Per the notice below, the New York State Education Department (NYSED) has issued practice guidelines for the use of teledentistry.

New York State Teledentistry Guidelines

As recommended by the New York State Board for Dentistry

Advisory Notice: The following advisory constitutes a general discussion of the issues that may arise when a licensee provides professional services.  The discussion is intended to alert practitioners to questions and concerns that they may want to consider with their legal counsel, if necessary, and are not to be construed as a directive or other requirement to take any particular action.  The Advisory cannot be used as the basis for a charge of professional misconduct.  The statements are generally based upon statutory and regulatory provisions relating to the practice of dentistry, but are not legal interpretations of any of these provisions.  The citations to the provisions of law, regulation, and Regents Rules are included to add clarity to the discussion.

What is Telepractice?

Telepractice is defined as the provision of professional service over geographical distances by means of modern telecommunications technology.  This generic term includes, for example, telehealth, teletherapy, teledentistry, telemedicine, telenursing, etc.  Telepractice is used by many professionals in a growing number of areas including, but not limited to, health care (telehealth).  These professional services may include communications between a practitioner and a patient or a practitioner and designated caregiver, as well as practitioner-to-practitioner consultation and conferencing.  Examples of technologies that may be used to provide these services are telephones, including cellular devices, e-mail, instant message, video chat, and the computer applications or portals used to facilitate these modes of communication.  Telepractice may also include the keeping of electronic medical records or EMRs.

In accordance with New York State statute, full licensure and current registration are required of any professional who practices in New York State, unless specifically suspended or waived pursuant to an Executive Order issued by the New York State Governor during a disaster emergency.  All New York State licensed professionals are responsible for adhering to the same laws, rules, and regulations and for upholding the same standards and competencies when engaging in telepractice as they are when practicing without the use of technology over a distance.

Teledentistry refers to the use of telehealth systems and methodologies in dentistry.  The delivery of services via teledentistry must comply with all laws, rules, and regulations in New York State.  Including, but not limited to NYS Education Law, Title VIII, Art. 133; 8 NYCRR Part 61 and Part 29 of the Rules of the Board of Regents.  The same standards that apply to all forms of dental practice apply to teledentistry, including all ethical considerations.  The benefits of teledentistry for patients of New York State and for all patients, are increased access to care and reduced or contained treatment costs.  The benefits to the dental profession are reduced disparities in treatment between urban and rural areas, and access to second opinions, preauthorization, and other insurance requirements to help improve outcomes.

Teledentistry Issues

Teledentistry should be considered a modality and applied only as appropriate to address the patient's needs.  In order to engage in teledentistry in an effective, safe, and legal manner, licensed dentist and licensed dental hygienist providers should consider the following:

A.  Licensure Requirements:

1.  A dentist or dental hygienist using teledentistry to practice dentistry on patients in NYS must be licensed and currently registered to practice dentistry or dental hygiene in New York State and must provide proof of identity, jurisdiction and licensure status to the patient.
2.  Education Law §6610 provides for the following exemptions related to licensing requirements:
   • A dentist or a dental hygienist licensed in some other state or country from making a teaching clinical demonstration before a regularly organized dental or medical society or group, or from meeting licensed dentists in this state for consultation, provided such activities are limited to such demonstration or consultation.
   • A dentist licensed in another state or country who is employed on a full-time basis by a registered dental school as a faculty member with the rank of assistant professor or higher from conducting research and clinical demonstrations as a part of such employment, under the supervision of a licensed dentist and on the premises of the school.  No fee may be charged for the practice of dentistry authorized by this subdivision.
   • A dentist licensed in another state or country who is visiting an approved dental school or any other entity operating a residency program that has been accredited by a national accrediting body approved by the department to receive dental instruction for a period not to exceed ninety days from engaging in clinical practice, provided such practice is limited to such instruction and is under the direct supervision of a NYS licensed dentist.
3.  All dentists, providing consulting services, whether licensed in NYS or in another jurisdiction, must have a valid dental license to practice within the state they are consulting from, abide by competency requirements and have sufficient knowledge of dentistry laws, rules, and regulations of the state where a patient resides.

 B.  Teledentistry Provider Responsibilities

When practicing teledentistry:

• The teledentistry health care provider may provide any treatment deemed appropriate for the patient within their scope of practice, including prescriptions, if the evaluation performed is adequate to justify the action taken.  The health care provider is responsible for knowing the limitations of the care he or she can provide, no matter how the care is delivered.  Just as in a traditional setting, teledentistry dentists should recognize situations that are beyond their expertise, their ability, or the limits of the available technology to adequately evaluate or manage the existing circumstances, and to refer such patients for appropriate care.  The evaluation performed must be adequate to justify the action.
• The relationship for teledentistry should mirror those parameters that would be expected for similar in-office dental encounters.  The relationship between a teledentistry health care provider and patient are based on a mutual understanding of their shared responsibility for the patient's oral health care and is established when the dentist agrees to undertake diagnosis and/or treatment of the patient and the patient agrees that the dentist will diagnose and/or treat, whether or not there has been or is an in- person encounter between the parties.
• The dental provider should establish a practitioner-patient relationship with the patient.  The absence of in-person contact does not eliminate this requirement.
• The dental provider should make appropriate effort to confirm the patient's identity and location.
• The dental provider should confirm and document that the patient is physically located in a jurisdiction in which the dentist is licensed.
• The dental provider should make appropriate efforts to confirm that the minor's parent or legal guardian is present when required.
• The dental provider may delegate allowable tasks to New York State licensed dental hygienists through teledentistry such as taking and transferring images and performing procedures that fall under general supervision.
• The dental provider should not directly or indirectly engage in false, misleading, or deceptive advertising of teledentistry services.
• There will be no allowance for fee-splitting through the use of teledentistry services.
• The delegation of tasks through teledentistry must be under the general supervision of a NYS licensed and registered dentist.  Specifically, pursuant to NYS Education Law §6606, the practice of dental hygiene may be conducted in the office of any licensed dentist or in any appropriately equipped school or public institution but must be done either under the supervision of a licensed dentist or, in the case of a registered dental hygienist working for a hospital as defined in article twenty-eight of the public health law.  Pursuant to a collaborative arrangement with a licensed and registered dentist who has a formal relationship with the same hospital in accordance with regulations promulgated by the department in consultation with the department of health.  Such collaborative arrangement shall not obviate or supersede any law or regulation which requires identified services to be performed under the personal supervision of a dentist.  When dental hygiene services are provided pursuant to a collaborative agreements, such dental hygienist shall instruct individuals to visit a licensed dentist for comprehensive examination or treatment.
• Teledentistry does not meet the definition of personal supervision when the dentist is not physically present.
• All providers are responsible for knowing the limitations of the care he or she can provide, no matter how the care is delivered.
• Dental hygienist providers are allowed to originate a teledentistry session in collaboration with a Dentist.

C.  The Role of the Dental Hygienist in Teledentistry

The dental hygienist can be instrumental in identifying areas of concern to help determine the need for asynchronous or synchronous care, or determine the potential need to disqualify teledentistry and to recommend a face to face interaction with a dentist.

1.  Asynchronous: which includes information being gathered and used to evaluate the patient's condition and transmitted through a secure electronic communication system and stored for review by a dentist or specialist prior to future consultation and treatment planning.

The dental hygienist in a clinical setting may facilitate the access to care by:

a. Triaging the patient.  This is particularly important in clinical settings including but not limited to nursing homes, hospitals, or school-based programs.

b.  Completing patient assessment, including but not limited to, medical and dental history.

c.  Exposing the appropriate radiographs.

d.  Documenting the patient encounter, including chief complaint by collecting data about the dental problem.

e.  Uploading patient data (i.e., photos, radio graphs, clinical notes, video).

f.  Sending the clinical information to the dentist for evaluation.

g.  Communicating to the patient the dentist's observations, diagnosis, and results.

2.  Synchronous - which includes real time consultation through live video using advanced telecommunication technology.

The dental hygienist in a clinical setting may facilitate the access to care by:

a.  Virtually connecting the patient with the dentist.

b.  Triaging the patient.

c.  Completing patient assessment: including medical and dental history.

d.  Exposing appropriate radiographs.

e.  Taking the video of the patient's oral cavity and face.

f.  Facilitating the communication between the patient and the dentist.

D.  Confidentiality

The licensee shall ensure that the electronic and/or digital communication is secure to maintain confidentiality of the patient's medical information as required by the Health Insurance Portability and Accountability Act (and other applicable federal and state laws).  Confidentiality shall be maintained throughout the appropriate processes, practices and technology, including disposal of electronic and/or digital equipment and data in order to ensure confidentiality, encryption, password restricted access, and other technologies should be used whenever possible.

E.  Patient Records

• Dental providers providing teledentistry services must document the encounter appropriately and completely so that the record clearly, concisely, and accurately reflects what occurred during the encounter.  Read more Recordkeeping guidance for Dental Providers.
• Such records should be permanent and easily available to the patient, legal guardian or their designees and other practitioners in accordance with patient consent, direction, and applicable standards.
• Dental providers should maintain the security and confidentiality of the patient record in compliance with applicable laws and regulations related to the maintenance and transmission of such records and have a mechanism to make such records readily available to other providers as data sharing is vital to patients who need the advice of a specialist, but who may not have one nearby.
• Patient Dental records are subject to the same confidentiality and privilege as any other medical record, consistent with all established laws, regulations and guidelines governing Patient healthcare records and should include, but not be limited to: demographics, medical and dental history, OTC prescribed medicines diagnostic notes, radiographs, consent forms, all communications relative to the patient, and all other pertinent information that is applicable to regular in office patients.

F.  Consent

1. The dentist should obtain and document appropriate informed consent for teledentistry encounters.  Because of the unique characteristics of teledentistry, it is best practice for the informed consent to include but not be limited to:

a.  The manner in which the dentist and patient will use particular enabling technologies, the boundaries that will be established and observed, and procedures for responding to electronic communications from patients.

b.  Limitations on the availability and/or appropriateness of specific teledentistry services that may be hindered as a result of the services being offered through teledentistry.

2.  All treatments should be preceded by pre treatment radiographs, patient evaluation data, a thorough informed consent discussion, and an acknowledged and signed informed consent document by the patient and provider.

a.  There should be a clear understanding by the patient or legal guardian that it is the role of the dentist to determine whether the condition being diagnosed or treated is appropriate for a teledentistry encounter.

b.  Requirements for explicit patient or legal guardian consent should be in place to forward patient identifiable information to a third party.

c.  Informed consent should include the contact information for the New York State Office of Professional Discipline and a description of, or link to, the patient complaint process.

d.  Informed consent should cover the same information as in the traditional in office informed consent form.

e.  The patient should be informed of the way their information is to be shared; and made aware of the risks of having electronically transmitted information intercepted despite the efforts to maintain security of the information.

G.  Standard of Care

Dentists and Dental Hygienists using teledentistry will be held to the same standard of care as practitioners engaging in more traditional in person care delivery, including the requirement to meet all technical, clinical, confidentiality and ethical standards required by law.  Failure to conform to the standard of care, whether rendered in person or via teledentistry, may subject the practitioner(s) to potential discipline.

H.  Patient Evaluation

An appropriate history and evaluation of the patient should precede the rendering of any care, including provision of prescriptions.  Not all patient situations will be appropriate for teledentistry.  Evaluating the adequacy and significance of any examination remains the responsibility of the teledentistry health care provider.  Since, by definition, teledentistry does not involve in person contact between dentist and patient, if circumstances require in person contact, a credentialed dentist may provide in person observations.

I.  Prescriptions

Prescribing medications, whether in person or via teledentistry, is at the professional discretion of the dentist.  The dentist, in accordance with current standards of practice, should evaluate the indications, appropriateness, and safety considerations.

• All New York State laws relative to prescribing medications and/or appliances should be documented and kept in the patient's file.
• The indication, appropriateness, and safety considerations for each prescription, either for medication, laboratory services or dental lab services, provided via teledentistry services must be evaluated by the licensee in accordance with applicable law and current standards of care and consequently carries the same professional accountability as all prescriptions delivered during an in person encounter.
• A dentist who prescribes as part of the provision of teledentistry services shall comply with all New York State requirements.