Five-year-old Katherine Turcios looked skeptical as a hygienist held up a pen-sized dental instrument for the kindergartener to examine.
“No pica,” she told Katherine, assuring her it wouldn’t hurt. Then she placed it in the child’s hand so she could see for herself that it wasn’t sharp.
During her hour-long appointment at Danbrook Elementary School in Anaheim, a specially qualified hygienist and two assistants took Katherine’s X-rays and photos. Then they uploaded the images for review by a dentist who was miles away; he or she would get back with a treatment plan within 48 hours.
By the time Katherine climbed down from the chair to return to her classroom, a gathering of school officials were there to cheer her on.
She was among the first patients of Danbrook’s new teledentistry program, a pilot effort in what its creators believe is a key strategy for eliminating dental health disparities statewide.
“We would hope this becomes a successful model to deliver care in all underserved communities,” said Ria Berger, CEO of nonprofit dental provider Healthy Smiles for Kids of Orange County in Garden Grove.
Healthy Smiles is working with medical clinics to roll out the teledentistry effort in three more Orange County schools and 24 Head Start programs by spring of 2017.
Close yet far away
While it’s not unusual to upload medical images from remote areas to specialists in far-away cities, what’s more surprising about the Anaheim model is that it’s taking place in urban areas where dentists are plentiful.
But proximity doesn’t always mean access. Even though 70 percent of the kids at Danbrook are publicly insured through California’s Denti-Cal program, finding a dentist who accepts Denti-Cal can be difficult.
In April, an independent state agency wrote a scathing report calling for an overhaul of Denti-Cal, criticizing its low reimbursement rates and outdated bureaucracy. The report said that dentist participation in the program has declined by 15 percent since 2008 despite 5 million new patients.
One recommendation from the report, by the Little Hoover Commission, was to support legislation AB 648, which would establish a grant program to more widely implement the teledentistry model being put in place in Orange County. AB 648 made it through the Assembly in June and is awaiting Senate action.
The Danbrook program replicates a model tested over six years in 50 sites around the state and designed by Paul Glassman of University of the Pacific School of Dentistry in San Francisco.
A study in June confirmed the benefits of the model, called the Virtual Dental Home, which assigns specially qualified hygienists to work on site – at schools, community centers and senior centers. The dental staff brings portable equipment, including a reclining chair, X-ray camera and water pic, holding office hours every week and sending records to dentists electronically to supervise treatment.
The study found that the majority of children participating received all the care they needed on site without having to go on to a dentist office and with no adverse outcomes reported.
“Through our model, we were able to keep two thirds of our patients healthy with only hygienists touching them. That’s a huge advance over what traditionally happens in populations where they get no care until the disease is advanced, and then they end up in the emergency room of a hospital,” Glassman said.
The demonstration not only sought to prove that teledentistry can deliver sound oral health care but that it can do it more economically.
“We can keep people healthy at a much lower cost,” Glassman said. And by working remotely, “We can reach people who aren’t being reached.”
Under Glassman’s model, specially credentialed hygienists can fill most cavities on site with a temporary filling expected to last for the life of the baby tooth. This method doesn’t require a drill or needles. Other on-site procedures include cleaning, fluoride application and sealants if necessary.
Barriers to care
Gaps in insurance aren’t the only reason why lower income children don’t get dental care. Some don’t have insurance; at Danbrook, Healthy Smiles will examine uninsured patients and offer them fluoride varnish. Uninsured patients needing further treatment will be steered toward Denti-Cal enrollment or referred to Healthy Smiles’ dental offices off site.
But even among the insured, some parents don’t have a car or they can’t take the time off during the work week, a common problem at Danbrook, said Elisa Briseno, director of program development at Healthy Smiles.
Some barriers are educational, she said. While many parents are strict with “no candy” policies, they don’t always realize the effects of sugar drinks. And the bacteria that causes baby teeth to rot will do the same to the adult teeth that replace them, experts say. Further, family members pass the bacteria to one another, which is why dental decay is now viewed as an infectious disease.
One result is 51 million lost school hours each year in the U.S.
Principal Ligia Valera is well familiar with the effects of poor dental care on students, which is one reason she is excited about the teledentistry program coming to her school, Wilson Elementary in Santa Ana.
“Right now I have a parent who came to me yesterday and said, ‘Is it true there will be some dentists on campus for my kid? His teeth are rotted’,” Valera recalled. Other students rely on numbing medications for toothaches or feel self-conscious about their breath or smiles.
Tomas Alvarez of Anaheim, whose daughter Emily was among the first dental patients at Danbrook, said he was grateful for the convenience of on-site care. While he tries to take his kids to the dentist every six months, he hasn’t always managed it during times when the family didn’t have a car.
When it came time for Emily’s school dental appointment, he asked if he could sit in because he wanted to know how the kids would be treated. Not only was he glad she got X rays and a cleaning, he appreciated being made to feel welcome. And Emily had no complaints.
“When she got home she said she was happy that everyone treated her nice. She even got hugs from the dental assistants,” he said.