Recent data out of California has shown that close to 90,000 children go to the emergency room for dental care each year. Although the cost of those visits is tens of millions of dollars, often little more is done than prescribing antibiotics to control infections. While that is important, after such a visit a child’s teeth remain decayed, posing significant risks for adult dental health problems, which can lead to illnesses, deaths, huge out of pocket costs and reduced job opportunities if teeth are noticeably missing.
But California is now also the first state in the nation to permit dentists to take care of underserved kids and adults virtually. A law passed at the end of September vastly expands the Virtual Dental Home, a demonstration project that uses telehealth technology to bring dental services directly to patients in community settings, such as preschools, elementary schools and nursing homes.
Under the program, dental hygienists and assistants perform preventive care and provide patient information electronically for review by an off-site dentist. Under the direction of the dentist, the providers can also place temporary fillings—no drilling required—which can last for years, according to Jenny Kattlove, an oral health policy analyst for The Children’s Partnership, a children’s advocacy group. Patients who need more advanced care are referred to a dentist, and often they’re the dentist who worked with their technician.
A recent Pew study examined how the Virtual Dental Home worked at an elementary school in Sacramento, where the program provided cost-effective services to low-income children who did not have a regular source of dental care. Care under the Virtual Dental Home is paid for under California’s Medicaid program.
According to research by the University of the Pacific Arthur A. Dugoni School of Dentistry, which operates the Virtual Dental Home pilot program, more than 30 percent of Californians are unable to meet their oral health needs through the traditional dental care system. More than half of California’s Medicaid-enrolled children received no dental care in 2012 and even fewer received preventive care services.
NewPublicHealth recently spoke with Kattlove about the new law and its potential as a model for dental care for low income individuals across the country.
NewPublicHealth: What is the most significant advantage of the Virtual Dental Home?
Jenny Kattlove: The Virtual Dental Home is a way to diversify or disperse the workforce so that all the professionals are working at the top of their skills and expertise. By putting dental hygienists in a community setting and having them take care of the majority of the care that the child needs, the dentist can be in the clinic or in their dental office taking care of the more complex needs and supervising the hygienist.
NPH: Where are the hygienists located and where do they set up the remote tele service?
Kattlove: The hygienists are in various locations: Head Start sites, in schools, assisted living facilities and in residential centers where individuals with developmental disabilities live. So, the Virtual Dental Home doesn’t just reach underserved kids—it also reaches other underserved communities that have difficulty getting the dental care they need. And all the equipment fits in the trunk of his or her car and it takes just 15 minutes to set everything up, including a x-ray system the size of large blow dryer. In a school they might use an empty classroom and in a Head Start site just a corner of the room.
The hygienist sends the data over a secure online server to the supervising dentist. Within about 48 hours, the dentist takes a look at all of the records and develops any needed treatment plan. For the most part, the dental hygienist can carry out what’s in the treatment plan, and there are a number of options.
One possibility can be that the child needs what’s called interim therapeutic restoration, and this is one of the changes that was allowed through the legislation. It’s a temporary filling that requires no anesthesia and no drilling, and it’s very similar to a sealant, but it actually goes a little bit deeper. And while it is temporary, they can last years, and no interim therapeutic restoration—at least through the Virtual Dental Home—has been recommended to be replaced. The procedure actually stops the decay from progressing.
NPH: Will the dentist feel that they’re fairly compensated? Is there a concern that not enough dentists will step up to work with these hygienists?
Kattlove: To date, there has not been a problem identifying dentists who want to participate, and I think that’s because California has a fairly robust federally qualified health center system, so the majority of the dentists are working in clinics that focus on this exact population. In terms of being fairly compensated, the legislation that we helped to get enacted will now allow the dentist to be reimbursed for the dental visit. Before it was all grant funded and it was a demonstration project.
This is a way more cost-effective way to provide dental care to underserved kids, because a dentist visit is a lot shorter when the child doesn’t have to come in and there’s not that overhead. Instead, the dentist is taking about 10 minutes or so to review the records and do the review. So, it actually provides service at a lower cost so there’s a cost effectiveness to it while still providing high-quality, safe dental care. Reimbursement rates are an issue in California and have impacted the number of private dentists that will see children enrolled in Medi-Cal, but to date the sort of creator of the Virtual Dental Home hasn’t had difficulty recruiting dentists to participate.
NPH: Do you think that other states will look to the California model now that the legislation has been passed?
Kattlove: We do think that there’s going to be implementation of basically a telehealth-enabled dental care service delivery system based on what works for each state, although specific legislation may be needed to address the scope of practice for both hygienists and dentists. Dr. Paul Glassman, who created the Virtual Dental Home, is providing technical assistance to both Oregon and Hawaii, and they are both looking at models similar to California’s. I think this is really a huge victory for California kids and can be a model for underserved kids across the nation.
