Utilize emerging artificial intelligence (AI) technology to have patients remotely scan their mouths with a smartphone. This is important since dentists have no visibility into X-rays during a teledentistry visit. AI scans can benchmark nearly every surface of every tooth against 10 million indexed images and generate an objective screening or snapshot of the patient’s tooth and gum health in far greater detail than the naked eye and a laptop camera can.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Cindy V. Roark, DMD, MS.
Dr. Cindy Roark serves as Senior Vice President and Chief Clinical Officer at Sage Dental Management, LLC, where she is responsible for overall clinical leadership and enterprise-wide clinical strategic planning, with a heavy emphasis on research and development. As a special area of interest, Dr. Roark is one of the preeminent global leaders in the adoption of Artificial Intelligence to improve dentistry diagnosis and outcomes. Dr. Roark brings 20 years of private practice, non-profit, and DSO experience to Sage Dental Management. Sage Dental is a national leader in the dental services industry, recently highlighted for innovative performance during the COVID-19 pandemic.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
Absolutely! I grew up in Tennessee, and I would never have imagined being in the role I am in today but for the fact that I was raised by a long line of strong women. I earned my dental degree Magna Cum Laude from the Henry M. Goldman School of Dental Medicine at Boston University. In addition to owning a successful private practice in Massachusetts, I served as Clinical Officer for two national Dental Service Organizations and was formerly the Director of General Dentistry and Associate Professor at the Vanderbilt University Medical Center. Once I stepped into a dental leadership role, I realized that I needed to be bilingual in business and dentistry in order to be an effective leader. This realization prompted me to pursue a Master of Science in Health Care Management degree from Harvard University. My health care management masters opened all sorts of doors in business that I could not have predicted. For instance, I hold a toothbrush design patent, I’ve had the opportunity to work in international supply chain and product development, and I serve as the Chief Clinical Scientist for RisunTech based in Shenzhen, China.
Can you share the most interesting story that happened to you since you began your career?
The most interesting stories to me are the ones that honor the incredible complexities of being human.As dentists, sometimes we need to be reminded we are working on a human body and not a machine.I once had a patient who requested veneers — a fairly standard request. However, her health history showed that she had a metastasis and recurrence of breast cancer. Typically, everyone from insurance carriers to the dental board would say that this is not a patient that will be able to enjoy this elective procedure very long. For that reason alone, she had been told by a previous dentist even though she was stable and non-invasive veneer procedures existed, she was not a strong candidate for the procedure. However, I have deep and personal experience around metastatic disease and know that how one feels is often critical to how one responds to treatment. I asked the patient why she would want to undergo the procedure at this time. She stated, “I just want to feel pretty, for once.” It nearly broke me that the one thing this person wanted was to feel in control of her body and good about herself for however limited amount of time she might have remaining. I did move forward with the most minimally invasive veneers on the market and it was absolutely the right choice for that patient, at that time, against all rational training. She outlived the timeframe she was given in terms of longevity by far, and she used to say at recall appointments, “It’s not how you feel, it’s how you look…and I look good!” (Her words not mine!) It was a lesson in treating a whole patient versus a set of symptoms. I have never forgotten her.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
I grew up in somewhat limited circumstances early in life, so when I was young and my grandfather asked what I wanted to be when I was older, I said that I wanted to be a success and to make a lot of money. His response?
“Cindy, success doesn’t mean making a lot of money. Success means making a difference that you were here at all.”
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
As I said before, after becoming a dentist, I did not picture myself utilizing that skill set to work in a business management role. Tom Marler, CEO at Sage Dental, was also CEO at a previous company that I joined when I sold my practice and moved to Florida. I credit him with seeing that business leadership potential in me that I had not — at least at that point — seen in myself. He was the first to give me a seat at the table.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Dentistry is a fundamentally manual task. I can’t fix a broken tooth through a camera. In fact, “diagnosis” if you will, medicolegally still requires X-rays, which I can’t take during a teledentistry visit. So teledentistry is really all about triage, but triage is very important. Remember, visiting the dentist is on the list of people’s top three fears. I find that patients are so fearful that it can be easier for them to get over the mental hurdle to do a teledentistry visit than it is to show up at my door, because they know it won’t hurt.
On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
In-person presence is critical to actually providing care in the mouth. I can often get a patient out of pain with a prescription. However, prescriptions simply treat symptoms and do not fix the problem. Ultimately, a prescription can’t do anything to improve the look and function of a broken tooth.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)
To best care for my patients remotely I recommend the following:
- Utilize emerging artificial intelligence (AI) technology to have patients remotely scan their mouths with a smartphone. This is important since dentists have no visibility into X-rays during a teledentistry visit. AI scans can benchmark nearly every surface of every tooth against 10 million indexed images and generate an objective screening or snapshot of the patient’s tooth and gum health in far greater detail than the naked eye and a laptop camera can.
- Do not end the triage appointment without scheduling a follow-up appointment in the office. This encourages the patient to definitively deal with the cause of the dental pain or issue (fracture, decay, infection) instead of just temporarily stopping the pain symptoms.
- Encourage patients not to delay routine dental cleanings and maintenance. During the current COVID-19 pandemic, many patients have delayed routine care, either due to desire to limit trips outside of the home or fear of exposure to the virus in a dental setting. But many do not realize that on February 2rd, 2021, Dentistry Today published an article stating that patients with gum disease who contract COVID are 3.5x more likely to be admitted to intensive care, 4.5x more likely to need a ventilator, and almost 9x more likely to die than those without gum disease. For those reasons, preventive maintenance is more important now than ever before. Research from the ADA has also shown that dentistry, as a field, has done an exceptional job at infection control with no outbreaks traced to dental offices at this point. This is not our first rodeo when it comes to shielding ourselves (and our patients) from infectious germs, so prevention should not be delayed.
- Fabricate home periodontal medicament trays for patients in high-risk demographics who have active periodontal disease and are fearful to come in for multiple visits. Utilizing either IoGel (molecular iodine based gel) or hydrogen peroxide based gels at home to prevent worsening of periodontal disease is extremely important. Why? Because you can’t grow bone back. Once tooth-supporting bone is lost, which is the definition of periodontal disease, the bone is lost for good. It is a far better strategy to focus on preventing further loss with a gel carrier tray at home, than to avoid the dentist completely during the pandemic.
- Prescribe over-the-counter night guards for clenching. We all know that professional night guards are superior to the boil and bite ones available over the counter. However, according to the ADA Health Policy Institute, 70% of dentists have seen an increase in visits for pain associated with tooth clenching and grinding. In a teledentistry situation, recommending an over-the-counter solution can often determine if clenching and grinding are the source of the inflammation and pain. Once this has been determined, and the patient is already on the road to recovery, you can schedule an appointment for them to fabricate a longer term, more appropriate night guard.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
I use an AI solution for orthodontics called Dental Monitoring. This is one of the coolest solutions I have seen in years. I loved it even before the pandemic from the perspective of being a busy parent of a teen in braces. (I simply did not have a schedule that permitted me to commit to 22 orthodontic visits over the span of the next year and a half!) What Dental Monitoring allows us to do is scan orthodontic patientsvia smartphones at home. AI reads the scan, then benchmarks and communicates with the patient and the parent weekly. However, the beauty of the scan is that it detects whether the orthodontic wire is still active. Old school ortho has us coming in whether we need to or not for tweaking and changing wires monthly. If the scan reveals the pre-bent wires are still working, there isn’t a need to come in for that visit. Dental Monitoring means that the orthodontist might only need to see a patient six to eight times over the course of treatment, not 22. Also, the patient, the parent, and the orthodontist can all see the scan progression of tooth movement. An extra bonus is that visualizing progression of an orthodontic case is often highly motivating for teens. They get to see the incremental movement and “before” and “during” images. I have seen some use these scans in viral social media videos. Finally, Dental Monitoring allows me to responsibly check on a patient’s oral health anywhere in the world with an internet connection. This version of tele-dentistry blows the traditional method out of the water.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
For me, the AI remote smartphone scanning by Dental Monitoring has been the most helpful in terms of giving me the full picture of a patient’s dental situation via telehealth. If someone simply snaps a picture on their phone or shows me their mouth on a computer visit, I get very limited, macro information. A scan that reads tissue inflammation, recession, and tooth health often down to 10ths of a millimeter, gives me a far better picture of the foundation of the house. That way, I can make a more informed decision about next steps. With a broken tooth, for instance, I need to know whether foundation is healthy before I recommend a crown or recommend a different type of treatment. I think everyone agrees that more information is better.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
I would love to see insurance carriers cover the cost of remote scans every month, so I could more proactively tell if dental health is improving or getting worse. Periodontal disease has been linked to all types of co-morbidities from Diabetes to heart disease to Alzheimer’s disease. Given the connection between dental health and overall health, that simple solution has the ability to impact overall health in important ways. The scan would automatically detect deterioration and alert the patient that it is time for a visit. In essence, this would change visits from every 6 months to only when necessary.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
Yes, I wish they knew that their oral health was inextricably linked to the overall health of their bodies. An American Academy of Endodontics study found that the pandemic had caused serious disruptions in dental home care habits of people across the U.S. Everything from brushing and flossing less frequently, to snacking more on sweets has occurred due to both the quarantine and the lack of structure in daily routines. Slouching on oral hygiene during the pandemic can have significant medical consequences. We all get lazy but given the connection between gum disease and COVID severity… just don’t.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
Yes, there is a company out of California named Pearl, Inc. They have a product called Second Opinion software that is in late-stage FDA approval. This is an extremely important tool for the future of dentistry. Dentistry has needed consistency for a very long time. I think we have all at some point seen studies that show that if you give 10 dentists a chart and x-rays, you will get 10 different diagnoses! Diagnosis is highly variable, and variability leads to confusion and distrust from patients.
What Second Opinion does is run digital x-rays through AI software in real-time to benchmark them against millions of images, such that a dentist knows before he or she even enters a treatment room where the areas of concern are. Now, in reality, AI-driven functionality is used in medicine every single day to screen for skin cancer, read MRI’s and CT scans, etc. The capability far exceeds the accuracy level and efficiency of the human eye. Dentistry, oddly enough, remains behind the times. I truly believe the public deserves this level of consistency that has not been possible prior to an AI solution. It is more of an augmented intelligence since the software does not replace the dentist. The technology simply assists on the diagnostic side in a consistent manner.
Is there a part of this future vision that concerns you? Can you explain?
I, personally, am not concerned, but as a group, dentists do get concerned that somehow AI solutions will replace the need for their career entirely. However, that line of reasoning doesn’t hold a great deal of merit, given that dentistry is procedure-based. It will be a very long time before an AI-enabled robot could step in and do a filling. Additionally, I hear that dentists fear an AI-based solution will read the x-rays and find fault with their previous work. That may be true, but the work would have been poor whether it was detected or not. If you look at it that way, AI should “up the game” of every dentist because you can’t fool the algorithm. It’s either decay or it’s not. I think many dentists fear the spotlight on their technical skills. To date, no one has been looking.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂
In an ideal world, I would institute an AI screening on all long-term care facility patients every six months. We have many measures in place on the medical side, yet, statistics show that some nursing home patients have not had an oral exam in 10 years — and we know how problematic the inflammation associated with periodontal disease is for one’s overall health. This idea is the brainchild of Dental Monitoring’s CEO, Philippe Salah. He is definitely the type of CEO who wants to better the world. I know that dependent care facilities in the U.S. have extremely limited access to care. This type of simple scan could help them triage quickly and effectively, such that dentists are brought in only when necessary and for those with the greatest oral health needs. To have technology tell us what a patient no longer can is a wonderful thing.
How can our readers further follow your work online?
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.