Abstract
Purpose: Access to adequate dental services is limited for children in rural communities in the United States.The purpose of this paper was to describe how two school-based teledentistry programs increased access to oral health services for children and adolescents living in rural areas.
Methods: The School-Based Telehealth Network Grant Program (SB TNGP) was designed to expand access to, and improve the quality of health care services in schools through telehealth. Data were collected from July 1 to December 31, 2019 on 164 students at 7 preschool sites by Marshfield Clinic Health System (MCHS) and on 1,467 students at 57 school sites by Children’s Dental Services (CDS).
Results: Both MCHS and CDS reported that over 99 percent of encounters were successfully completed using telehealth technology. Both grantees reported that 99.4 percent of students received an oral health evaluation/screening, primarily through a dental hygienist traveling to the school site connected to a dentist or advanced dental therapist through telehealth. One half of the students had dental caries (50.6 % MCHS; 48.6% CDS). Both grantees referred all students with dental caries for oral health follow-up care.
Conclusions: By utilizing dental hygienists traveling to school sites and connecting with centrally located dental professionals through telehealth, both grantees increased access to needed oral health care services for rural children. Oral health screening in school settings using dental hygienists with teledentistry can provide an efficient way to identify students at high risk for dental caries and offer a valuable strategy for oral disease prevention and control.
- teledentistry
- telehealth
- telemedicine
- pediatric dentistry
- school-based health care
- dental hygienists
- access to care
Introduction
Dental caries is a common, chronic childhood illness in the United States (US). Healthy People 2030 reported that 13.4 percent of children and adolescents aged 3 to 19 years had active and untreated tooth decay in their primary or permanent teeth.1 Poor oral health can lead to pain, infection, and tooth loss, which may have life-long impact. According to the World Health Organization, tooth loss can affect children’s nutritional intake as well as their growth and development and may lead to malalignment of permanent (adult) teeth.2 Studies have shown that children with dental pain are three times more likely to miss school3 and generally have poorer overall health and worse school performance.4 Unfortunately, over 30 percent of the US population live in Dental Health Professional Shortage Areas (DHPSA).5. Access to adequate dental services is particularly limited for children living in rural areas6 with studies citing reasons such as higher rates of poverty, lower rates of insurance, fewer dentists, and greater distances to travel to a dental office for care.7-9
Telehealth presents a potential solution to this lack of access to oral health services in rural communities. The use of telehealth in oral health (teledentistry) generally involves a dental clinician traveling to a remote site and connecting either through live video (synchronous) or store-and-forward (asynchronous) technology to a dentist or other dental professional at a larger setting.10 Recent systematic reviews concluded that the validity of using teledentistry for oral care examination and diagnosis is comparable or superior to in-person oral screening in both adult and pediatric populations.11,12 Results from another systematic review demonstrated consistently high clinician satisfaction with teledentistry, improved clinical outcomes, and evidence of cost savings.13 Consequently, teledentistry has evolved in its implementation in the field in recent years. These changes were further hastened by the COVID-19 public health emergency and regulatory adjustments promoting telehealth adoption and use.
One approach to addressing oral health needs in children and adolescents has been to offer health care programs at their school site. School-based telehealth offers an opportunity to expand and enhance access to oral health care services. However, telehealth was only utilized by 12% of school-based health clinics in 2016-17.14 More research is needed to explore how school-based teledentistry programs can address the gap in access to oral health services.
In September 2016, the Health Resources and Services Administration (HRSA) Office for the Advancement of Telehealth (OAT) awarded grants to 21 organizations across the country for the School-Based Telehealth Network Grant Program (SB TNGP). This grant program was designed to demonstrate how telehealth can expand access and improve the quality of health care services offered in schools. Grants were targeted to rural schools in provider shortage areas providing telehealth services to children and adolescents, with a focus on five clinical areas: asthma, behavioral health, diabetes, healthy weight, and oral health. The purpose of this paper was to describe how school-based teledentistry programs increased access to oral health services for children and adolescents living in rural areas based on results from two grantee organizations.
Methods
Teledentistry encounters with students were documented by two SB TNGP grantees who specialized in oral health and did not provide telehealth for the other clinical areas. The Marshfield Clinic Health System (MCHS) and Children’s Dental Services (CDS) goals and approaches to teledentistry are briefly described.
Marshfield Clinic Health System operated in a state with 36% of counties designated as DHPSAs and selected rural communities that qualified as DHPSAs. The MCHS worked with two dental centers operating near these rural communities. Each dental center worked with Community Action Association locations for Head Start (HS) programs and established memorandums of understanding for the program. The selection of specific HS programs was based on MCHS’s internal assessment of community needs. The chosen communities had a high percentage of low-income Hispanic/Latinx families. Marshfield Clinic Health System offered dental screenings to these rural preschools. Participating schools sent consent forms home with children for parents/guardians to consent to teledentistry services with an option to opt out of fluoride varnish application.
A dental hygienist traveled to the schools and typically set up in a school lunchroom or office. Students came in one at a time for dental screening and fluoride varnish application, if appropriate. A dentist at one of two dental centers could talk with the student via a two-way video connection on a laptop computer. The dental hygienist used a laptop with USB connected intraoral camera along with software that allowed the remote dentist to connect to the device and use the camera to see the teeth and conduct the examination. In some locations with limited broadband, MCHS provided a hotspot for connectivity as well. On average, the dental hygienist and remotely located dentist screened 23 children per preschool site per day. Different teams of dental hygienists and dentists provided the services, and all received training on how to use the equipment and software platform and had technical support from the software vendor and MCHS. Dentists from MCHS made occasional site visits with a focus on building and maintaining relationships between MCHS and preschool site personnel rather than delivering services. Dental assistants were sometimes sent to assist the dental hygienist as working with young preschoolers could be challenging. Likewise, some of the remote dental providers had a dental assistant in the office assisting them, generally for scribing. After the basic assessment, a summary report was sent to the student’s parent/guardian indicating if the student needed urgent, emergent, or routine oral health care.
Children’s Dental Services identified counties with high needs through a needs assessment and determined that the target population for this project would be children and adolescents from low-income families. The CDS operates in a state with 29 percent of counties designated as DHPSAs and selected schools that were located in rural communities that qualified as DHPSAs. A system of referrals for dental services was already in place among CDS’s network partners. Schools were selected based on their accessibility to these network partners and approval from the school district administration. For ease of operation, all schools chosen were within school districts with which CDS had an established relationship. Children’s Dental Services provided a full scope of oral health services in schools and Head Start centers, targeting students who did not have a dental home; parent/guardian consent forms were distributed at participating schools.
Dental hygienists or licensed dental assistants traveling to the school site with portable equipment used a store and forward (asynchronous) telehealth connection to a dentist or advanced dental therapist at the CDS dental headquarters location. All the materials uploaded into the patient record were visible almost immediately at the remote location for the dentist or advanced dental therapist to view. A laptop, intraoral camera, digital x-ray sensors, a dental electronic health record (Open Dental), and hot spot for schools with limited or no Wi-Fi were used by the clinicians at the school site. The program was staffed with 1.0 FTE dentists, 1.5 FTE registered dental hygienists, 1.0 FTE advanced dental therapist, and 1.5 FTE licensed dental assistants. Staff were trained at the headquarters location by the clinical manager and dental director; CDS’s information technology group provided individual training as well.
Data Collection
As part of this initiative, OAT funded the Rural Telehealth Research Center (RTRC) to serve as a data coordinating center for the program and an extensive literature review was conducted to identify possible measures for data collection.15 These measures were reviewed and went through three rounds of scoring by the research team, external experts, and the SB TNGP grantees for clarity, importance, usability, sensitivity, and feasibility.15 The oral health measures selected were: 1) number of students who received a School-based oral health evaluation/screening; 2) number of students who received a school-based dental screening and were diagnosed with dental caries; 3) number of students who were referred for follow-up oral health services; and 4) number of eligible students who received a dental sealant on a permanent molar as a school-based dental service.
The RTRC translated the measures into data elements and created and implemented the school-based Telehealth Evidence Collection (S-TEC) tool to systematically collect data from SB TNGP grantees.15 The tool went through multiple iterations of internal testing among research team members and other affiliated personnel. Following testing of the tool, the software was beta-tested by grantees. Grantee feedback and comments were addressed before the data collection tool was submitted to HRSA and the Office for Management and Budget (OMB) for review. Following OMB approval, the S-TEC tool, data element dictionary, and user manual were distributed to all grantees and training webinars were provided by the RTRC research team. Data use agreements were established between RTRC and each grantee, and all involved entities secured Institutional Review Board Human Subject Review approval as needed. The grantees reported data at the school, student, and encounter level on all telehealth services provided in schools from July 1 to December 31, 2019. A prospective observational cohort design was used; descriptive statistical analyses were performed using statistical software (Stata 16, StataCorp; College Station, TX, USA).
Results
Demographics
Data were collected on students at 7 school sites by MCHS (n=164) and at 57 school sites by CDS (n=1,467). Student populations had similar characteristics with the exception of a higher percentage of younger and Hispanic/Latinx students at MCHS than CDS. Schools served by MCHS focused on pre-kindergarten or early childhood education and ranged in age from 3 to 5 years with a mean age of 3.6 years (SD = 0.6). In contrast, schools served by CDS represented a broader student population ranging in age from 1 to 18 years with a mean age of 8.1 years (SD = 4.1). Over half (56%) the students were in primary schools (aged 5 to 11 years), 23% were in secondary schools (aged 12 to 18 years), and the remaining 21% were in pre-kindergarten (aged birth to 4 years). Of all students served by CDS, 12 % were identified as having special health care needs including behavioral challenges, deafness, or the need to be treated in a wheelchair. The CDS clinicians were able to serve 89 percent of these students, with 11 percent referred to a traditional clinic for follow-up services. Sample demographics are shown in Table I.
Participant demographics
Telehealth Encounters
The distribution of encounters per student for teledentistry services is shown in Table II. The MCHS group saw each student once for teledentistry services. The CDS saw 70.6% of the students once, however the remaining 29.4% of students were seen for additional teledentistry encounters. Both MCHS and CDS reported that over 99% of encounters were successfully completed using the telehealth technology.
Distribution of teledentistry encounters
Clinician Participants
All MCHS schools were visited by a dental hygienist with a dentist connected remotely through video, thus the encounters involved two clinicians working synchronously. At the CDS school sites, a variety of clinician types were involved in teledentistry encounters. For the first encounter, a dental hygienist provided service in 42.2% of cases and a licensed dental assistant and an advanced dental therapist combination provided services in 39.7% of cases. For subsequent encounters, a licensed dental assistant and advanced dental therapist combination were the most frequent clinicians for the second encounter (58.9%) and third encounter (64.0%) with dental hygienists providing care in 21% of second and third encounters. In cases involving an advanced dental therapist visit on-site for restorative care, telehealth was used to connect to a supervising dentist at a remote site for supervision under a Collaborative Management Agreement. Other types of clinicians, either alone or in combination, provided teledentistry care in the remainder of cases.
Services Provided
All but a few students received multiple oral health services during teledentistry encounters. At MCHS, 95.7% of students received an assessment in which the dentist examined the child’s teeth and noted dental caries, a report to the child’s parent/guardian on follow-up needs, and a fluoride varnish application. At the CDS sites, nearly all students received a fluoride varnish application, and many students received x-rays, prophylaxis/scaling, a clinical examination and assessment, and oral health instructions, especially during their first encounter. A breakdown of the services provided along with the most common restorative procedures and number of fluoride applications is shown in Table III.
Oral health services provided in teledentistry encounters*
Incidence of Dental Caries
Both grantees reported that 99.4 percent of students received an oral health evaluation/screening. Evaluation/screening results for both grantees indicated that half of the students had dental caries (50.6% MCHS; 48.6% CDS). At the CDS school sites, the prevalence of dental caries varied by age. While 17.0% of the pre-kindergarten students had dental caries, 55.6% of the primary school students and 60.5% of secondary school students had dental caries. All students who were identified with dental caries during screening were referred for oral health follow-up by both the MCHS and CDS providers. For the MCHS sites, this consisted of a letter to the parent/guardian with recommendations for follow-up care. At the CDS sites there were additional encounters provided by a dental hygienist, which were followed up by a dentist or advanced dental therapist. If restorative treatment needs were identified, the dentist or advanced dental therapist followed up with an in-person appointment. Of the students screened by CDS, most (98%) wished to receive ongoing care from CDS as their “dental home” provider and were subsequently linked to CDS for that purpose.
Discussion
While the two school-based teledentistry programs described in this paper differed in the services provided, the services provided aligned with the age of the student populations served and individual patient needs. In particular, the MCHS programs focused on preschool settings and completed assessments and fluoride varnish applications for all students and identified half of the students with dental caries who received recommendations for further services. In contrast, CDS programs served the entire pediatric and school age population (pre-kindergarten, primary, and secondary) and provided screening, preventive, and restorative services, sometimes through multiple encounters, for students needing treatment. Both program types demonstrated that dental clinicians traveling to school sites and connected through telehealth with centrally located dentists and advanced dental therapists increased access to needed oral health care services for children living in rural communities.
Findings from this study highlight various staffing approaches for teledentistry. The MCHS administered programs sent a dental hygienist to schools who then connected to a dentist at the central site via video. In contrast, CDS used multiple combinations of traveling dental hygienists or licensed dental assistants sending images to hub dentists or advanced dental therapists. The teledentistry relationship enabled a traveling dental hygienist or advanced dental therapist to have virtual, real-time access to a supervising hub dentist in the event of any questions encountered. This approach enabled traveling clinicians to complete nearly all (97%) of the of diagnosed treatment under their respective scopes of practice and reduced the need for an in-person visit with a dentist by half (52%). These approaches to staffing are similar to other teledentistry programs across the country.16,17 However, researchers in both Australia and in rural areas of New York have employed a different staffing approach involving teachers who have been trained to use intraoral cameras to take images that could be sent to hub dentists for diagnostic evaluation.18-21 The use of role substitution, such as using mid-level dental providers supported by remotely located dentists, to provide treatment in addition to screening is becoming increasingly accepted17,22 but has been limited in some areas due to state regulations.16
Both teledentistry programs described in this paper found that half of the students exhibited dental caries. Numerous studies have established the validity of teledentistry for identifying dental caries,11,12 but only a few studies have reported on the dental caries rates in established school-based teledentistry pro-grams. Notably, the rate in the sites serviced by MCHS and CDS was 20 to 25% higher than those reported in children attending inner-city preschool centers.19-21
Multiple communication and technology innovations including high-capacity broadband networks, electronic health records, digital imaging, and lightweight portable equipment such as small intraoral cameras, have enabled the development of teledentistry.16 A comparison of the costs of teledentistry and traditional dental screening approaches in a study of Australian school children found that the teledentistry approach was half the cost of the traditional dental screening approach which involved dentists performing screenings.18 The estimated savings were due primarily to the lower salaries of mid-level dental professionals and the avoidance of travel costs by rural patients and their families to receive such services.
Strategies to increase access to and utilization of oral health services must be tailored to the special needs of rural populations, given the limited supply of dental clinicians.7 Children residing in rural areas have been shown to have higher unmet needs for evidence-based preventive oral health care services (fluoride varnish application and dental sealants) and to have poorer dental health status than their urban counterparts.6 Teledentistry is an emerging modality to improve access to oral health services in areas with inadequate availability of general and specialty oral health care, such as rural communities.16 While concerns around technical reliability and diagnostic accuracy have been expressed by dental professionals, there is increasing acceptance of teledentistry among oral health care providers as a means to improve communication, practice, patient management, and patient satisfaction.22 Studies have also shown high rates of compliance and treatment completion among rural children who receive teledentistry consultations.23 Team approaches involving mid-level dental providers using teledentistry have demonstrated repeatedly to be a valid screening approach.11,12 A recent systematic review concluded that teledentistry could be especially beneficial in areas with limited access to care due to dental workforce shortages, as in rural school-based programs.11 Dental screening in school settings can provide an efficient way to identify, triage, and appropriately refer high-risk students for oral health care, thus offering a particularly valuable strategy for oral disease prevention and health promotion.24 Other benefits of school-based teledentistry have included faster times to treatment, reductions in appointment no-show rates, and decreased patient anxiety.16 Teledentistry cost reductions have the potential to save significant human and other economic resources that can be redirected to improve oral health care in rural and other underserved areas.18
This study had limitations. The decision to implement teledentistry was determined by the school administrators, not through a randomized assignment process which may lead to selection bias in the data collected. Second, because the grantees were funded to deliver care via telehealth to underserved populations, there are no data on a comparison sample of students who did not receive teledentistry services in similar settings and the data are observational. Third, the data collection period covered one semester or six months of data which limited the sample size.
Conclusion
Providing oral examinations/screenings via teledentistry in school settings using dental hygienists and other dental professionals provided an efficient and high-quality mechanism to identify students at high-risk for dental caries and thus offer a particularly valuable strategy for oral disease prevention and control. In addition, preventive care, oral health education, and referrals for follow-up care addressed the routine, urgent, and emergent oral health needs of this underserved population.
Acknowledgement
The authors would like to acknowledge the following individuals for their assistance and expertise in identifying measures that were used in the SB TNGP data collection: Kimberley S. Fox, Amanda Burgess, and Karen Pearson at University of Southern Maine, Steve North at Center for Rural Health Innovation, and Christopher M. Shea at University of North Carolina Chapel Hill. The authors would like to also acknowledge the involvement of Clarissa Cook, Linda S. Health, Uday Manchala, Megan M. Ryan, and Craig Rose at Marshfield Clinic Health System. Finally, the authors acknowledge the leadership and support of Carlos Mena at the Office for the Advancement of Telehealth in the Health Resources and Services Administration.
Footnotes
This manuscript supports the NDHRA priority area, Population level: Access to care (interventions).
Disclosure
This study was supported by the Office for the Advancement of Telehealth (OAT), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) to the Rural Telehealth Research Center under cooperative agreements #UICRH29074 and #U3GRH40003. The School-Based Telehealth Network Grant Program provided funding for delivering school-based telehealth services to grantees: Marshfield Clinic Health System (Grant #H2ARH30300) and Children’s Dental Services (Grant #H2ARH30291). The information, conclusions, and opinions expressed are those of the authors and no endorsement by OAT, HRSA, or HHS is intended or should be inferred.
- Received November 23, 2021.
- Accepted June 8, 2022.
- Copyright © 2022 The American Dental Hygienists’ Association
