forsyth et al. 2012; Ogden et al. 2000; 34 Yi et al. 2015). Finishing treatment sooner than expected often gives the team the ability to accommodate any unexpected delays or challenges that present in the operating room slate. Our study found that there was no statistically significant difference in the average error percentage of the predicted versus actual skin-to-skin time between in-person consultation (IP), virtual health consultations with pretreatment photographs as a whole (VHP), and virtual health consultations without pretreatment photographs (VHP0). Our findings differ from what was found in the diagnostic accuracy of referrals to eye casualty clinics based on smartphone lenses (Mamtora et al. 2023), which found that diagnostic accuracy was significantly higher when an image was included with the history (akin to our virtual health with pretreatment photographs [VHP]) than if a history alone was given (virtual health without pretreatment photographs [VHP0]). This difference implies that pretreatment photographs are not clinically relevant for these dental consults. The similarity in the average error percentages in our study could be due to the practice experience of the 11 attending pediatric dentists. Experience with clinical and associated radiographic examinations, as well as providing treatment dental treatment under general anesthesia, leads to recognition and appropriate estimation of time needed when provided with pretreatment photography and/or dental history. Likely, a much higher average error percentage would be noted during virtual consultations if pediatric dental graduate students were predicting skin-to-skin time without an attending pediatric dentist. In addition, the histories that were provided in (Mamtora et al. 2023) were based off a questionnaire, which is appropriate for a referral. Our virtual health clinic histories were obtained through dialogue, which allowed the opportunity to obtain more information and a thorough dental history, leading to greater accuracy. Furthermore, when the average error percentages of the predicted versus actual skin-to-skin time found from each type of virtual consultation were compared to the value found from in-35 person (IP) consultations, the average error percentage from virtual health consultations with pretreatment photographs of poorer quality (VHP1) was significantly higher. This higher average error percentage could be attributed to lower-quality images providing less information to appropriately estimate the required time for dental treatment. Practical experience of the attending pediatric dentists would suggest naturally erring on the side of overestimation, to allow for unexpected challenges. Furthermore, a study comparing the image quality of patient-submitted photographs to diagnostic accuracy in teledermatology found that photos with a lower photograph quality rating scale score led to an increased likelihood of additional tests required to make an accurate diagnosis (Tuknayat et al. 2023). On average, treatment variance between the conditions, as well as the error percentage of the predicted versus actual number of teeth treated, was not statistically significant. This is consistent with the results found in the literature, finding no significant difference between treatment accuracy of intraoral photograph examination compared to direct examination in a prison disease screening program (Santipipat et al. 2023). Certainly, effective dialogue during the virtual consultation and the experience of attending pediatric dentists aid in making assessments as accurate as the current in-person standard. In addition, detailed dental histories from referring healthcare providers who may have had a chance to assess the patient for a direct oral examination could influence the accuracy of treatment required. One may even expect more accurate treatment estimates from referrals with a dental background as their reason for referral would naturally give a more detailed idea of the condition of the mouth. Interestingly, not shown in results, there was no significant relationship between the accuracy of estimated treatment time and number of teeth for treatment and the source of referral (Dentist, Physician, Dentist + Physician, BCCH Patient, Other). Finally, evidence in the literature has shown instances where the presence of decay on the 36 surfaces of certain teeth is positively associated with the presence of caries on others (Ardenghi et al. 2008). Oftentimes, it is much easier for a caregiver to obtain a higher-quality photograph of or visually observe the maxillary anterior teeth than the posterior teeth. Confirmation of anterior caries in this region (either through direct intraoral examination, caregiver-obtained photography, or consultation dialogue) has been shown to be a good predictor of caries on posterior teeth (Ardenghi et al. 2008). Though not statistically significant, our findings suggest a trend that higher quality pictures (VP3 and VP2) available during virtual consultations can provide lower time variances than virtual consultations with lower quality (VP1) or no pretreatment photographs (VP0), as well as in person consultations (IP). One reason for this involves higher quality images allowing clearer visualization of the condition of the oral cavity, leading to more accurate estimations of required skin-to-skin time. To obtain a higher-quality intra-oral photograph for virtual visits, a certain level of patient cooperation is required. The in-person consultation group includes cooperative and uncooperative children. These uncooperative children will not be able to tolerate intra-oral examinations in the dental chair, leading to just as poor a diagnostic assessment as a virtual health visit with lower quality photographs. Both types of visits have incomplete information, which is compensated for by overestimating the needed OR time by 15 – 16 minutes (as found in this study). Interestingly, we found that the average treatment variance for virtual health consultations with poor-quality pretreatment photographs (1.6) was higher than every other consult type (ranging from -0.6 to 0.4), including virtual health consultations without photographs (0.4). This trend was also observed in the error percentage of estimated skin-to-skin time, where the virtual health with the poorest quality pretreatment photographs (VP1, 105.5%) was higher than virtual health consultations with no pretreatment photographs (VHP0, 55.69%). As alluded to earlier, virtual 37 health consultations in the absence of pretreatment photographs naturally place a greater emphasis on dialogue with the caregivers. In the virtual, synchronous discussions, there is time to ask the parent about symptoms such as difficulty eating, waking up with pain, and pain so severe that pharmacological management is explored. The two largest photograph characteristic group for virtual consultations were those with photographs of fair quality (32.6%) and those with no photos available (29.7%). This may suggest not only a challenge capturing photographs, but high-quality images for virtual dental consultations. Instead of relying on caregivers to take the photographs, intraoral photographs could be taken at practice of the referring provider. This could help reduce the burden and stress on caregivers, especially for those who may not be technologically adept. In addition to the tutorial video that is sent to families with instructions for capturing intra-oral photographs, development of a feedback mechanism or service could help improve photograph quality prior to the virtual consultation appointment. The current tutorial video consists of images showing caregivers how to take photographs and is supplemented with simple written instructions in the video. Audio instructions could also be added in multiple languages to help cater to those who may be unable to follow the visual instructions. A study investigating the effectiveness of audiovisual and verbal instructions on patient performance during visual testing found the combination of audiovisual instructions lead to greater motivation and confidence during the test (Maheshwari et al. 2023). Finally, specific instructions regarding camera angles, distance, lighting, background, flash and child positioning can help in further standardizing photographs received (Zoltie et al. 2022). Studies have long since identified the importance of standardization in comparisons, dental treatment planning (Bengel 1985; Casaglia et al. 2015) and surgical outcomes (Sommer and Mendelsohn 2004). 38 5.1 Virtual Health Helps Equalize Pediatric Dental Access Families who utilized these virtual health dental consultations, on average, had a primary residence that was statistically further away from BCCH than those families who utilized in-person consultations (in-person = 60.8km, virtual health = 138.9km, p=0.003). This preference for teledentistry by rural families is similar to what has been reported by others (Marques et al. 2022; Smrke et al. 2020). Families prefer virtual health appointments since expenses incurred from travel are reduced (Cook et al. 2000; Fricton and Chen 2009; Smrke et al. 2020; Zhang et al. 2021). The virtual health option saves families the need to travel to Vancouver twice, once for the exam and once for the treatment. This benefit has encouraged BCCH-DC to now give priority to patients who live farther away. In the lower mainland, the majority of patients who were healthy and under the age of 4 followed up with community pediatric dentists (72%), with more than a quarter following up with community general dentists (28%). Patients from rural communities do not have access to specialists and will find a dental home in a general dental office. This is consistent with the literature that community general dentists do play an important role in the dental care of healthy pediatric patients (Clark et al. 2014). As the number of co-conditions present in a child increased, the more likely they were to continue follow-up care with BC Children’s Hospital dental clinic, or a community pediatric dentist. This not only speaks to the expected increase in specialized care for patients who present with multiple co-conditions but also to the flexibility of community pediatric dentists' ability to provide dental care to both healthy and medically complex patients. 5.2 Study Strengths and Limitations To our knowledge, our study is the first of its kind to observe the role synchronous teledentistry with caregiver-derived photographs can play in the planning of full mouth 39 rehabilitation under general anesthesia in a pediatric dental clinic. The tracking of predicted and actual skin-to-skin times offered a unique way to assess accuracy. The comparison of virtual health consultations with and without pretreatment photographs to the gold standard, in-person consultation carried out by an experienced, certified specialists in pediatric dentistry is a good design and should reveal any shortcomings of the VH format. To improve this study, we could plan to examine each patient in both in person and virtual visits. With this information, 2 treatment plans could have been compared to generate within patient sensitivity (ability to detect caries when it is present, avoiding false negatives) and specificity (ability to correctly identify caries-free teeth or avoid false-positives). Even though it was not practical to have within patient comparisons, we showed that the VH format is valuable and should be continued. Especially because BCCH is responsible for providing care to all the children of BC who need advanced, specialized services. On a smaller scale, our study may reassure specialists who have not used virtual health to incorporate this approach into their practices. Furthermore, virtual health can be explored for other purposes such as recall exams for children with severe behavioural challenges or who live in remote locations. Perhaps a hybrid model with the option to have one in-person and one virtual visit per year. Many families face challenges getting to BCCH-DC and delay their recalls by years in some cases. This can at least give providers the opportunity to check in with caregivers regularly with virtual visits to help ensure that the children are not experiencing any symptoms of infection, pain, or obvious signs of caries. This study is not without its limitations. This retrospective study is reliant on the accuracy of the records of many pediatric dentistry graduate students and supervising attending pediatric dentists. These records may not place an emphasis on this study’s objectives, and careful 40 interpretation is required. We also relied on caregiver photographs which were not of high quality compared to standardized, professional photographs. Future prospective studies can ask caregivers to go to a dental office to have these photographs taken by a dental provider. Another possibility is to train school teachers to take the photographs in a standardized manner as published in a study from Saudi Arabia (AlShaya et al. 2022). Due to the high availability of schools in rural communities, this could be an easier way to improve intraoral photography. Though the months chosen for analysis were evenly distributed over a 12-month span to capture different time points in the year, we did not include every patient that was seen for general anesthesia consultation in that year. The sample size of our study compared to the previous studies assessing teledentistry discussed in this thesis was much higher (Azimi et al. 2023; Estai et al. 2022). This led to the presumption of a sufficient sample size. However, there is a certain level of novelty in our study which makes the information needed for precise power analysis not readily available. It is possible a power analysis will show that a larger sample size was needed to detect statistically significant differences. Another issue is that the 12-month span is focused after the beginning of the COVID-19 pandemic, which could have influenced our procedures. Certainly, the virtual health rollout took place during the study period. Had we followed the GA times over a longer period, we might have seen an improvement in the quality of the photographs. We also would like to know how the pandemic itself affected our treatment times. The treatment variances presented in our study shed light on the number of teeth requiring treatment but do not advise on the type or extent of treatment estimated for each patient and the accuracy of estimation. As pediatric dental treatment under general anesthesia can vary from a simple one-surface restoration to pulpal treatment with full coverage restorations, our study does not provide a detailed understanding of the treatment needs of these patients. We also could not 41 assess DMF on each tooth since clear visualization of the teeth was often not possible, even with in-person examinations. Finally, as this study is limited to the BC Children’s Hospital dental clinic, there may be a limitation to the generalizability of the findings. Community pediatric dental offices always have patients who are coming from long distances, especially in the interior, northern BC, and Vancouver Island. There is a code for remote assessment that can be used for such virtual consultations (08011), so with the dissemination of these findings, there may be wider uptake across the province and across Canada. 5.3 Future Research Our study contributes to the growing evidence that provides opportunities for the implementation of telehealth into medical and dental practices. Extensions of the study are to examine the radiographs provided by dentists to see how this piece of information affect treatment plan accuracy. In place of estimated versus actual skin-to-skin time comparisons, the estimated versus actual cost could be used as a tool in assessing accuracy. It is possible that cost estimates will provide more continuous data than skin-to-skin times for the case. In our study, booking time for cases is completed in 15-minute blocks, which lacks some accuracy. Cost of treatment can capture the actual number of teeth and types of restorations required. Future research can involve a controlled, prospective study design to help avoid some of the limitations of a retrospective design. Another modification for the future is to improve photograph quality by recruiting health care providers to take standardized photographs. Finally, we encourage other facilities that see pediatric patients for treatment under general anesthesia to participate in a replicate study in the private practice setting. Such practice-based research would 42 provide more real-world data applicable to the specialist in the community and help more families experience the benefit of telehealth visits. 43 Chapter 6: Conclusion Our findings highlight that the children who present to BCCH-DC are more likely to be male, less than 7 years old, and present with 1 or 2 co-conditions. In addition, these patients are more likely to have an ASA classification of I or II and utilize in person visitation as the main modality of consultation. Families who did utilize virtual dental consultations lived significantly farther from BCCH than those who opted for in person consultations. Furthermore, our study highlights that there were no significant differences in the accuracy of estimated skin-to-skin times and estimated number of teeth treated that were made in virtual or in person dental consultations. Virtual dental consultations can be effective for planning pediatric dental treatment under general anesthesia, particularly for children who live farther away. Furthermore, we conclude that caregiver obtained photographs are beneficial, but not essential for treatment planning during virtual dental consultations. By addressing the chief complaint, obtaining a detailed dental history provided by the caregiver, and considering the age of the child, experienced pediatric dental specialists can make an accurate prediction of how many teeth require treatment and how much time the treatment will require. 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Thesis/Dissertation
eng
Craniofacial Science
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Richman, Joy M.
A comparison of in-person versus virtual health consultations for full mouth rehabilitation in pediatric dental patients
Text