Telemedicine consulting in the patient preparation and planning of prosthetic tooth replacement

Introduction. In the management of edentulous spaces, there is a permanent need of a dentist-prosthetician in charge to consult other specialists. Modern telemedicine, based on powerful computer and telecomunication systems, offers an adequate answer to these challenges, being able to transfer and obtain clinical data and consultation information over large distances. Using smartphone or a computer, the teleconsultant acces the system, downloads and review the data and photographs and gave suggestions. The system then enables direct, real time contact with the consultant, chat, or directs them to contact each other by phone. Case report. We presented telemedicine consulting in the patient preparation and planning of prosthetic tooth replacement in 3 cases with different teleconsultation requirements: the first case for prosthetic rehabilitation of his upper teeth, the second one for prosthetic management of his partial edentulousness and “a growth on his gums” in the vestibular region of the frontal teeth and the third one for prosthetic management of total edentulousness of her upper jaw. We used the system of telemedicine in dentistry, established at the Faculty of Medicine in Kosovska Mitrovica. The operation was based on the computer application system XPA3 Online, computer networking and mobile smartphone network. All consultations were succefull with no need for further procedures in regional center. Conclusion. The use of a mobile smartphone has brought about the mobility and availability of teleconsultant specialists in an extent never seen before. Prostheticians are thus able to offer better service to their patients and improve the quality of management of partially or totally edentulous patients, especially in rural areas.


Introduction
Nowadays, in the era of intense development of medicine, the need for the opinion of other experts about the patient problem at hand is an everyday necessity.More people (and more eyes) involved, focused experience of a larger body of experts, and problem solving from the point of view of different specialties, enable realization of long desired simpler and high quality patient management.This is especially the case in insufficiently clear or ambiguous situations.Based on the use of sophisticated computer and communication technology, it is able to offer an effective specialist consultation, to reduce overall costs, and to broaden the scope of dentistry health care to encompass the whole world, including inaccessible regions 1 .
On the other hand, in spite of ever growing needs for such methods in dentistry, they are being utilized much less compared to medicine 2 .The reason for such a situation is the absence of an adequate regional or national center for processing and coordination of consultations.
Our system of telemedicine in dentistry is based on the formation of a telemedicine center at the Faculty of Medicine University of Priština Kosovska Mitrovica.The operation is based on the computer-medicine application system XPA3 Online, and a wide availability of computer networking and mobile smartphone network.The procedure implies permanent availability of professionals of almost all specialties in the telemedicine center of this University.Always alert specialists carry with them their smartphone devices or they have Internet access in their immediate surroundings.If a dentist need some specialist consultation, he/her collects relevant clinical and patient history information according to the adopted procedure, takes digital photographs, targeted radiographs, and orthopan tomography, and logging onto the system site uploads the information to the central server.He/her can choose the consultant personally or requests specialist consultation of any available teleconsultants.Emergency of the request can also be determined as low, normal, or high urgency consultation.The central server looks for the available specialists and place calls or sends them SMS information about the received request for teleconsultation, stating the topic of the request and number of accompanying digital files.Using smartphone or a computer access point, the teleconsultant logs on the system, downloads and review the data and photographs.Immediate review is also possible, as well as suggestions and counseling of the dentist requesting consultation, and the reply is posted on the central server.The system then informs the requester of teleconsultation about the received reply, enabling also a direct, real time contact with the consultant, chat, or directs them to contact each other by phone.The requester receives the reply, possibly with schemes and photographs.
The aim of this paper was to present telemedicine consulting in the patient preparation and planning of prosthetic tooth replacement.

Case reports
The following cases could illustrate the use of this technology.

Case 1
A 67-year-old male patient contacted his dentist.in Belgrade for prosthetic rehabilitation of his upper teeth.Since the observed status of the teeth was not clear enough, the dentist decided to request a specialist consultation with the specialists in dentistry prosthetics, oral surgery, and endodontics, via the Teledentistry Center of the University of Priština Kosovska Mitrovica.Digital intraoral photographs were taken from different angles and aspects, and already made retroalveolar radiographs were digitalized.After accessing the Internet and opening of www.XPA3.comdomain, authentication and authorization of the dentist were made by the XPA3 Online system, enabling the formation of a new request for teleconsultation.The request was filled in, available clinical and anamnestic data about the patient and his disease were described, and accompanying files were uploaded to the system.The request was then sent.The system instantly informed available teleconsultants, who had 24 h at their disposal to give their opinion and suggestions.Teleconsultants reviewed the received request on their laptops, analyzed the problem and send their reply via the system (Figures 1 and 2).The dentist received the responses, and based on the teleconsultation advice and suggestions, successfully managed his patient both preprosthetically and prosthetically.

Case 2
A 52-year-old, male patient, visited his dentist in the Serbian enclave in Kosovo and Metochia for prosthetic management of his partial edentulousness and "a growth on his gums" in the vestibular region of the frontal teeth.The patient was partially immobile due to his right leg fracture and very concerned about the appearance of this tumor.Since the transport to the appropriate specialist was additionally complicated by bad weather, the dentist sent an emergency request for teleconsultation via the XPA3 Online system of the telemedicine center, using a dial-up Internet connection.After the receipt of the request, the application software of the system effectuated teleconsultation with the adequate specialist (in oral surgery) for instant data review.The teleconsultant, using his smartphone and General Packet Radio Serbice (GPRS) Internet connection, downloaded the consultation data, and based on the available information, photographs, and radiographs, made a distant clinical diagnosis of epulis (a benign lesion situated on the gingiva) (Figures 3 and 4).The consultation was completed in the requested period (4 h), including re-consultations with another three specialists of oral surgery who achieved a full agreement about the diagnosis of Giant cell epulis (K06.8) and suggested surgical removal.The patient was completely managed in the period to come, with histopathology confirming the distant clinical diagnosis.

Case 3
A female patient, aged 48 years, came to the Department of Dentistry Prosthetics of the Dentistry Clinic in Niš for prosthetic management of total edentulousness of her upper jaw.Since the presence of atypical uneven spots, such as osseous and soft tissue exostoses and plicae, was significant, the therapist required specialist consultation of another specialist in dentistry prosthetics and a specialist in oral surgery.Fifteen digital photographs were taken, out of which twelve showed intraoral status of the ridge in vestibular, occlusal, and palatinal views, three photographs showed the face en face, left, and right profile.The photographs, with the accompanying comments, clinical finding, description of the required suggestions, and digital orthopan file, were posted on the central server (Figure 5).The application algorithm found the available specialists in the relevant fields and immediately contacted them.Based on this telemedicine consultation, the patient was successfully managed with minimal surgical preprosthetic preparation.

Discussion
A huge advance has been made in the sphere of telecommunication technology and computers, enabling rapid and effective medical consultations at large distances.The presence of wireless data transfer at high speeds, WCDMA and HSPA technologies with standard speeds of 7.0 Mbps within mobile phone network providers, as well as widespread use of smartphone devices with powerful operation systems and rapid processors, enabled patient review and examination at almost any place and at any time.Pretreatment consultation, consultation during the treatment, and post-treatment consultation are becoming a standard for any patient in an insufficiently clear situation.
It has been a customary practice so far that such consultations are initiated and effectuated through e-mail in case of Store and Forward technology or through direct streaming of binary information in case of Real Time consultation 3 .However, e-mail transfer of information has an important flaw if photographs or accompanying files are numerous and have to be downloaded and reviewed one by one; in order to eliminate the flaw, Aziz and Ziccardi 4 have suggested that files should be merged into one PowerPoint presentation and transferred as a single file to be opened and read by smartphone devices or computers.The finding of ours was that these shortcomings could be completely eliminated by the use of telemedicine central application XPA3 Online as an intermediary between the dentists and their teleconsultants.The application itself performs the listing and clinet download of the files to smartphone devices or computer Internet browsers.
A dentist-prosthetician, in the planning of an intervention usually consults an endodontist or oral surgeon in insufficiently clear clinical situations.In these cases, a phone call has been the traditional method of requesting and starting a consultation; patient referral and sending of medical documentation to both specialists then usually followed.If the patient could not be transported, the conclusion has been based only on the verbal description of the case.The University Center of Telemedicine in Kosovska Mitrovica here provides prostheticians and patients with a means of accurate data transfer and review of the data by the requested specialists, enabling them too to make an instant patient appointment for the necessary intervention.The method is conditioned only by having a personal computer or smartphone device at disposal, both with Internet access.Not only that this enables appropriate specialist consultation to be made, but also the requesting of teleconsultant opinion regardless of his whereabouts.In oral surgery, telemedical solutions have been demonstrated in the field of diagnosis and treatment planning for impacted third molars based on a similar principle of using a central server which coordinates teleoral surgeons 5 , and the issue of chronic periapical processes can be elucidated using teleendodontics without any statistically significant difference between the actual clinical conditions and via the Store and Forward method at a distance [6][7][8][9] .
Apart from the role in pretreatment period, distant consultations in dentistry prosthetics have a vital role in the manufacturing of fixed or mobile replacements, with distant planning of the architecture of skeletonized prosthesis, superstructure of dental implants, design of inlays, onlays, and mini-bridges using the CAD/CAM technology, and correction of the angle of tooth ablation [7][8] .
In the posttreatment period, such a telemedicine method enables a dentist-prosthetician to get an insight into the possible problems in patients who are no longer present at the dental clinic.A prosthetician is able to inspect the mouth cavity for possible changes reviewing the relevant photographs, to detect changes or damage to the replacement surface, esthetic or functional disorders or shortcomings, occlusal problems, and may also examine posttreatment radiographs.A patient himself can contact his prosthetician and explain to him visu-ally the posttreatment situation which causes discomfort or dissatisfaction (e.g., a diastema between the frontal teeth) 4 .A patients may himself take photographs of the spot of irritation with his prosthetic replacement and send them to the dentist using video teleconsultation service 10 .
The first author of this paper had received from a previously unseen patient the photograph of irritation as the result of inadequate upper total prosthesis, representing epulis fisuratum, after which the diagnosis was confirmed and clinically managed.

Conclusion
The utilization of telemedicine methods in dentistry prosthetics is a rapid and effective way of getting a necessary specialist consultation.These methods should be widely available and appropriately supported both technically and technologically by the system for management and coordination.The necessary preconditions for that are already in place, above all the technology of digital photography, radiography, and widely spread Internet access.The expansion of mobile smartphone technology significantly contributes to the mobility and wide availability of the methods.Our own task is to work to improve the education of both professionals and their patients and to offer appropriate training.In this way we can all contribute to the improvement of dental care of our patients in the domain of dental prosthetics.

Fig. 5 -
Fig. 5 -Data input, preparation of telemedicine consultation and input of 16 digital pictures showing serious osseous and soft tissue exostoses of upper alveolar ridge.