Training dental hygienists to place interim therapeutic restorations in a school-based teledentistry program: Oregon's virtual dental home.

OBJECTIVES: The objectives of this study on Oregon's virtual dental home were to: 1) demonstrate the feasibility of pilot project training of existing Expanded Practice Dental Hygienists (EPDHs) to perform interim therapeutic restorations (ITRs) in the community settings after diagnosis by the supervising dentist via teledentistry and 2) evaluate satisfaction of parents/guardians of children participating in a pilot program that provides school-based/on-site preventive dental care services utilizing expanded scope EPDHs to conduct dental screenings and place ITRs. METHODS: This demonstration project was a 4-years longitudinal cohort study (2016-2019) in the school/community-based settings focusing on children in kindergarten to 3rd grade. EPDHs and dentists from a Dental Care Organization were trained to utilize teledentistry and EPDHs were trained to place ITRs, the latter provided onsite dental care. Data was collected regarding child's demographics and oral health status; and parents reported level of satisfaction from services received by their children. Data analysis included descriptive statistics and logistic regression analysis to assess the relative importance of demographic and clinical factors on caries status. RESULTS: Onsite dental care was provided to 759 children. Of repeat patients (n = 377), 201 (53.3%) children had untreated decay at their first visit. Of these, 13% saw improvements in oral health status at their most recent visit (MRV). There were 162 ITRs planned out of which 50 patients received 99 ITRs. No adverse events were experienced. Of the repeat children receiving ITRs (n = 43), 28% saw improvement in their caries status at their MRV. Parents reported very high levels of satisfaction with the dental care program. CONCLUSION: Oregon's virtual dental home project was successful in training EPDHs to perform ITRs safely in school settings after caries diagnosis by the supervising dentist via teledentistry and in integrating this component into a regular school-based preventive dental program.

Interventions Focusing on Children with Special Health Care Needs.

The term children with special health care needs encompasses a wide variety of conditions. When considering interventions, a broad definition of children with special needs is suggested in this article along with a focus on developing specific treatment recommendations based on a thorough data-gathering process and developing customized recommendations for children based on their unique circumstances. An area for future research is increasing the understanding of the relationship between customized recommendations and the underlying special health care needs.

Interprofessional Collaboration in Improving Oral Health for Special Populations.

People with complex medical, physical, and psychological conditions are among the most underserved groups in receiving dental care and consequently have the most significant oral health disparities of any group. The traditional dental care delivery system is not able to deliver adequate services to these people with "special needs" for a variety of reasons. New systems of care are evolving that better serve the needs of these groups by using interprofessional teams to reach these individuals and integrate oral health services into social, educational, and general health systems.

Potentially preventable dental care in operating rooms for children enrolled in Medicaid.

BACKGROUND: In this study, the authors examined the prevalence and cost of care for children enrolled in Medicaid for potentially preventable dental conditions who receive surgical care in hospital operating rooms (ORs) or ambulatory surgery centers (ASCs). METHODS: The authors analyzed Medicaid data from 8 states to find cases in which children aged 1 to 20 years received surgical care in ORs or ASCs in 2010 and 2011 for potentially preventable diagnoses, as defined with diagnostic codes. RESULTS: For 6 states with complete data, there were 26,373 cases in 2011 in which children received OR or ASC surgical care for potentially preventable conditions. These cases represent approximately 0.5% of all children enrolled in Medicaid in these states and approximately 1% of children enrolled in Medicaid who received any dental care. There were $68 million in total Medicaid payments for these cases, with an average of $2,581 per case. Diagnostic codes indicated that 98% of cases were related to treatment of dental caries. More than two-thirds of the cases (71%) were children aged 1 to 5 years. CONCLUSIONS: Extrapolation to the United States suggests that approximately $450 million in additional expenditures occurred in 2011 because of OR or ASC surgical care for potentially preventable pediatric dental conditions, primarily related to early childhood caries. PRACTICAL IMPLICATIONS: Strategies to improve prevention of early childhood caries, including community- and family-based education, and to increase access to timely and early dental care for low-income children could reduce the burdens and costs of these dental problems.

Disruptive Innovation and the Oral Health System.

Disruptive innovation is a process whereby companies or industries that have succeeded in the past by producing ever more sophisticated and expensive products and services end up losing their customer base because eventually others enter to serve a market more in line with true consumer needs. The U.S. oral health system has followed this path and is now perfectly positioned for disruptive innovation. Among the innovations that are already disrupting the industry and will increasingly do so are consolidation of dental practices, bringing care to where people are through telehealth- health connected teams and Virtual Dental Homes, and payment systems that provide incentives for lowering costs and improving the health of the population.

Geriatric Dentistry in the 21st Century: Environment and Opportunity.

The aging of the baby boomers in the 21st century is creating unprecedented numbers of vulnerable older adults. The increase in people keeping their teeth and their increasingly complex conditions all point to more people with more complex needs. Although these demographic shifts are providing unparalleled challenges for our health care system, they also bring new opportunities to develop and implement innovative systems for reaching and maintaining the oral health of older Americans.

Interprofessional practice in the era of accountability.

A large and increasing segment of the population does not access the traditional oral health care system until they have advanced disease, pain and infection. Opportunities for improvement of this situation include applying new science in chronic disease and caries management, using community-based telehealth-connected teams, emphasizing interprofessional practice by integrating oral health into educational, social service and general health systems, and focusing attention on oral health outcomes in the era of accountability.

The potential for telehealth technologies to facilitate charity care. Creating virtual dental homes.

The dramatic increase in broadband connectivity is opening up the possibility for using telehealth-connected teams in an improved system for charity care. The Virtual Dental Home demonstration taking place in California provides a model for the development and deployment of such teams. Teams using telehealth connections to provide oral health care can transform episodic or one-time visits into an ongoing system of care with a much greater emphasis on prevention and early intervention techniques and a greater likelihood of improved oral health for the population.

Promoting oral health through community engagement.

Persistent health disparities still exist in the U.S. despite decades of focus on the importance of prevention. Individual behaviors are the major contributor to oral health. By partnering and linking with community organizations, oral health professionals can expand their reach, overcome the obstacles to delivering effective prevention activities in dental offices and improve the oral health of the most underserved and vulnerable populations, who bear the greatest burden of dental disease.

Managing caries in virtual dental homes using interim therapeutic restorations.

The Pacific Center for Special Care at the University of the Pacific, Arthur A. Dugoni School of Dentistry has developed the virtual dental home (VDH) system, which uses allied dental professionals trained to place interim therapeutic restorations (ITR) under the general supervision of dentists. This paper reviews the scientific basis for the ITR, as used in the VDH system, in managing caries lesions and delivering oral health care to underserved and vulnerable populations.

The oral health of vulnerable older adults and persons with disabilities.

Demographic trends in the United States show that the number of people with one or more disabilities is going to increase dramatically over the coming decades. This paper describes the types of disabilities that make up this increase and documents growth of this population over the next 40 years. Dental care market forces are defined and analyzed as they will influence the ability of vulnerable elders and people with disabilities to purchase dental care. The capacity of the dental profession to deliver appropriate high quality dental services to vulnerable elders and people with disabilities is also discussed. Dental disease trends are presented along with a description of the changing living arrangements characterized by the newly termed "senior industry." The paper concludes with the disquieting conclusion that the need for dental care among vulnerable elders and people with disabilities will dramatically increase while the capacity of the dental profession will not keep up with the expanding need and demand for dental case across the entire U.S. population. Thus, disparities in oral health and access to dental care are likely to occur for vulnerable able older adults and persons with disabilities.

Oral health delivery systems for older adults and people with disabilities.

This article describes new oral health care system models designed to meet the needs of a rapidly growing population of older adults and people with disabilities. These populations are not currently able to access traditional dental offices and clinics to the same degree that younger and much healthier population groups do. So new models proactively target specific community organizations where these high-risk underserved population groups live, work, go to school, or obtain other health or social services. Collaborative on-site and clinic-based teams establish "Virtual Dental Homes" that provide ongoing, year-round access to oral health services designed to prevent mouth infections, deliver evidence-based preventive care, and restore infected individuals to stable and sustainable oral health. These new delivery models are beginning to demonstrate better health care delivery, better health outcomes, and the potential to drive down total health care costs for older adults and people with disabilities.

Pre- and postdoctoral dental education compared to practice patterns in special care dentistry.

There has been limited research into the impact of predoctoral experiences and postdoctoral general dentistry residencies on the practice patterns of dentists in the care of patients with special or complex needs. This study was undertaken to determine if educational experiences with special populations had a relationship to practice patterns after graduation or residency. University of the Pacific alumni who graduated between 1997 and 2007 were surveyed regarding their pre- and postdoctoral dental education and their practice patterns for the care of patients categorized as medically compromised, frail elders, and developmentally disabled. Definitions for each patient category were provided. Alumni were asked about their practice setting and postdoctoral education. Thirty-one percent (n=526) of those surveyed responded. Regression analyses showed respondents not in private practice were more likely to have completed a postdoctoral general dentistry program (Advanced Education in General Dentistry or General Practice Residency) after dental school compared to respondents in private practice (p<0.001). Across all age groups, respondents not in private practice treated significantly more patients with developmental disabilities than those in private practice (p<0.001). Respondents not in private practice treated more medically compromised patients younger than age sixty-five compared to respondents in private practice (p<0.01). Interestingly, those in private practice treated significantly more patients over sixty-five who were also classified as medically compromised (p<0.05). Pacific alumni who completed postdoctoral training in general dentistry were found to practice more often in non-private practice settings. Alumni in non-private practice settings reported treating a higher percentage of medically compromised patients below age sixty-five than their counterparts in a typical private practice. The pre- and postdoctoral experiences of treating special needs populations appear to have a relationship to graduates' practice setting and patient population.

Using telehealth technologies to improve oral health for vulnerable and underserved populations.

Telehealth refers to the use of technology to provide health care at a distance. The important and increasing role of telehealth in the delivery of health care has been recognized for several decades. Although there are fewer reports on the use of telehealth to deliver oral health services, evidence is emerging that these technologies can enhance the ability of the oral health delivery system to reach vulnerable and underserved populations.

The virtual dental home: bringing oral health to vulnerable and underserved populations.

Large and increasing oral health disparities in the U.S. population led the Institute of Medicine to call for expanded research and demonstration of delivery systems that test new methods and technologies. These new methods include delivering oral health services in nontraditional settings, using nondental professionals, expanded roles for existing dental professionals and new types of dental professionals, and incorporating telehealth technologies. The virtual dental home is a system that demonstrates the characteristics called for by the IOM.

In-person versus "virtual" dental examination: congruence between decision-making modalities.

This study evaluated the agreement of a dentist's conclusions reached through an in-person versus a virtual examination. The dentist determined whether a patient was healthy enough to be treated only by allied dental personnel in a community setting or whether the patient needed to be seen by a dentist. The study concludes that a virtual examination is a strong substitute for an in-person examination and validates the application of telehealth-enabled examinations.