ADEA CCI Liaison Ledger

Spotlight on Innovation: University of the Pacific, Arthur A. Dugoni School of Dentistry

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By Nicole Fauteux

Third Prize Poster: “Innovation Through Collaboration—An Overview of the University of the Pacific, Arthur A. Dugoni School of Dentistry Virtual Dental Home Program”

Might taking care of patients mean taking care to patients?

During the 2016 ADEA CCI Liaisons Summer Meeting in June, faculty from the University of the Pacific, Arthur A. Dugoni School of Dentistry (Dugoni School) presented a new model of dental care developed at the school’s Pacific Center for Special Care. Called the Virtual Dental Home (VDH), the new model employs telehealth technologies and intraprofessional dental teams to deliver care to underserved populations in residential facilities, Head Start centers and elementary schools.

The Problem

According to Fixing Denti-Cal, a 2016 oversight report on California’s Medicaid dental program, “Denti-Cal consistently falls short in caring for one-third of the state’s 39 million residents and half of its children.” The report continues, “[M]illions of people encounter [difficulties] searching for dentists who accept new Denti-Cal patients or office hours that accommodate their work schedules. At least five counties have no Denti-Cal providers at all and many other counties have no providers who accept new Denti-Cal patients. The special needs and developmentally disabled population is especially hard hit and unable to find providers.” These access barriers translate into “excessive demand for emergency care and dental surgery.”

The Innovation

Just as it is no longer necessary to hop on an airplane to talk face-to-face with a colleague on the other side of the globe, dentists no longer need to be in the same room as their patients to deliver care. Portable equipment for taking digital radiographs, electronic health records and internet connections make it possible today to gather dental information in the field, store it electronically and then forward the records to dentists, who can assess their patients remotely. By working in collaboration with dental hygienists and dental assistants, dentists can also oversee the remote delivery of some preventive and therapeutic services.

Digital technologies are essential to this innovative model, but the VDH breaks ground in other ways as well. The model also builds on a change in the California Dental Practice Act that came about through the efforts of Dugoni School’s VDH pioneers. 

California has an unusual mechanism for modifying laws that affect the delivery of health care. The Office of Statewide Health Planning and Development (OSHPD) allows organizations to initiate pilot projects to test whether proposed changes are both safe and effective. Demonstration projects that benefit patients can then become the basis of new law.

Paul Glassman, D.D.S., M.A., M.B.A., Director of the Pacific Center for Special Care, had been aware for a long time that many underserved patients had difficulty getting to a dentist’s office. He teamed up with other groups interested in finding a way to address this problem, and they concluded that allied dental professionals working with a collaborating dentist could keep these individuals healthy in the community without bringing them to a dental clinic.  The plan would require teaching allied dental providers to conduct two activities that previously fell outside their scope of practice under the state’s dental practice act:

  • Using protocols to decide which radiographs to take.
  • Placing interim therapeutic restorations.

Dr. Glassman took advantage of the OSHPD mechanism to initiate a pilot project that would allow Dugoni School faculty to educate a cadre of allied professionals in both of these skills and ultimately to test the proposed VDH model in eleven communities and fifty sites across California.

According to a report by Dr. Glassman and colleagues, intraprofessional teams of VDH dentists, dental hygienists and dental assistants provided nearly 53,000 procedures to almost 3,500 patients during the six-year pilot. The teams succeeded in keeping healthy—without in-person visits to dentists—half of the long-term care-facility patients and two-thirds of the children treated.

The pilot demonstrated the following outcomes:

  • Interim therapeutic restorations (temporary bonded fillings using glass ionomer) showed a high retention rate.
  • An independent dentist evaluator deemed acceptable all of the procedures performed by allied dental providers.
  • No adverse outcomes were reported. 

The VDH achieved its goal of getting safe and effective dental care to people who were not being served through traditional avenues of care. A subsequent financial analysis suggested that the model could be an economically viable and less costly way to treat Denti-Cal patients. As a result, the state passed legislation to incorporate VDH activities in the scope of practice of the state’s allied dental providers. The law also requires the state to pay dentists in its Denti-Cal program for covered services regardless of whether the services are provided in-person or through the use of “store-and-forward” teledentistry.

Educational Implications

California requires its dental hygiene programs to prepare their students to provide all services that are within their scope of practice. To meet this need, Dugoni School has been working with California’s dental hygiene programs to educate faculty in teaching students to make decisions about radiographs and to place the specified temporary restorations. Dugoni School also expects to work with the state’s two programs that educate Registered Dental Assistants in Extended Functions, the other group of allied dental providers whose scope was expanded by the law. 

Within the dental school itself, Dugoni School has also begun a new teledentistry rotation for all senior dental students. They will review records gathered in the community to develop treatment plans and determine what care allied personnel can provide remotely and for what services the patient must be referred to a traditional clinical setting. In January, Dugoni School’s dental hygiene students, with faculty supervision, will begin taking records in the field, uploading them for review, and in subsequent appointments, providing care in community locations. Within a few years, Dugoni School’s dental and dental hygiene students will graduate having experience providing care in telehealth-connected dental teams and VDHs. 

Next Steps

The use of teledentistry is catching on elsewhere. Dugoni School has contracts in Colorado, Oregon and Hawaii to implement the VDH model, and other states have copied California’s legislation to formulate their own teledentistry laws.

“In a decade,” Dr. Glassman predicts, “the Virtual Dental Home will be widespread in practice, and schools will be incorporating it in their curricula. I think we’ll see a wave moving across the country, probably from west to east.”

His colleague, Paul Subar, D.D.S., Ed.D., FACD, Associate Professor of Dental Practice and Director of Special Care at Dugoni School, agrees. “We have an older population that’s living longer; more people are having trouble getting to a dentist for even basic dental care,” he says. “We really think the Virtual Dental Home is a way for dentists to reach beyond their four walls.” 

This development will be critical, says Dr. Subar, if California is to reduce the cost of emergency dental care. He says there were more than 90,000 emergency department visits for dental abscesses in California last year alone.

Dr. Subar acted as spokesperson for the VDH at the June ADEA CCI Liaisons meeting. The following people helped Dr. Subar craft the presentations that propelled the Dugoni School poster to success:

  • Co-author Alan Budenz, M.S., D.D.S., M.B.A., Professor, Department of Biomedical Sciences and Vice Chair, Department of Dental Practice
  • Lucinda Lyon, RDH, D.D.S., Ed.D., CCI Liaison and the Dugoni School’s James R. Pride, D.D.S. Carolyn L. Pride Endowed Chair for Practice Management

The team plans to use the prize money to support the workforce research being conducted within the Department of Dental Practice.

   


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