Meet Dr Ramesh Balasubramaniam, the driving force behind TOM

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Dr Ramesh Balasubramaniam
A/Prof Ramesh Balasubramaniam says the current pandemic has pushed the progress of tele-oral medicine forward. Photography: Frances Andrijich

People with facial pain living in regional and remote areas can now access an oral medicine specialist for an initial and even subsequent consultations without ever having to leave home. By Kerry Faulkner

Associate Professor Ramesh Balasubramaniam (OAM) is a leader in the field of oral medicine nationally and now also the driving force behind TOM or TeleOralMedicine—a new service that gives people, particularly those in regional communities, easy access to Australia’s leading oral medicine specialists nationally.

He’s recruited 20 specialists from around Australia to be part of TOM and listed on its website where patients with a referral from a GP or dentist can log in and book appointments for consultations conducted over the phone or via video. 

Dr Balasubramaniam is president of the Oral Medicine Academy of Australasia and explains he created TOM because he’s committed to ensuring everyone has access to health services and there are simply not enough oral medicine specialists working outside metropolitan areas. 

He says while regional towns have tried to attract them, few oral medicine specialists are interested in relocating permanently and those who visit regularly for clinics eventually find the travel too much and burn out. 

“Although there are training programs out there, we’re very, very short of specialists on the ground,” he says. “What TeleOralMedicine enables us to do is to actually facilitate care for patients in rural and remote areas of Australia all around the country or anyone restricted by age, for example, and in a care facility,” he says. 

TOM in practice

The process of seeing a TOM specialist works like this: a patient in Karratha in the north of Western Australia, for example, who is more than 1500kms from an oral medicine specialist in Perth, may have a mouth ulcer they are worried about. The person can visit their GP or local dentist who will take pictures of the ulcer to upload to TOM and generate a referral to a specialist. A TOM receptionist will email the patient to confirm the referral and invite the patient to have a consultation by phone or video. 

The patient choses a suitable time from those available on the website—the specialist they ‘see’ initially could be anywhere in Australia, such as in Sydney or Melbourne. After that consultation a report is generated for the patient and the referring doctor. If the ulcer needs further investigation, the patient may be asked to attend a specialist in person in Perth who will also have a copy of the report.  

Dr Balasubramaniam explains the biggest advantage is that people in remote areas are advised as to whether their problem is serious enough to warrant a trip to the city for treatment, which can be inconvenient given the cost of airfares, accommodation and loss of wages through missed work. 

What TeleOralMedicine enables us to do is to actually facilitate care for patients in rural and remote areas of Australia all around the country or anyone restricted by age, for example, and in a care facility. Dr Ramesh Balasubramaniam, creator, TeleOralMedicine

“Once they’ve had that initial consultation, the specialist provides their recommendations. It could be as simple as the specialist saying, ‘This is nothing but something called geographic tongue. Please don’t take three days off work and get on a very expensive flight only to find out that it’s merely a benign thing that does not require treatment.’ Or they might get a result that’s something in between with the specialist deciding, ‘Well, actually this does need to be looked at. It does need to be cut out, but it’s not urgent. Come down during Christmas when you’re here in Perth for shopping.’ We’ll tie the two together so they’re not making that extra trip,” Dr Balasubramaniam explains.

“And of course, if the patient needs a biopsy or injections and that sort of thing, they’ll come in, but the advantage here now is the specialist will be able to give them advice like, ‘You know what, you’re going to have to come in for a biopsy,’ and they can come in prepared.

“And if they were going to come to Perth, they’ll come in and see the specialist and stay for a week or two and get the results back, commence treatment, and then have follow-up care with their new specialist. And maybe then, hopefully the new specialist will recognise the difficulties with traveling, like the cost of travel and facilitate some consultations again via telehealth, and maybe they’ll just have to come in once a year rather than three or four times a year for that face-to-face.”

Dr Balasubramaniam says the referring doctor or dentist doesn’t need any special equipment to take the pictures for the referral and while a digital SLR camera is most desirable, the quality of images from a smartphone is sufficient.

“Most dentists now have these fantastic cameras. They take beautiful pictures. But phones now are producing really, really good pictures. There’s actually something called the telescope where you can attach a tongue depressor with an embedded light, and they take really fantastic photos.”

He says oil rig workers offshore, people in remote communities, service men and women and the aged in homes or others who for physical reasons can’t attend a specialist, can now access oral medicine specialists. 

“Well, we’re not restricting it. Anyone can choose to use it. I mean, if you happen to be five minutes away from a clinic but you choose to have a consultation on TeleOralMedicine because you want that opportunity to figure out if it’s worth going in, you’re more than welcome to do that.”

The man behind TOM

Born in Malaysia and studying largely in the US, Dr Balasubramaniam is based in Perth and was instrumental in having the field of oral medicine recognised as a speciality in WA in 2009.  His list of achievements since then is long; he lectures at UWA and has been awarded for his public speaking skills; he has an OAM and is founder of his own business Perth Oral Medicine and Dental Sleep Centre. Most notably he is also co-author of the leading textbook in his field, Contemporary Oral Medicine, published in 2019. “My primary interest is in facial pain,” he explains. “I’ve always been drawn by the suffering of an individual’s pain. I’ve found that fascinating in the nicest way possible. Why would someone be in pain and why are they so distressed? Why do they have pain behaviours because along with pain, you feel depressed and anxious. So, that has always been a draw for me. 

When [COVID] happened, I saw an opportunity to service Australians because in oral medicine, unfortunately for us, we’re working in an area of unmet need. There are just simply not enough specialists.

Dr Ramesh Balasubramaniam, creator, TeleOralMedicine

“I’m still very, very involved in oral and facial pain and as my career evolved, I felt I’m probably better off training oral medicine specialists who can provide that care and getting those services out there. 

“And as president of the Oral Medicine Academy of Australasia, I saw that as an opportunity to help do that.”

He says telehealth is not a new concept; there have been papers written about tele-oral medicine for years. 

“I mean, we’ve been calling patients on their phones to provide prescriptions and provide advice for years, but it’s never been viewed as an equivalent service to face-to-face contact.

“COVID-19 has almost created this opportunity by taking away the options—telehealth is now the necessity rather than an option. 

“And the beauty about oral medicine, in particular, more so than any other field in dentistry, is it lends itself to this telehealth service because it’s very much a consultation-type service.”

This has recently been validated by the ADA which approved the item code 919 for dentistry telehealth services as an emergency item code and it is supported by some health funds. 

“Telehealth a couple of years ago, as you can imagine, would have never taken off. Patients would have seen it as too much of a barrier: ‘What do you mean you’re not seeing me face-to-face?’ Obviously, with COVID, we’ve been forced to treat some patients or care for some patients, provide recommendations and meet with them via teleconference, whether via video or by phone. 

“So, when this happened, I saw an opportunity to service Australians because in oral medicine, unfortunately for us, we’re working in an area of unmet need. There are just simply not enough specialists.”

A/Prof Balasubramaniam will be a speaker at this month’s ADA FDI World Dental Congress. Find out more at 2021.world-dental-congress.org.

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