Digital Health InnovationsThe Virtual Dental Home Program: Increasing Access to Dental Care Using Teledentistry

1. Introduction

In a recent Lancet series on oral health, the key message was "oral health matters" (Watt et al., 2019, 2020). This idea is based on the premise that oral health is an important aspect of overall health and well-being (Watt et al., 2020).

Research has consistently highlighted the association between oral diseases and several noncommunicable diseases and conditions such as cardiovascular diseases, diabetes, cancers, pneumonia, obesity, and premature birth (Sabbah et al., 2019). Globally, over 3.5 billion people are reportedly affected by oral diseases, with the prevalence still rising particularly in lowand middle-income countries (Peres et al., 2019). More than 530 million children suffer from dental caries affecting primary teeth, and severe periodontal (gum) disease affects almost 10% of the global population (Peres et al., 2019). Untreated dental decay accounts for the highest oral disease burden. An important factor underlying the high dental disease burden is low oral health awareness compounded by limited access to dental care (Peres et al., 2019; Watt et al., 2019, 2020). Access (defined as "freedom or ability to obtain or make use of" (Merriam-Webster, n.d.) to dental care is often determined by factors such as affordability and accessibility of care (Crall, 2006).

In many countries, oral diseases disproportionately affect the poor and socially disadvantaged populations (Watt et al., 2019); access to dental care is also most challenging for these populations (Institute of Medicine and National Research Council, 2011). In the United States widespread oral health disparities are reported (American Dental Association Health Policy Institute [ADAHPI], n.d.) with less than 40% of the adult population reporting actually visiting a dentist in 2013, with cost being the primary challenge reported. Interestingly, the most common oral health conditions are largely preventable and can be effectively treated in their early stages. However, dental care treatment is often not affordable as dental care is typically not included in universal health coverage packages.

In recent times, there has been more interest in the use of telehealth technologies for health care delivery. This interest is being driven by the increased recognition of its potential to improve access to health care and improve health outcomes (America's Health Insurance Plans, 2019; Enlund & Vesey, 2019). Teledentistry is part of this broader digital health transformation that is leading to better outcomes, at a lower cost and with greater patient and provider satisfaction, thus increasing the ability to reach the quadruple aim (Freeley, 2017). To increase access to dental care for rural, remote, and socially disadvantaged populations in California, the Pacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry is deploying technology through the Virtual Dental Home Program to reduce existing barriers.

2. The Virtual Dental Health Program

Currently, the majority of the U.S. population does not receive regular dental care. The American Dental Association estimates that only about 40% of the population has a single annual dental visit (ADAHPI, n.d.). Many people face significant barriers to accessing dental care such as the cost of dental care, geographic distribution of dental offices and clinics, and linguistic and cultural barriers. In California, according to the Pacific Center, children's access to dental care is limited in 32 of the state's 58 counties (Glassman, Harrington, Namakian, & Subar, 2012). About 24% of all children in the state complete elementary school without ever having seen a dentist; the situation is even worse for low-income children. In 2013, only 41% of children eligible for MediCal received any dental services.

The Virtual Dental Home System of Care (VDH) was therefore established to bridge the gap and facilitate access to dental care (Glassman, Helgeson, & Kattlove, 2012). It is a comprehensive care system that uses telehealth-connected teams and store-and-forward (asynchronous) record review for provision of full-service dental care (Glassman, Harrington, Namakian, & Subar, 2012). Specifically, the program uses telehealth technologies and electronic health records to facilitate a comprehensive community-based system of care (Glassman, Harrington, Namakian, & Subar, 2012; Glassman, Helgeson, & Kattlove, 2012). It leverages the ease of technology use to facilitate access to populations that would otherwise be deprived. The system is termed the Virtual Dental Home because it provides all the essential ingredients of a "health home," using geographically distributed, telehealth-connected dental teams. The VDH is a community-based oral healthcare delivery system, through which people receive dental diagnostic, preventive, and early intervention services in nonclinical community settings. It reaches people where they live, work, or receive educational or social services, reducing the need to travel to receive dental care. The idea is to link community-delivered early intervention and prevention services with more advanced services delivered in dental offices (Glassman, Helgeson, & Kattlove, 2012).

The VDH program uses affordable, portable dental equipment and telehealth technology to link community-based dental hygienists and expanded function dental assistants with dentists in dental offices (Glassman, Harrington, Namakian, & Subar, 2012). Enrollees therefore have access to a full dental team and comprehensive dental care. The dental hygienists/assistants collect dental records (including intraoral photographs, teeth charting, and digital x-rays) while offering preventive and simple therapeutic services (teeth cleanings, fluoride applications, and dental sealants). The obtained clinical information is then uploaded through a secure web-based cloud storage system for later asynchronous review by a dentist. Based on the uploaded data, the dentists diagnose, complete the exam, and develop treatment plans for patients. Services provided include health promotion and prevention education, dental disease risk assessment, preventive procedures, and placement of interim therapeutic restorations. The system was also useful for tracking and supporting the individual's need for and compliance with recommendations for additional and follow-up dental care. The VDH helped eliminate barriers accessing care such as geography, transportation, and time (Crall, 2006). It also addressed the needed oral health awareness that improves the access of care for vulnerable and underserved persons.

3. Impact

In the first 6 years of operation, the program was executed in 50 California Head Start preschools, elementary schools, community centers, residential care facilities for people with disabilities, senior centers, and nursing homes (Glassman, Harrington, Mertz, & Namakian, 2012; Glassman, Harrington, & Namakian, 2016; Glassman, Helgeson, & Kattlove, 2012). During this 6-year period, 3,442 patients were seen including 2,862 children and 580 adults (Glassman, Harrington, & Namakian, 2016). The program provided more than 50,000 dental procedures to over 2,900 individuals. Approximately two thirds of the children and half the adults with complex health conditions seen via the VDH system received all the care they needed at the community site (Glassman, Harrington, & Namakian, 2016; Glassman, Helgeson, & Kattlove, 2012). This was care they most likely would not have received otherwise.

Using teledentistry to increase access to dental care has implications for not only dental health but also overall health, well-being, and quality of life (Sabbah et al., 2019; Watt et al., 2019). It is also a cost-effective measure because early adoption of preventive dental care reduces future costs of dental treatment (Glassman, Harrington, Namakian, & Subar, 2012). The cost of the dental services delivered via VDH was estimated to be approximately one third of the cost of delivering the same services in a traditional dental office setting (California Assembly, 2013; Glassman, Harrington, & Namakian, 2016). The findings from the initial evaluation of the program were used for advocacy. These findings motivated the state legislature to authorize statewide program expansion as well as the inclusion of billing for telehealth technology services via DentiCal in 2015 (California Assembly, 2013; Glassman, 2019; Schwarz, n.d.). Since then, other states such as Oregon, Hawaii, and Colorado have developed and implemented similar programs (California Assembly, 2013; Glassman, 2019; Pacific Center for Special Care at the University of the Pacific School of Dentistry, n.d.).

4. The Future

Teledentistry, described as a disruptive innovation (Christensen. 2003), can be implemented using a number of methodologies including synchronous, asynchronous, and mobile health. The VDH is evidence of the successful use of an asynchronous approach. Although the uptake of teledentistry has been relatively slow, the recent experience with COVID-19 has accelerated its acceptance and use among both providers and patients (Brian & Weintraub. 2020). Major challenges to adopting teledentistry have been ethical, legal, and regulatory issues; payment policy issues; definition of the scope of practice; and liability coverage (Jampani et al., 2011). In particular there are concerns regarding cybersecurity and patient confidentiality, as well as the risk of nonlicensed persons generating dental exams.

The VDH program has particularly shown the potential of teledentistry to increase access to care for the underserved. It was successfully used for dental health education, consultation, and triage (Pacific Center for Special Care at the University of the Pacific School of Dentistry, n.d.). Teledentistry could be used for preventing unnecessary visits to the emergency room, physician offices, and dental offices for dental complaints. For patients, it could reduce dental anxiety and long waiting times at dental clinics thereby improving patient experience. For dental professionals it could reduce stress and burnout. Additionally, it could help reduce overhead costs for dental offices and increase revenue by reducing the supplies and equipment used in dental offices potentially reducing the cost of care. Ultimately, it has the capacity to reduce oral health access and use disparities between rural and urban areas thus benefiting the entire health system.

A number of changes that will likely require telehealth technologies are already emerging in medicine such as integrated care, interprofessional collaboration, and value-based care (O'Neil et al., 2017). Many of these changes are slowly being adopted into oral health care delivery. Thus, the importance of teledentistry for care delivery is likely to increase in future. For example, telehealth technologies may be useful for deploying interprofessional collaborative health teams including medical and dental providers to provide care. The shift from volume-based care to value-based care that emphasizes preventive care is another example. A value-based system is driven by data that can easily be gathered using telehealth methods. These changes imply a need to develop new models of dental care that will incorporate telehealth technologies. Similarly, innovative technologies that can help streamline workflow making care delivery more efficient will also be vital. As the teledentistry model of care continues to evolve, supportive policy changes for the widespread adoption of teledentistry-enabled preventive services and care coordination will be required.

5. Conclusion

The VDH is an exemplar of the potential for deploying digital innovations in the dental care industry. The use of telehealth-connected teams to reach people who do not traditionally receive regular dental care, provides the opportunity to reduce the improve oral health at population level, reduce the effect of dental neglect, and lower the cost of care. Teledentistry has the potential to completely revolutionize the field of dentistry in the near future.

Case Discussion Questions

• Q1.List other digital technologies that could be adopted for dental practice.
• Q2.Consider how the technologies listed in question 1 could be deployed effectively and their possible impact.
• Q3.List other challenges not mentioned in the case for the adoption of digital technologies in dentistry.
• Q4.Consider the identified barriers to the uptake of teledentistry and suggest potential strategies for addressing these barriers.

Be sure to answer each question with good detail.