Accuracy of Telemedicine Consultations in Oral and Maxillofacial Surgery During the COVID-19 Pandemic.

PURPOSE: Telemedicine has been an emerging trend over the past few years and has seen an exponential rise due to the COVID-19 pandemic. The purpose of the present study was to determine the accuracy of planned oral surgery treatment for patients seen initially by telemedicine in the department of oral and maxillofacial surgery during the pandemic.
METHODS: This was a retrospective cohort study. Record review of all patients who received telemedicine consultations during the pandemic time frame of March 1, 2020, to March 1, 2021, was performed. The primary outcome was to confirm the accuracy of the planned oral surgery treatment. Accuracy was defined as the ability to conduct the planned surgery with chosen anesthesia (local anesthesia, valium + local anesthesia, intra venous sedation, general anesthesia) at the immediate follow-up appointment without the need for further preoperative testing, evaluation, and consultation. The secondary outcomes were to determine the change in surgical plan, anesthesia plan, and medical plan. Predictor variables included age at the time of telemedicine consultation, gender, race, ethnicity, and the type of consult. Descriptive statistics and logistic regression analysis were executed.
RESULTS: The study sample comprised 286 (64.56%) females and 157 (35.44%) males. The age range of the study population was 9 to 92 years, with a mean age of 33.88 years (standard deviation = 16.29 years). In the cohort of 443 patients who obtained telemedicine consultations, 98.19% were successfully treated at the following appointment. Four hundred thirty-one (97.3%) out of the 443 telemedicine consults were pertaining to dentoalveolar concerns. Logistic regression analysis showed that neither age nor gender has significant effects on the change of surgical and anesthesia plans.
CONCLUSIONS: Telemedicine can be effectively utilized in performing consultations for routine oral surgical procedures, especially dentoalveolar surgeries. Besides, a preoperative assessment to determine anesthesia and setting of care can also be determined during telemedicine consultations. However, given the lack of control group and the observational nature of this study, the results must be interpreted with caution.

Introduction

The worldwide pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has enhanced the use of telemedicine across many disciplines in medicine and dentistry. Virtual consultations have not only helped preserve medical resources including personal protective equipment (PPE) but have also assisted in reducing the risk of exposure to the patients and health care providers, while maintaining patient’s access to care. , Additionally, telemedicine has also played a role in caring for patients who reside in rural and underserved areas, assisted and senior living facilities. , Other advantages include saving medical transportation costs and travel time not only for the patient but also for caregivers. Owing to these benefits, telemedicine has evolved across multiple specialties, including oral and maxillofacial surgery, as a valuable tool for providing patient care.

Telemedicine was already in use by oral and maxillofacial specialists prior to the COVID-19 pandemic; however, it was not as prevalent as it is now. Several studies have supported the use of telemedicine in oral and maxillofacial surgery during the pandemic. The majority of these studies were clinician and patient satisfaction surveys.6, 7, 8, 9

The purpose of this study was to determine the accuracy of planned oral surgery treatment for patients seen initially by telemedicine in the department of oral and maxillofacial surgery during the COVID-19 pandemic. Accuracy was defined as the ability to conduct planned surgery with chosen anesthesia [local anesthesia (LA), valium + LA, intra venous (IV) sedation, general anesthesia (GA)] at the immediate follow-up appointment without the need for further pre-operative testing, evaluation, and consultation. The investigators hypothesized that the telemedicine consultations are accurate when planning oral surgery treatment. The specific aims of the study were to measure the accuracy of planned oral surgery treatments with respect to the change in surgical, anesthesia and medical plans.

Materials and Methods

Study Design

To address the research purpose, the investigators designed and implemented a retrospective cohort study. This study was approved by the University of Rochester Research Subject Review Board (STUDY00005871). The study population was composed of all patients who received telemedicine consultations from the department of oral and maxillofacial surgery during the pandemic time frame of March 1, 2020 – March 1, 2021. Patient charts were accessed through the hospital’s electronic health records. To be included in the study sample, patients had to obtain a telemedicine consultation, finish a post-consultation visit, with completed records. No restrictions on age, gender, race, and ethnicity were placed. Patients were excluded, if the tele-medicine consultation did not result into a post-consultation visit and if they had incomplete records.

Workflow Employed for the Tele-Medicine Consultations

The tele-medicine consultations were performed by the first-year residents and non-categorical interns under the supervision of the attending in the department of oral and maxillofacial surgery. The consultations in the form of zoom video visits were scheduled for 30 minutes duration anytime from 8:30 am to 4 pm, Monday through Friday. The visits were scheduled upon receiving appropriate referral and imaging required for the consultation. The residents were initially directly supervised for the entire length of consultation and when merited to perform consultations properly were allowed to progress to perform majority of the consults by themselves with the attending joining in the last ten minutes to review the imaging, diagnosis and the treatment plan, and to clarify or answer any questions. The order and set of questions asked during the tele-medicine consultations were no different than the in-person consultations. Next, the airway exam consisted of the examination of neck mobility, range of motion, and maximal incisal opening. Patients were asked to keep their mouth wide open, with protruded tongue and phonate, to visualize their uvula and faucial pillars. Patients were also asked to show their profile view to assess for the thyromental distance. After history taking and examination, patient’s imaging sent over by the referring provider was reviewed with the patient utilizing the share screen mode on the zoom platform. The referral, patient’s examination and imaging findings were tallied to form a diagnosis. Based on all the available information, a treatment plan was formulated. Patient was then explained risks, benefits, and alternatives of the procedure. Additional treatment related instructions were provided. After the completion of zoom video visit, patients were scheduled for a procedure by our staff members.

Study Variables

The predictor variables in this study included the age at the time of telemedicine consultation, gender, race, ethnicity, and the type of consult. The primary outcome variable of the present study was to confirm the accuracy of the planned oral surgery treatment for patients seen initially by telemedicine in the department of oral and maxillofacial surgery during the COVID-19 pandemic. Accuracy was defined as the ability to conduct planned surgery with chosen anesthesia (LA, valium + LA, IV sedation, GA) at the immediate follow up appointment without the need for further pre-operative testing, evaluation, and consultation. The secondary outcome variables were to determine the change in surgical plan, change in anesthesia plan and change in medical plan.

Data Collection and Data Analysis

Information on the variables mentioned above was entered in an excel data sheet and transferred to SAS for the data analysis (SAS version 9.4, Cary, NC). Descriptive statistics were obtained to characterize the study variables. Multiple logistic regression with backward model selection was used to study the association between each outcome and some covariates of interest, such as age, gender, race, ethnicity, and type of consult. Statistical significance was set at 0.05.

Results

A total of 443 patients met the inclusion criteria for the retrospective record review and data analysis. As presented in Table 1 , the study sample comprised of 286 (64.56%) females and 157 (35.44%) males. The age range of the study population was 9 to 92 years, with a mean age of 33.88 years (standard deviation [SD] = 16.29 years). As shown in Table 2 , 431 (97.3%) out of 443 telemedicine consults were pertaining to dentoalveolar concerns. Logistic regression analysis shows that neither age (odds ratio [OR] 1.013, 95% CI 0.998-1.029, p=0.0930) nor gender (OR 0.647, 95% CI 0.376-1.113, p=0.1156) has significant effects on the change of surgical plan ( Table 3 ). Similarly, neither age (OR 0.979, 95% CI 0.950-1.010, p=0.1804) nor gender (OR 0.523, 95% CI 0.221-1.238, p=0.1406) has significant effects on the change of anesthesia plan ( Table 4 ).

Table 1

Descriptive Statistics: Age, Gender and Race Distribution of the Study Cohort

Age
N	Mean	Std Dev	Median	Minimum	Maximum
443	33.88	16.29	29	9	92
Gender
Gender		Frequency		Percent
Female		286		64.56
Male		157		35.44
Race
Race		Frequency		Percent
Asian		5		1.13
Black		93		20.99
Native		3		0.68
Other		18		4.06
Unknown		90		20.32
White		234		52.82

Table 2

Type of Consults Performed Utilizing Telemedicine

Type of Consult/Diagnosis
Type of Consult/Diagnosis	Frequency	Percent
Dentoalveolar	431	97.3
Orthognathic	1	0.23
Pathology	3	0.69
TMJ	6	1.35
Trauma	2	0.45

Table 3

Results of the logistic regression analysis of change of surgical plan

Odds Ratio Estimates
Effect	Point Estimate	95% Confidence interval		P-value
Age	1.013	0.998	1.029	0.0930
Gender F vs M	0.647	0.376	1.113	0.1156

Table 4

Results of the logistic regression analysis of change of anesthesia plan

Odds Ratio Estimates
Effect	Point Estimate	95% Confidence interval		P-value
Age	0.979	0.950	1.010	0.1804
Gender F vs M	0.523	0.221	1.238	0.1406

Change in Surgical Plan

Change in the surgical plan was noted in 63 (14.22%) out of 443 patients. However, none of these patients were rescheduled or cancelled on the day of surgery. The changes in the surgical plan were minor. Addition of non-restorable and impacted teeth was noted in 32 patients. Deletion of teeth that appeared restorable and the patient expressed getting them restored was reported in ten patients, the non-restorable teeth were extracted, and patient’s visit was completed. 14 patients did not want all four 3rd molars extracted at the same time and therefore phased treatment was performed as per patient’s desire. The reasons for the change in surgical plan are documented in table 5 .

Table 5

Change in Surgical Plan

Number of Patients	Reason for Change in Surgical Plan
32 patients	Addition of non-restorable and impacted teeth
2 patients	Deletion of alveoloplasty quadrants
1 patient	Bone grafting after the extraction was not performed due to financial concerns
10 patients	Deletion of teeth that appeared restorable and patients expressed getting them restored, the non-restorable teeth were extracted, and patient’s visit was completed
14 patients	Patients did not want all four 3rd molars extracted at the same time and therefore phased treatment was performed as per patient’s desire
2 patients	Underwent biopsy in addition to the planned treatment
1 patient	Bilateral arthrocentesis as opposed to just the right side
1 patient	Underwent maxillary labial frenectomy in addition to the planned treatment

Change in Anesthesia Plan

Change in the anesthesia plan was noted in 22 (4.97%) out of 443 patients. The reason for a change in anesthesia plan is documented in table 6 . The anesthesia plan of 11 out of 22 patients was changed from IV to LA due to pregnancy, financial restrictions, inability to arrange an escort, several unsuccessful IV attempts, and elevated blood pressure. The anesthesia plan of 5 out of 22 patients was changed from IV to GA due to several medical reasons and anticipated surgical difficulty of the procedure as described in table 6.

Table 6

Change in Anesthesia Plan

Number of Patients	Reason for Change in Anesthesia Plan
11 patients were changed from IV to LA	3 patients were pregnant1 patient had financial restrictions1 patient had elevated blood pressure for IV sedation1 patient couldn’t arrange for an escort1 patient: we were unsuccessful in placing IV and after several attempts the procedure was converted into LA4 patients: the reason was not documented
5 patients were changed from IV to GA	1 patient: it was determined that the inferior alveolar nerve was riding higher up in between teeth roots of # 32 and the procedure would be better performed in operating room1 patient had an esophagogastroduodenoscopy scheduled with gastroenterology service at our hospital and requested for a combined oral surgery procedure.1 patient: after the ASA monitors were placed, we noted bradycardia with heart rate in low 30s. We decided to not proceed with sedation and referred him to a cardiologist for further work up.1 patient reported seven seizures a day prior to the presentation for sedation.1 patient was extremely aggressive during IV placement and due to safety concerns, we re-scheduled the procedure to be performed in the operating room.
2 patients were changed from LA to IV	Reason not documented.
1 patient was changed from GA to IV	Due to the operating room cancellation during the COVID-19 patient surge at our hospital.
1 patient was changed from LA to GA	This patient was extremely anxious, couldn’t have tolerated the procedure under LA and was not a sedation candidate.
1 patient was changed from GA to Valium	As the patient wanted a sooner appointment.
1 patient was changed from IV to Valium	The patient’s covid test was old and had to get a new test performed as per the hospital protocol. The patient didn’t want to remain NPO until the results of covid test were final. We accommodated the patient under LA and Valium later in the day.

Change in Medical Plan

No change in the medical plan was recorded in 443 patients.

Discussion

The purpose of this study was to determine the accuracy of planned oral surgery treatment for patients seen initially by telemedicine in the department of oral and maxillofacial surgery during the COVID-19 pandemic. Accuracy was defined as the ability to conduct planned surgery with chosen anesthesia [local anesthesia (LA), valium + LA, intra venous (IV) sedation, general anesthesia (GA)] at the immediate follow-up appointment without the need for further pre-operative testing, evaluation, and consultation. The investigators hypothesized that the telemedicine consultations are accurate when planning oral surgery treatment. The specific aims of the study were to measure the accuracy of planned oral surgery treatments with respect to the change in surgical, anesthesia and medical plans. The study findings revealed 98.19% (435 out of 443) of patients could undergo their procedure at the immediate appointment following a tele-medicine consult.

Results from the current study generated several outcomes. First, a change in the surgical plan was noted in 63 (14.22%) out of 443 patients. Although the percentage was relatively high, the change in the surgical plan was minor, including the addition or deletion of the teeth for extraction, performing phased treatment, addition of a biopsy to the plan, and addition of the laterality for arthrocentesis. It is important to note that none of these patients whose treatment plan was changed were rescheduled or cancelled on the day of surgery as described under the results section. Second, a change in the anesthesia plan was noted in 22 (4.97%) out of 443 patients. Out of 22 patients, only eight patients were unable to get the procedure on the planned surgery date, and 98.19% (435 out of 443) of patients could undergo their procedure at the immediate appointment following a tele-medicine consult. Third, no change in the medical plan was recorded in 443 patients.

Our results indicate that telemedicine can be very effectively utilized in performing consultations for routine oral and maxillofacial surgery procedures, especially dentoalveolar surgery. Telemedicine was already in use for oral and maxillofacial surgery prior to the COVID-19 pandemic to improve access to patients in remote locations. Rollert et al. studied 35 patients retrospectively to estimate the effectiveness of telemedicine consultations for pre-operative assessments. In their study, efficiency was defined as the capability to complete the surgery with general anesthesia at the immediate following appointment without the need for additional pre-operative testing, evaluation, or consultation. The authors noted that 33 out of 35 (94%) patients were able to successfully undergo surgery with general anesthesia at the immediate appointment following consultation via telemedicine. In a separate follow-up retrospective study by Wood et al. of 335 patients over a 6-year period, authors found telemedicine consultations were successful 92.2% of the time in utilizing the data obtained to formulate a diagnosis and treatment plan. Furthermore, patients were identified accurately 99.6% of the time for the clinic or hospital operating room setting. This result is consistent with the present study that noted 98.19% of the patients could undergo their procedure at the immediate appointment following a tele-medicine consult. The present study investigated the accuracy of planned oral surgery treatment for patients seen initially by telemedicine in the department of oral and maxillofacial surgery during the COVID-19 pandemic and is similar to the study performed by Wood et al., who measured the efficiency and reliability of telemedicine consultations for preoperative assessment of patients.

A comparative study conducted by Champion et al. enrolled a total of 69 patients who were randomized into either in-person group or telemedicine group for post-operative care after their third molar surgery. Following their post-operative visit, patients were administered a satisfaction survey questionnaire. The authors noted no statistically significant difference between the satisfaction scores of the two groups. However, patients in the telemedicine group reported statistically significant increased satisfaction pertaining to cost effectiveness as they did not incur travel expenses and parking costs. Additionally, the telemedicine group did not have to take time off from work and was able to save the opportunity costs.

Several studies have supported the use of telemedicine in oral and maxillofacial surgery during the pandemic. The majority of these studies were clinician and patient satisfaction surveys.6, 7, 8, 9 A survey study conducted by Al-Izzi et al. amid COVID-19 pandemic to assess clinician and patient desire and willingness for virtual consultations in maxillofacial surgery concluded that teleconsultations were well accepted by all clinicians. Additionally, they also noted that 149 out of 151 (98.7%) were able to complete planned treatment based on the working diagnosis established during the virtual consultations. This result is consistent with the present study. However, Al-Izzi et al. carried out their study during the pandemic over a short period of time, and their sample size was very small.

Telemedicine has been used in other areas of oral and maxillofacial surgery and has proven successful. It’s application in diagnosing of maxillofacial fractures through teleradiology has shown promising results. A study performed by Brucoli et al. triaged 467 facial trauma patients over four years utilizing telemedicine system from peripheral hospitals to correctly refer them to maxillofacial trauma hub center. The authors noted teleradiology allowed for an exchange of information between the specialists at the trauma hub center and their colleagues at a local peripheral hospital, thereby providing an effective way of completing remote consultations. In the present study, 431 (97.3%) out of 443 telemedicine consults were pertaining to dentoalveolar concerns. Only two patients with maxillofacial trauma were seen for a consultation via telemedicine. One patient had left mandibular angle fracture and the other patient had bilateral displaced nasal bone fractures. Both patients were appropriately triaged and treated by our service in the operating room.

Telemedicine has been used effectively in the management of the temporomandibular joint disorders. A multicenter, non-randomized clinical study conducted by Salazar-Fernandez et al. included 710 patients with temporomandibular joint disorders in the standard group and 342 in the telemedicine group. From the telemedicine group, only 35 (10%) patients presented with TMJ pathology that required maxillofacial surgery. The remaining 307 (89.7%) received non-surgical treatment in the primary care center via high-resolution consultations. In the present study, only six patients with temporomandibular joint dysfunction were seen via telemedicine. All six patients were diagnosed correctly, and their MRI findings were discussed utilizing telemedicine. All six patients were surgical candidates and were appropriately treated following their telemedicine appointments.

A possible impediment to a broader application of telemedicine is the reimbursement for the providers. To address this concern Nadella et al. performed a study in which the authors reviewed the reimbursement rates of 6,082 submitted claims for the telemedicine and in-person visits in an academic oral and maxillofacial surgery practice. The authors found mean reimbursement per insurance payor was $98.07 for a telemedicine visit. Their study results suggested that there were no major differences in the financial reimbursement rates between telemedicine and in-person office visits. The average reimbursement for a telemedicine consultation by the insurance payors in our study was $63.80. A potential reason for this difference could be varying reimbursement policies between states and by payors. Future studies can compare the reimbursement rates between diverse insurance providers and amongst different states across the United States.

The present study has a few limitations. First, lack of a control group that received in-person consultations. Second, the majority of the telemedicine consultations were performed for dentoalveolar concerns. Third, only patients who obtained telemedicine consultations and had finished a post-consultation visit were included in the study. Therefore, this study sample did not include patients who had difficulty utilizing the tele-medicine system. Finally, this was a retrospective study, and there was some missing information in the electronic record pertaining to reasons for the change in anesthesia plan for a few patients. Despite these limitations, this study brings its own significance as it determined the accuracy of planned oral surgery treatment for patients seen initially by telemedicine in the department of oral and maxillofacial surgery during the COVID-19 pandemic. Limitations notwithstanding, our study included a relatively large cohort of patients who obtained telemedicine consultations, and 98.19% were successfully treated at the following appointment.

Conclusion

The use of telemedicine has become widespread since the onset of the COVID-19 pandemic. The results of this study suggest that telemedicine can be very effectively utilized in performing consultations for routine oral and maxillofacial surgery procedures, especially dentoalveolar surgery. Besides, pre-operative assessment to determine anesthesia and setting of care can also be determined during telemedicine consultations. Future studies should emphasize on utilizing a control group of in-person consults to compare the accuracy between the two groups.