Virtual Dental Homes Improve Care and Cut Costs

Residents of Kingsley Manor in Hollywood, Calif, no longer have to find a way to get to the dentist’s office. The office has come to them.

The Arthur A. Dugoni School of Dentistry at the University of the Pacific will use a $275,000 grant from the California Wellness Foundation to operate a virtual dental home at the retirement community. Dental hygienists will use telehealth technology to link up with dentists elsewhere to provide care on site.

“Hygienists collect a full set of diagnostic records,” said Dr. Paul Glassman, professor at the university. “They’re taking x-rays. They’re taking photographs. They’re doing dental charting. It’s really populating a full electronic dental health record, the same dental records that you would see in a dental office that, as people say, has gone paperless.”

The equipment is portable and can be set up in about 20 minutes. For example, it includes a digital x-ray machine that is about the size of a large hair dryer. Glassman notes that it takes a lot less radiation to expose a digital sensor than traditional film. All of the patient’s information then goes into a laptop and uploaded to a cloud-based server, which associated dentists can access from their offices.

“Between patients or during lunch or at the end of the day, the dentist will get on the computer and review the records and make a diagnosis and a treatment plan,” said Glassman, adding that consultations with dentists in real time is logistically difficult and unnecessary. “If the hygienist captures images one day and the dentist views them the next day, it’s no big deal.”

In fact, Glassman says that only about a third of the patients seen at these remote locations ever require referral to a dentist for more invasive care like extractions and implants. Meanwhile, virtual dental homes like the clinic at Kinglsey Manor provide a full range of other preventative treatments.

On location, dental hygienists perform fluoride varnishes, cleanings, scalings, replanings, prophys, and sealants. Additionally, California is one of a handful of states that allow dental hygienists and extended function dental assistants who have completed appropriate training to perform interim therapeutic restorations.

“There is no anesthesia or drilling involved,” said Glassman. “They use hand instruments to clean out the soft material, whether that’s a little bit of yesterday’s lunch or some soft decayed tooth material. They don’t even have to remove all of the decay in the tooth. And then they’re able to bond in a tooth-colored filling material.”

These materials adhere to the tooth and seal in decayed structures to stop decay from progressing. Unlike temporary fillings, which can fall apart within a few weeks, these restorations are designed to last for many years. Dentists then only need to monitor them, later deciding if replacement is necessary or not.

This kind of accessible care is necessary, Glassman says, because more than half the population of the United States is not getting dental care on a regular basis. Only about 46% of children see a dentist annually, he says, with worse numbers for low-income populations: of this group, only about 25% of children and 20% of working age adults have an annual visit.

“The people visiting dental offices these days in general are the wealthiest and healthiest in the country. More dentists are doing mostly diagnostic and preventative work because they’re working on mostly healthy people,” Glassman said. “So why don’t people access dental offices? If you do surveys, people say that dental care is too expensive.”

Other factors play into the lack of care as well. For example, low-income populations may face transportation barriers in getting to dental offices. They may have difficulties taking time off work for appointments. Cultural barriers are present, too, as the makeup of the dental profession doesn’t always match the makeup of the patient population.

“Some people see dental care as being something that’s delivered by rich white people for rich white people,” Glassman said. “Then there’s the whole culture of poverty where people sort of begin to accept their lot in life as having bad teeth and toothaches and losing their teeth.”

The Pacific Center for Special Care, which Glassman directs, has created best-practice models for developing virtual dental homes to fulfill this need. Its network treats otherwise underserved populations in schools, community centers, residential facilities, and other group settings for underserved populations all over the Golden State.

“We have been working in 13 different communities, all the way from Eureka down to San Diego,” said Glassman. “It’s been about 50 different sites where this idea has been tested over the last 6 years.”

Dental caries represent the biggest problem for children, and virtual dental homes can play an instrumental role in treating and preventing them. But Glassman also notes an interesting and emerging change in dental care for aging patients such as those at Kingsley Manor—senior citizens with actual teeth.

“Baby boomers were raised in a time when there was more fluoride in the water so people had better dental health growing up,” said Glassman. “And pretty much the baby boom generation has grown up with the idea that they’re going to keep their teeth their whole life. That’s very different from previous generations.”

Complicating matters, many elderly patients take at least one of the 400 medications that cause dry mouth, which in turn causes tooth decay. Yet these patients often have impaired mobility and are unable to get to dental offices, in addition to living on a fixed income, making virtual dental homes at locations where they live essential to oral health.

“It’s sort of the perfect storm of people who need a lot of care and have a lot more difficulty getting it,” Glassman said.

So far, Glassman reports success in treating these patients with preventive care and early intervention, eliminating the need for more extensive care later. Overall, the virtual dental homes have retained about two thirds of the patients they have been seeing.

“And these have been purposefully picked populations of people with the least access to dental care, most likely to actually have advanced dental disease, most likely to have problems and end up in the emergency room,” Glassman said. “We’re able to keep about two thirds of the populations of those sites healthy with the hygienist being the only one physically touching them.”

Insurance companies are on board with using this preventive care to save costs in the long run. The goal of the 3-year grant is to demonstrate the program’s efficacy and ability to be self-sustaining. For instance, recent legislation in California now requires the Denti-Cal insurance program to pay for services provided through virtual dental homes and other telehealth centers.

“We’ve been testing this delivery system model for 6 years and very clearly demonstrated we can make it work,” Glassman said. “We can get care delivered in community sites. We can emphasize prevention. We can have dentists involved through the teledentistry system. We can make referrals. We’ve demonstrated all that.”

Now, Glassman explains, there is a billing stream for these programs to pay for themselves through revenue. The Pacific Center for Special Care is working with the Queens Care federally qualified healthcare center to provide staffing such as hygienists and dentists and help it understand the new billing regulations so these programs can shift from grant-funded to billing-funded projects.

“Once commercial dental benefit companies begin to realize that they can reduce costs and do a better job of actually making people healthy at a lower cost, then it’s going to become pretty widespread across the dental benefit industry,” Glassman said.

As virtual dental homes see greater use, these locations will need personnel who are familiar with the model. That’s why the university will use a federal grant to begin training students in teledentistry practices. Faculty and students in its hygienist program will perform the work in locations around San Francisco, and dental students back at school will review records and make treatment recommendations.

“By the time they graduate, we will be the first school in the country to graduate students who have had experiences working in these telehealth connected teams,” Glassman said.

These facilities aren’t being set up to compete with established dental practices, though. On the contrary, they are opportunities for dentists to expand their practices and reach out to patients they otherwise would not have the opportunity to see, Glassman says.

Glassman encourages dentists to learn more about the model at his course, Expanding Dental Practices Using Telehealth Connected Teams, at next spring’s meeting of the California Dental Association. More information also is available at virtuadentalhome.org.

“The idea was the dental office ended at the 4 walls of your office. That’s where the practice was. But now we have the option to be able to extend into the community where some members of the team are at a site like Kingsley Manor, doing the diagnostic records and preventive procedures, and even these interim restorations,” Glassman said.

“But it’s all one practice,” he said. “It’s a very different way of thinking about what a dental practice is and how you keep people healthy in the long run.”