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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.30 no.2 Madrid mar./abr. 2008




Telemedicine in maxillofacial surgery

Telemedicina en cirugía maxilofacial



J. Herce López1, C. Salazar Fernández2, Á. Rollón Mayordomo3, D. Moreno Ramírez4, F. Garrachón5, P. Serrano Moya6, J.M. Pérez Sánchez7

1 Médico Residente.
2 Facultativo Especialista de Área.
3 Jefe de Sección.
4 Facultativo Especialista de Área, Unidad de Lesiones Pigmentadas. Departamento de Dermatología.
5 Director Área Quirúrgica.
6 Directora Gerente.
7 Jefe de Servicio.
Servicio de Cirugía Oral, Maxilofacial y Estomatología. Hospital Universitario Virgen Macarena de Sevilla, España





There is a group of pathologies that tolerate little delay and require optimal use of the resources available to us in our daily work as oral and maxillofacial surgeons. For instance, oral cancer has a high mortality and other pathologies, which otherwise are not serious, have a high morbidity and care burden, e.g., oral surgery and temporomandibular joint dysfunction. Among these resources, the use of new technologies in medicine has become routine practice in every specialty.
Among these technologies, telemedicine is becoming prominent. We believe that telemedicine could be an optimal system for screening patients for referral from primary care to hospitals. The development, use, and advantages of teleconsultation as a tool used in a clinical management unit for the diagnosis and treatment of temporomandibular joint disorders is described. The potential use of teleconsultation in other fields of oral and maxillofacial surgery is evaluated.

Key words: Telemedicine; Maxillofacial surgery; New technology.


En nuestra especialidad el cáncer oral, debido a su elevada mortalidad, así como otras patologías de menor gravedad pero de gran morbilidad y presión asistencial como la cirugía oral y la patología de la articulación temporomandibular, nos obligan a minimizar las demoras optimizando los recursos de que disponemos. Dentro de estos recursos, la aplicación de las nuevas tecnologías a la medicina se está imponiendo en todas las especialidades. Entre estas nuevas tecnologías, está adquiriendo un papel protagonista la telemedicina. Creemos que ésta nos puede servir como sistema óptimo y eficaz de cribado y derivación de pacientes desde atención primaria (AP) hasta el nivel hospitalario. En el presente artículo describimos todos los detalles relacionados con el desarrollo, la utilización y las ventajas de una teleconsulta como herramienta integrante de una unidad de gestión clínica para el proceso diagnóstico y terapéutico de la patología de la articulación temporomandibular valorando de esta forma su aplicabilidad en otros ámbitos de la cirugía oral y maxilofacial.

Palabras clave: Telemedicina; Cirugía Maxilofacial; Nuevas Tecnologías.



New systems of clinical management by intervention processes tend to minimize diagnostic and therapeutic delay in many pathologies. In our specialty, oral cancer, due to its high mortality (5-year survival 50%),1 and other, less serious pathologies that have a high morbidity and care burden, demand that we reduce delay by optimizing available resources. Among these resources, new technologies in medicine are coming into use in every specialty.

"Modern telecommunications promise a solution for one of the most pressing problems of society, how a limited number of resources can be shared by a large number of users, understanding as resources all instruments, services and, especially, knowledge."2 This philosophy has guided the introduction of telemedicine systems throughout the world. Since 1996, when the first study on telemedicine in maxillofacial surgery was published,3 to February 2007, only 13 articles are found in PUBMED with the key words telemedicine and maxillofacial surgery. Most of them describe the use of telemedicine systems to broadcast directly or synchronously, as in videoconferences.4-7 However, the good results obtained with teledermatology in our hospital area 8 suggest that telemedicine can be used as a system for screening and referring patients from primary care to hospitals, not only for pathologies whose impact is due to their seriousness, such as oral cancer, but also in pathologies others that represent a care burden due to their high prevalence (dental inclusion and temporomandibular joint pathology).

Although the project for introducing telemedicine in our department includes precancerous lesions and oral cancer, as well as dental impaction and temporomandibular joint (TMJ) pathology, the pilot study will be conducted with temporomandibular pathology (TMDS).

We describe in this article the details of the development, use, and advantages of teleconsultation as an integral tool of a clinical management unit for the diagnostic and therapeutic management of temporomandibular joint pathology. We expect to be able to evaluate its applicability to other areas of oral and maxillofacial surgery.


Justification of telemedicine in maxillofacial surgery. Objectives of TMJ teleconsultation

As with any initiative that is proposed as an improvement over the existing system, the baseline situation must be assessed. We analyzed the epidemiologic data of TMJ pathology in the department database in 2006. Of 1758 patients with an index visit in the maxillofacial surgery outpatient clinic of HUV Macarena of Sevilla in 2006, 390 (22.18%) consulted for TMJ dysfunction. Of 390 patients, only 127 (32.56%) were diagnosed as temporomandibular dysfunction syndrome (TMDS), Wilkes stage IV or V, or presented some other TMJ pathology that required maxillofacial surgery (condylar hyperplasia, cysts, tumors, etc). The remaining 263 (67.44%) patients had primary muscular pathology (fundamentally myofascial syndrome) or TMDS, Wilkes stages I, II and III, which is why they could be correctly managed in the primary care center, thus avoiding unnecessary travel and expense. In view of the fact that our hospital district includes populations located more than 50 miles (90 km) away, this is no small matter.

Therefore, the search for a patient selection system in primary care that facilitates specialist care within a reasonable time period is a priority in our clinical unit.

For that reason, we established the following objectives for TMJ teleconsultation:

1. To provide adequate and efficient specialistmedical opinions in primary care to 60-70% of the patients with temporomandibular pathology (TMDS).

2. Selection of patients with TMDS requiring maxillofacial surgery.

3. Reduction of the delay in providing specialist care to patients with TMDS.

4. Reduction of the care burden of the outpatient clinics of our specialty and improved care for other pathologies (oncology, oral surgery, etc).

5. Encouragement of the relation between the primary care physician and specialist by providing new routes of communication with our unit.

6. Preliminary assessment of the use of teleconsultation in other maxillofacial surgery settings (precancerous lesions, oral surgery, etc). Teleconsultation for patients with TMJ dysfunction is being used as a pilot program for introducing this tool in other areas of our specialty.

7. To conduct research in the field of TMDS to investigate the epidemiology and diagnostic and therapeutic protocol of this pathology in our health area.

8. To apply the development of new technologies to the field of maxillofacial surgery.


Technical fundamentals of teleconsultation

The technical platform of TMJ teleconsultation is a deferred, or asynchronous, telemedicine system, also known as a storeforward system. This designation refers to the fact that the information (clinical history data and digital image) is first compiled and stored and then sent by electronic mail to the maxillofacial surgeon responsible for teleconsultation (Fig. 1).

This methodology has several advantages over real-time telemedicine systems. Most importantly, it is not necessary for the patient, primary care physician, and teleconsulted specialist to coincide in time and space. In addition, the technological and organizational difficulties of a consultation by videoconference are avoided. It also allows more patients to be evaluated per session and reduces costs by leveraging existing resources like electronic mail and radiology digitalization in our hospital.


How teleconsultation works. Referral circuit

By conducting each phase of teleconsultation according to protocol, we unify and standardize the operation of all centers using this service.

Phase 1. The patient who is seen in the primary care center for TMJ dysfunction is assessed by the odonto-stomatologist, who completes the questionnaire prepared for this purpose (Table 1). This questionnaire is the physical substrate for transmitting the patient’s clinical information. It has been designed to be simple, accessible, and familiar for use by for any professional. It provides us with the necessary minimum information and radiographic images to correctly diagnose patients. In this initial visit, the primary care physician not only will clinically evaluate the patient, but will order an orthopantomogram and sagittal tomography of both TMJs with the mouth open and closed (or a Schüller projection radiograph). The physician will give the patient written instructions on the measures that the patient should follow until the next visit (soft diet, avoidance of stimulants and trigger factors, and to drink limeblossom or valerian infusions 2-3 times a day). The clinical questionnaire is sent by encrypted electronic mail through the Corporate Intranet Network of the Andalusian Health System (SAS, Spanish initials) to the address of the TMJ Unit. This questionnaire will be labeled with the Andalusia Unique Medical Record Number (NUHSA, Spanish initials) to avoid transmitting the patient’s personal data through the network.

Phase 2. This form and the radiologic studies will be evaluated in the TMJ Unit by the two maxillofacial surgeons responsible. After evaluating the patient’s clinical and radiological information, the maxillofacial surgeon will write a diagnostic and therapeutic report and send it by electronic mail to the consulting primary care center within 72 h. Part of the physical material will be a Word template labeled with the NUHSA (Table 2).


Phase 3. The patient will be scheduled for an appointment at the primary care center to be informed of the results of the report by the physician who requested the teleconsultation. The patient will be given instructions about the next steps to be taken, which will either be to complete treatment in primary care or to continue treatment with our department’s TMJ Unit.

Phase 4. Patients who are referred to the physical TMJ clinic for specialized care will take the report for an appointment within a maximum term of 7-15 days.

Development of the TMJ Unit and teleconsultation will transform the circuit of care for this type of pathology (Fig. 2).

The flow of direct communication between primary care and the oral and maxillofacial surgery department as a result of teleconsultation will allow the patient to obtained a specialist’s opinion within a maximum term of 4 weeks (a period that could be shortened by reducing the delay in radiologic studies, which currently take about 20 days), as opposed to 8 weeks in the traditional circuit (database of the Maxillofacial Surgery Department, HUV Macarena). The patient’s problem may even be solved without any need for travel in cases in which the pathology can be treated in the local primary care clinic.

Screening patients by teleconsultation also allows us to schedule hospital care for patients who require specialized treatment of their articular pathology within a maximum period of 30 days. Consequently, all patients seen in primary care for TMJ dysfunction are assessed by a maxillofacial surgeon, but only patients who required treatment by a specialist have to come to the hospital.


Criteria for screening patients with TMJ pathology for referral for treatment by maxillofacial surgery

The criteria for screening patients who require the care of a specialist (physical TMJ Unit) are:

1. Patient with a radiographic image suggestive of bone pathology that affects articular surfaces (bone tumor, condylar hyperplasia, malformation, fracture, ankylosis, or other), regardless of the clinical manifestations.

2. Patients with radiologic findings suggestive of arthrosis and intense clinical symptoms (restricted mouth opening, chronic pain, and history of lockjaw requiring reduction).

3. Patients with articular pathology who do not meet criteria for initial specialist treatment, but do not improve after receiving treatment for 1 year (according to the current protocol of the Oral and Maxillofacial Surgery- Stomatology Department, HUV Macarena, Sevilla).


Human, material, technological, and organizational resources

The TMJ unit is constituted by 2 maxillofacial surgeons with part-time dedication who perform the related functions of care, management, and training.

The specialized care unit will be equipped with a highcapacity computer terminal (Office-XP for Windows XP, PGP encryption software, and an electronic mail account of the SAS Corporate Intranet Network), printer, and telephone terminal (a telephone number for resolving primacy care problems will be set up).

The primary care center using the teleconsultation service will be equipped with computers and conventional software (Microsoft and Word Outlook). Each primary care center has an electronic mail account in the same corporate network.

The communication channel is supported by a heterogeneous system of asynchronous transfer mode networks (ATM) and integrated service digital network (ISDN) with a suitable bandwidth for the type of data that are going to be transmitted (now existent).


Diagnostic effectiveness and quality control. Cost-effectiveness analysis

An important aspect of developing of new diagnostic techniques is to evaluate the operation and the benefits of the new methodology. Although some teleconsultation studies exist in our specialty, ours is the first using a deferred or asynchronous telemedicine system, which is why literature citations on quality control measures and diagnostic effectiveness are not applicable to our project. The diagnostic effectiveness and quality control of the TMJ Unit will be evaluated by means of:

A. Effectiveness and diagnostic accuracy of the clinical questionnaire and radiographic images, including the rate of detection of relevant processes, precision, accuracy, and intrapersonal and interpersonal clinical-radiological agreement between primary and specialized care. The rate of clinical and radiological agreement between the two maxillofacial surgeons will be established.

B. To assess teleconsultation as a tool for screening or selecting patients with surgical TMJ pathology: we will assess the percentage of TMJ consultations resolved in primary care, the number of TMJ pathology requests submitted to the physical TMJ Unit and how many require surgical treatment. We will log the number of teleconsultation requests from patients in which primary care treatment has failed and they need re-evaluation and treatment in the physical TMJ Unit.

C. Satisfaction of physician users, patients, and maxillofacial surgeons: This will be measured by satisfaction surveys.

D. The satisfaction of hospital management will be evaluated by satisfaction surveys, the difference between the number of referrals from primary care for TMJ pathology before and after introducing teleconsultation, study of delays (maximum delay for first consultation, maximum delay for second consultation), streamlining of specialist care in more serious pathologies, and development of new technologies.

Cost-effectiveness analysis will be conducted by quantifying the number of patients assisted using this new system, including those treated in primary care and those referred to the hospital TMJ Unit. The main cost of management will be equipping the TMJ Unit with a high-capacity computer. Once the teleconsultation system is in operation, care through the internet is less expensive than the traditional visit. In addition to not requiring travel from distant areas to the hospital, it will considerably reduce the volume of first visits and follow-up in our outpatient clinics.


Confidentiality and data protection

Confidentiality and the protection of data transmitted through the Internet are one of the most controversial points of telemedicine in terms of its legal implications. According to the statutory law on the protection of information of a personal nature (15/1999) and Community directives on data protection (95/46 CE, 96/9 CE, 97/66 CE), as long as the anonymity of patients is safeguarded during telemedicine use, there should be no legal problems. For that reason, we have established four layers of protection of patients’ anonymity and all clinical information transmitted: firstly, teleconsultation requests are labeled with the NUHSA and no personal information of patients; secondly, PGP encryption software will be used and public and private passwords will be distributed among the terminals connected; thirdly, data transmission will be through the Corporate Intranet Network of the Andalusian Health Service, which is equipped with a security system for the communication channel, con sisting of a network of internal non-routable IP addresses with filters for certain protocols, and fourthly, access to terminals will be restricted by personal passwords.



Although our experience in the area of telemedicine is brief, it has received and effusive welcome from all system users. Management views it as a fast and safe way of optimizing existing resources and improving patient care and primary care odontologists are pleased to have a new tool for approaching specialists, which makes us optimistic about achieving the goals that we have set. Nevertheless, we are aware that a project as innovative and ambitious as the one that we are trying to develop in our department will not be free of difficulties and will require a major effort by all participants.



Javier Herce López
Calle Alcalde Manuel Camino Míguez Nº4
41960 Gines. Sevilla, España

Recibido: 09.07.07
Aceptado: 07.03.08



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