Following the Covid-19 pandemic, virtual clinics have been incorporated into practice by many dental specialities, ranging from orthodontic clinics  and triage for referrals  to head and neck oncology monitoring clinics . With lengthy waiting lists following the cessation of services , virtual clinics can aid triage and be utilised for new patient appointments. At the Edinburgh Dental Institute Oral Surgery Department, all new patients with appropriate radiographs attached to their referral have an initial consultation virtually. These radiographs, taken by their referring practitioner, are available on patients’ electronic records. The majority of the department’s virtual consultations are for elective care. Following a discussion about treatment options and a shared decision regarding a plan, patients are then booked directly into a treatment clinic. Following their procedure, they are discharged to their referring practitioner or reviewed through a virtual clinic. If further investigations are required following the initial consultation, these are arranged and reviewed virtually. This provides an efficient patient pathway whilst reducing the need for in person appointments (Fig. 1).
The results of our study show high levels of patient satisfaction with video clinics. These results compare similarly to other recent patient satisfaction surveys on virtual dental consultations. Rahman et al.  reported that 91% of patients surveyed could understand the virtual system and maintain good communication and that 97% felt they could express themselves clearly as if they had an in person consultation. Reported benefits included avoidance of travel and parking. 100% agreed the virtual consultation saved time and 97% would be happy to use video for future appointments. A similar study by Parker and Chia  also reported high levels of patient satisfaction with 97% of patients finding their video consultation easy to use and convenient and 93.7% reporting a positive experience. 95% of patients would use a video consultation again and 90% would recommend this style of consultation to a friend. Another study by Menhadji et al.  similarly reported over 90% of patients felt comfortable with their video consultation, 87% found their virtual consultation useful and 79.3% would recommend video consultation to others. A literature review by Almathami et al.  as well as a study by Barca et al.  also found high levels of patient satisfaction with medical online consultations and reported virtual consultations were as good as in person consultations.
With the incorporation of video consultations into practice, it is important that patients have as similar an experience as an in person consultation. The General Dental Council state that you should “give patients the information they need, in a way they can understand, so that they can make informed decisions” and ensure patients are given “sufficient information and a reasonable amount of time to consider that information in order to make a decision” . This is important for the consent process and for shared decision making regarding a patient’s treatment plan. A study by Shakir et al.  found that following consultation regarding third molar removal surgery, patient understanding and retention of the important information discussed was poor. Additional studies have shown that risk recall is better with written information compared to verbal information alone  and that verbal information should be supplemented with written or visual information . Use of a clinical mailbox to send digital PILs is a time and cost-effective method of delivering pertinent information. Some virtual consultation platforms, for example, Attend Anywhere, lack a straightforward means of sharing text links with patients during consultation and there is no way of accessing the link when the consultation has ended. Use of a clinical mailbox is a flexible way of sending patient information, regardless of consultation platform or device used. Their use can also be easily incorporated into telephone clinics. Anecdotally, patients report leaflets links are easy to retrieve in their email inbox for when they wish to access the reference information later.
This project has demonstrated an increase to 94% compliance for delivering PILs following consultation. Patient feedback regarding the digital leaflets was overwhelmingly positive with over 90% agreeing they were easy to access, that the leaflet was clear and easy to read, and that it contained relevant information. 86% of patients agreed that the leaflet helped with their understanding with the remaining 14% neither agreeing nor disagreeing. A study of dermatology patients requiring surgery found that most patients preferred to receive an email with information about their surgery prior to the procedure . This efficient and effective intervention allows patients to receive the same standard of care as if they were seen in person whilst ensuring they have sufficient information about their procedure.
There are many barriers to implementing change within a healthcare setting. Common reasons include: increased workload, staff commitment and attitude towards the intervention, and lack of support and training . Covid-19 has pushed the use of teledentistry and telemedicine; a change that was very well received from both patients and clinicians. The clinical mailbox introduced during this project to support teledentistry was designed to be as user friendly, time-efficient and straightforward as possible to overcome these barriers. Utilising email templates containing the hyperlinks to each digital information leaflet allows clinicians to personalise each patient’s email in an efficient manner by deleting the irrelevant information. 1 h of virtual training was delivered to all department staff members with in person one-to-one sessions available as required. 3 members of staff required an additional in person session to help set up the mailbox and gain familiarity with the template system. An electronic SOP distributed to all staff contained a guide for further reference and for new members joining the department. The increase in compliance to 94% and positive staff feedback demonstrates that several barriers have been overcome to implement mailbox introduction for departmental use.
The authors are not aware of any other studies regarding dental staff perceptions of emailing patient information leaflets following virtual consultations. However, there have been several studies reporting high levels of clinician satisfaction regarding video consultations in general [17, 26, 27]. A survey of Oral and Maxillofacial consultants, who pre-pandemic held mixed views about the benefit of virtual consultations, now report more positive opinions and believe that there is a place for them in future practice . The Covid-19 pandemic has forced all departments to adapt and following the positive incorporation of virtual clinics, departments appear more open to implementing new changes such as the introduction of a clinical mailbox to send PILs.
It is important to be cognisant of the limitations and barriers associated with teledentistry. Technical difficulties were encountered by 43% of our study’s respondents, with poor sound quality and poor internet connection noted as the most common. Issues with technology are cited in many studies as a barrier to successfully implementing virtual consultations [2, 8, 17, 18, 27] with one study stating that the standard of the consultation depended on the quality of devices and internet used . If healthcare settings are to incorporate technology into consultations, it is crucial that there is the IT infrastructure to support this.
It is reported that 85% of British adults sent or received an email in 2020 and that for those aged over 75, internet usage has increased from 29% in 2013 to 54% in 2020 , highlighting the population’s increase in digital literacy and access. Therefore, moving forward there is a large cohort of patients for whom email and digital consultations may be utilised easily. Data extrapolated from the first 100 virtual consultations showed that 80% of patients seen were under the age of 60 years. One third (33%) of patients seen were ranked as living in the least deprived area of the country. Patient demographics, internet access and digital literacy are important factors to consider when assessing potential barriers to accessing virtual consultations. Six per cent of households in the United Kingdom and 18% of over 64 s lack internet access and five per cent of internet users did not feel confident using the internet . Further studies into the impact of teledentistry on patient experience and level of engagement for different patient groups would be beneficial. Determining if age, gender, educational level, income and digital literacy have an effect on engagement and experience may help identify barriers to accessing care and highlight what further assistance may be required.
Concerns have also been raised regarding missed diagnoses , medico-legal issues [2, 9] and difficulties viewing all parts of the mouth through video [9, 27]. The majority of patients however, are still seen in person at some stage of their treatment journey with Wosik et al.  finding that 85% of their virtual consultations resulted in a face-to-face appointment. This allows for in person examination of the oral cavity to be completed, likely during a treatment appointment. For those seen by virtual consultation alone, a study by Perdoncini et al.  found that the successful diagnosis of oral lesions was comparable between virtual consultations and face-to-face consultations. Information governance is another area of concern raised however, the NHS have issued guidance to support the use of virtual consultations and email communication with patients [32, 33]. Considerations include patient consent, safeguarding confidential information, pre-agreed communications and adhering to record management policy. The email templates and SOP used in this project adhere to this guidance.
As departments move forward, implementation of a clinical mailbox can supplement virtual consultations. Virtual clinics are an excellent tool when used appropriately and they may also provide financial benefits. A previous study investigating the cost benefit analysis of treatment at EDI , found that a consultation appointment including a radiograph cost £250. It is estimated that the cost of a virtual appointment is £100–£150. Analysis carried out in the West Midlands NHS Trust  reported a reduction in failed appointments with virtual consultations and found that this consultation method was on an average of 2.5 min shorter than an in person patient appointment. This equated to an additional 52,000 h of available appointment time. Further studies are required on the cost–benefit improvement of virtual consultations on service provision [36, 37] but the cost savings for patients regarding reduced income loss, travel expenses and time have been widely reported [16, 35,36,37].
Amid concerns about the carbon footprint of dentistry, especially with the increased use of plastic for personal protective equipment following Covid-19 , digital leaflets provide an environmental and sustainable means of reducing paper waste. A bank of digital leaflets in different languages can be collated and a clinical mailbox could also be used in health promotion, for example to deliver smoking or alcohol cessation advice. Some departments have started using QR codes to allow patents to scan their leaflets . It is hoped that departments may find this pathway and the use of a clinical mailbox beneficial and something to consider implementing into their practice.