Improving Oral Health Using Teledentistry and Virtual Dental Homes: Concepts and Progress

By Adam Lampe, BA, Sevinch Djalilova, BS, Paul Glassman, DDS, MA, MBA, and Valerie Phillips, BS, MS, RDH, RDHAP on March 20, 2024

Introduction

Oral health care and maintenance of oral health are difficult to obtain for many people. This paper presents background on challenges faced by many groups and describes the potential for oral healthcare providers to use teledentistry to reach people who are not able to access the current, primarily clinic and office-based oral health system. It provides examples of states and projects that have created teledentistry supported VDH demonstrations and delivery systems.

Background

Access to Oral Health Care and Barriers to Oral Health

Dental diseases are primarily chronic conditions which occur in people of all ages and socioeconomic status but are more prevalent and less likely to be treated in people with certain social, economic, and geographic conditions and situations.Citation1,Citation2 While the majority of the U.S. population has some form of private or public dental coverage, most people (54.3%) do not even have an annual dental visit, and lower income Americans of all ages have more untreated disease and a greater need for dental treatment than higher income Americans.Citation3–5 Children growing up in families without dental insurance are three times more likely to need treatment for dental disease, while children with special healthcare needs (CSHCN) are four times more likely to have unmet dental needs.Citation1,Citation6 In addition, in the United States approximately $2.7 billion was spent in 2017 on hospital emergency department visits.Citation7 Much of the spending on hospital operating rooms (ORs) or ambulatory surgery centers (ASCs) is for potentially preventable early childhood caries.Citation8 Geographic determinants of health such as living in rural or non-fluoridated communities also influence oral health outcomes of an entire generation of people.Citation1,Citation6

Having a history of difficulty accessing dental care, long waiting periods between appointments, and the economic burden of delayed disease diagnoses can create a negative association with visiting the dentist.Citation9,Citation10 People who cannot afford to regularly obtain dental care do not receive consistent oral health instructions and may not take advantage of preventative treatments.Citation6 Pediatric patients who are not regularly monitored by a dental professional miss out on crucial desensitization to dental treatment and learning opportunities which can improve their oral health prevention habits.Citation11 Regular dental experiences during developing years could change the trajectory of a patient’s oral health status for the rest of their lives by building positive habits and decreasing chances of experiencing dental emergencies that may lead to missed school days or workdays and other consequences.Citation6 Regular dental visits are especially important for CSHCN who may need more desensitization to dental care than other children.Citation12

Teledentistry Adoption and Policy

One promising solution to access to care and oral health challenges involves the use of teledentistry in evolving delivery systems. Teledentistry was first used in the U.S. Army’s Total Dental Access Project in 1994, in which dental care costs were reduced, and care was extended to areas previously out of reach.Citation13 Since then, advances in technology have opened the door to new possibilities for interacting with people remotely. These innovations include cloud-based record systems, the ability to share and review electronic records from different locations, the ability for multiple people in different locations to interact with electronic record systems, devices which can detect oral lesions and even programmable electric toothbrushes which may be remotely monitored by the clinician.Citation14,Citation15

There is increasing evidence and policy and growing acceptance of the accuracy and validity of remote interactions and teledentistry examinations.Citation16–20 Additionally, recent studies have shown that even dental students using teledentistry were able to detect healthy structures with a 99% accuracy and carious tissue with a 74% accuracy using digital photos taken by the patient.Citation21,Citation22

There is also increasing acceptance of teledentistry in the policy environment. The use of teledentistry in the delivery of oral health services has been controversial. However, in the two decades since the demonstration of the Virtual Dental Home (VDH) system in California there has been increasing interest and policy support. In 2021, the ADA House of Delegates amended its teledentistry policy with Resolution 86 H–2021 providing specific guidelines and expectations for virtual dental service.Citation23 The policy supports a dentist making a diagnosis and treatment plan without an in-person visit if the diagnosis is made using the same level of information that is available in an office visit.Citation24 At the time of this writing, the CareQuest institute for Oral Health is preparing a Teledentistry Regulation and Policy Guidance: A Toolkit for Dental Boards, Policymakers, Providers, and Oral Healthcare Advocates for Promoting Access and Quality Care Through Teledentistry that will contain a set of model rules that policy makers can implement to ensure that the full advantage of teledentistry supported care is available in their jurisdiction. This policy toolkit will address rules already adopted in many states about issues such as the ability for a dentist to perform a remote examination; the ability for allied oral health personnel to collect oral health records in community sites; the circumstances where dental providers can interact with patients across state lines; the requirement that payment systems pay for oral health services without regard to whether they are performed in-person or using telehealth technologies; and other policy and regulatory issues.

Interest in using teledentistry in the delivery of dental care has risen since the start of the COVID-19 pandemic.Citation25–27 Predictions about the current and future supply of dentists have demonstrated a shifting demographic within the workforce in which more working dentists are retiring than dental students are graduating to fill their positions.Citation3 Incorporating teledentistry supported systems can allow the dental industry to serve more people and also respond to increasing consumer demand for more convenient and accessible care.Citation28 It is becoming clear that acceptance and expectations for the availability of teledentistry are increasing. This is leading to more people having positive experiences, more people hearing about those experiences, and social connections driving increased demand.Citation29

A 2022 systematic review of teledentistry applications has concluded that “current evidence supports teledentistry as an effective means for dental referrals, treatment planning and compliance and treatment viability.”Citation30 It also indicated that “asynchronous communication and the adoption of smartphones for image capturing are feasible and convenient for the implementation of teledentistry.” In addition, the review indicated that virtual access to oral medicine would allow for improved accessibility and care quality to the most vulnerable populations such as children, patients living in rural areas and those in long-term care or hospitals. In another study, use of teledentistry in treatment protocols resulted in the ability to make a diagnosis in 93% of the cases, which allowed a department to discern which pediatric patients need immediate care and which patients might be seen post-lockdown.Citation31 Remote dental appointments were also widely implemented during the pandemic and were effectively used for triage, follow-up and non-procedural care for patients facing a scarcity of providers in rural and remote areas.Citation32 Besides reducing appointment cancellations and increasing patient access, teledentistry has also been tested and deemed effective for consultations ahead of complex procedures such as dentoalveolar surgeries.Citation33 Finally, it has been found that frequent teledentistry appointments increase patient’s likelihood of having an earlier diagnosis of oral cancer which may lead to more timely follow-up for potentially malignant oral disorders as well as a better chance of receiving less aggressive treatments.Citation34,Citation35

In addition to increasing acceptance of teledentistry as a component of oral healthcare systems, there is expanding funding for oral health care delivered using teledentistry. A number of programs described below have been funded with federal, state, and local philanthropic grants. There is also increased recognition and support of teledentistry in public and private payment systems. An example of full recognition of the value of teledentistry supported oral health care is described in the recent California Medicaid Dental Program Provider Bulletin which clarifies that diagnostic and preventive services provided with the use of teledentistry will be reimbursed whether provided using synchronous or asynchronous teledentistry modalities.Citation36 Now in the California fee-for-service, managed care, and health center reimbursement programs, teledentistry can also be used to establish new patients as patients of a dental practice. Once that is done, the practice can bill for procedures performed for that patient using teledentistry supported care systems.Citation36,Citation37

Teledentistry Definitions, Coding, and Use Cases

As the use of teledentistry has increased, terminology has been developed to describe various locations in which teledentistry can be used and various methods for the use of teledentistry.  is a list of teledentistry definitions in general use in teledentistry.

 

Table 1. Teledentistry Definitions.

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The American Dental Association has created two codes in the Current Dental Terminology (CDT) code set that relate to the use of Teledentistry. They have created a Guide to Understanding and Documenting Teledentistry Events that includes definitions and documentation guidance for the two codes, D9995 teledentistry – synchronous real-time encounter and D9996 teledentistry – asynchronous information stored and forwarded to dentist for subsequent review.Citation38 These codes are to be reported in addition to other procedures (e.g., diagnostic) delivered to the patient on the date of service. In most payment systems, these codes are used for tracking the use of teledentistry in delivering dental care and are not directly reimbursed.

As the use of teledentistry has increased, a number of use cases have emerged. These use cases are listed in . More detailed information is available in the draft American Dental Association Standards Committee on Dental Informatics Technical Report Number 1112: Teledentistry.Citation39 This technical report contains far more detail about teledentistry use and considerations for creating and implementing teledentistry supported care systems than could be included in this paper.

 

Table 2. Teledentistry use cases.

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Development and Spread of the Virtual Dental Home System of Care

The Virtual Dental Home

One example of a full-service system of care is the Virtual Dental Home (VDH), developed by Dr Paul Glassman.Citation40,Citation41 As distinct from “dental home” systems that regard the dental office as the “home”, this model reaches people who do not regularly visit dental offices by bringing services to them. The VDH system emphasizes prevention and early intervention services in community settings while linking to and expanding the involvement of dental offices and clinics.

The Virtual Dental Home (VDH) is a community-based oral health delivery system in which people receive preventive and early intervention therapeutic services in community settings. It utilizes telehealth technology to link allied dental personnel in the community with dentists in dental offices and clinics. A six-year demonstration of this system involved 23 communities, 50 sites and about 3500 procedures.Citation42 The results indicated that registered dental hygienists in alternative practice (RDHAP), dental hygienists working in public health programs (RDH) and registered dental assistants (RDA), working in telehealth-connected teams, can keep most people healthy in community settings by collecting a full set of electronic records to be reviewed by a dentist and providing education, triage, case management, preventive procedures, and Interim Therapeutic Restorations (ITRs).

To determine if an in-office visit is necessary, the dentist can view the patient’s records through real-time via live telecommunication or review them asynchronously through a “store-and-forward” record system, make a diagnosis and treatment plan, and provide any needed instructions to the community team. The report of the VDH demonstration indicated that with the system and mix of services described above, two-thirds of low-income children in pre-schools and elementary schools could be kept healthy and verified by a dentist as healthy at school without needing to make a trip to dental office. The demonstration was conducted prior to Silver Diamine Fluoride (SDF) being available in the U.S. The authors of that study and this paper now estimates that as many as 80% of children could be kept healthy and verified by a dentist as healthy at school, without needing to make a trip to dental office.

When more complex dental treatment is needed, the Virtual Dental Home connects patients with dentists in the area.  contains a diagram of the typical workflow for VDH system. This system promotes expansion of dental practices and linkages between dentists in dental offices and community-based allied dental personnel. Most importantly, it brings much needed services to individuals who might otherwise receive no care.

Figure 1. The virtual dental home workflow model.

Figure 1. The virtual dental home workflow model.

 

The VDH demonstration included a California Health Workforce Pilot Project (HWPP).Citation43 The HWPP Program allows organizations to test, demonstrate, and evaluate new or expanded roles for healthcare professionals, or new healthcare delivery alternatives before changes in licensing laws are made by the Legislature. HWPP #172 tested the ability of allied oral health professionals (dental hygienists and dental assistants) to independently determine which radiographs to take in specified situations and to place Interim Therapeutic Restorations (ITRs) after receiving instructions to do so by a dentist without the dentist being present when the restoration is placed. In the demonstration, allied oral health professionals placed over 1000 ITRs.Citation42 The demonstration contributed to the successful result described above and led to the adoption of legislation, AB1174 (2014). This legislation incorporated these duties into the scope-of-practice of dental hygienists (RDH), registered dental hygienists in alterative practice (RDHAP), and Registered Dental Assistants in Extended Functions (RDAEF) who can now perform these duties after completing an approved course and being certified in these duties.Citation44,Citation45

The California Dental Transformation Initiative

In 2016, California began a Medi-Cal 2020 Waiver Program.Citation46 The aim of the waiver from the Federal Centers for Medicare & Medicaid Services (CMS) was to “transform and improve the quality of care, access, and efficiency of healthcare services for over 13 million Medi-Cal members.” One of the components of the Medi-Cal 2020 waiver was the establishment of a $750 million Dental Transformation Initiative (DTI) the intent of which was to “improve dental health for Medi-Cal children by focusing on high-value care, improved access, and utilization of performance measures to drive delivery system reform.”Citation47 One of the four “Domains” of the DTI was Domain 4 – Local Dental Pilot Projects (LDPPs).Citation48 The goals of the LDPPs were to address the DTI goals through “alternative programs and potentially use strategies focused on rural areas, including local case management initiatives and education partnerships.”

California Northstate University College of Dental Medicine (CNU) contracted with four LDPPs to support the development of the Virtual Dental Home system of care (VDH) within five counties. This work included developing partnerships with county designated “Lead Agencies”, dental care providers, advocacy organizations, and community sites such as pre-schools, schools, WIC programs and other locations to implement the VDH system.Citation49 A report of that work, The Virtual Dental Home: Building Best Practices into California’s Oral Health Care Delivery System for Children described the process and outcomes of that work.Citation50 There were multiple benefits from this program including:

  • Addressing Barriers to Dental Care for Children – children without previous access to dental care were reached. Most received all the care they needed at school and one site reported that they had a 95% recall rate because the care was brought to children at the site.
  • Advancing Oral Health Education and Creating a Culture of Oral Health – the VDH teams were able to interact with children and parents and school staff in a way and with a frequency that is not possible in a dental office and provide incremental suggestions for behavior change over multiple encounters to better support the adoption of positive oral health behaviors, referred to in these projects as “mouth healthy habits.”
  • Addressing Language and Cultural Barriers to Care – at the community sites, a significant number of families speaks Spanish as their primary language. The VDH teams included at least one bilingual (Spanish/English) member, many of them are from the community they serve or share similar backgrounds as many of the families they serve.
  • Acclimating Children to Dental Care – the VDH system was instrumental in helping children become comfortable with dental care in a setting that is familiar and safe to them. This helps to build trust that can translate into lifelong benefits in maintaining oral health.
  • Coordinating Care – VDH team members were able to support families’ understanding of oral health and help them navigate the oral healthcare system. They were able to support referrals when procedures were needed in dental offices or clinics. These referrals were far more likely to result in care than other referral systems.

 

While many of the sites established in the DTI programs had difficulty operating during the lockdown phase of the COVID-19 pandemic, most have restarted operation since and are continuing to grow.

Healthy Smiles for Kids of Orange County

One of the sites that was a part of the California DTI that was supported by Dr Paul Glassman and CNU was Healthy Smiles for Kids of Orange County (HSKOC). When the project started, 46% of the children enrolled in the Medi-Cal Dental Program in Orange County, did not have any dental visits in the past year.Citation51 A report of the DTI VDH project in Orange County, The Virtual Dental Home in Orange County: Building Best Practices into the Oral Health Care Delivery System for Children, described the unique aspects of the DTI work in that county.Citation52 HSKOC developed an extensive VDH system. They had 11 VDH teams, worked with 81 schools, 6 medical clinics, 1 preventive dental clinic, and 4 community-based organizations, and served 7,008 children. In part, they did this by building extensive relationships with several school districts across Orange County and developing partnerships with multiple health centers to support their community efforts. They connected children needing treatment in their own clinics and used their partner relationships to create a distributed network of providers who could provide in-office care in a wider geographic area than their own clinic could serve.

The UCSF/Tuolumne County Virtual Dental Home

The University of California, San Francisco (USCF) Dental Public Health Residency Program and Pediatric Dentistry Residency Program received a grant from the Federal Health Services and Resources Administration (HRSA) for a project to expand and integrate training of dental public health residents and pediatric dentistry residents.Citation53 One of the grant objectives is to provide experiential learning in rural counties to implement a virtual dental home and partner with rural health departments on dental public health projects.

With Dr Glassman acting as a consultant for the project, UCSF has partnered with the Tuolumne County Oral Health program supported Smiles Keepers program to implement a Virtual Dental Home system.Citation54 This VDH system is unique in that the design has the community team, composed of a Registered Dental Hygienist in Alternative Practice (RDHAP) and a Registered Dental Assistant (RDA) working in a school in a very rural area of Tuolumne County. The collaborating UCSF faculty and residents are approximately 150 miles away. The UCSF dentists are able to perform review records, perform virtual examinations, and provide program supervision and direction. They are even able to accept referrals for children with complex problems when there are no closer sources of care. However, when there is a need for less extensive care, they have developed agreements and relationships with dentists and dental clinics in Tuolumne County to provide that treatment.

Now in the third year of development, the program has become well established at the school with many parents expressing their appreciation that their children can have dental care at schools rather needing to make long trips to dental office outside of their rural community.Citation55 Preliminary results indicate that most children in the program can be kept healthy at school without needing to make a trip to a dental office, which is so difficult in this remote location. As the program continues to develop, it is expected to spread to other schools, pre-schools, and other sites in rural areas of Tuolumne County.

The Colorado SMILES Initiative

The first adoption of the Virtual Dental Home model outside of California was in Colorado. The Colorado Spanning Miles in Linking Everyone to Services (SMILES) project was started and supported by the Caring for Colorado Foundation.Citation56 In 2015, the foundation “embarked on a journey designed to change the way dental care is delivered in communities throughout Colorado”. The goal was to deliver care that works for people who had been left out of the traditional dental care system by using the oral health workforce differently. They wanted to eliminate barriers to care and ultimately improve access and outcomes for patients. They were joined by the Colorado Health Foundation in funding the Colorado SMILES project.Citation57 The project, using Dr Glassman as a consultant implemented the VDH model in six geographically distributed sites across Colorado that serve a variety of population groups and locations including schools, mental health facilities, and senior centers. The coalition, in addition to supporting adoption of the care model, was able to successfully address policy barriers to implementing the program.

  • The sites reported multiple areas of key learning and future plans.Citation58 Some of these include:
  • Success is dependent on having clinical champions at each site and on building strong relationships with the community sites being served.
  • It is important to ensure that there is understanding and buy-in of the VDH philosophy.
  • Reliable IT systems and connections are important when working in the community.
  • Behind the scenes organizational work is needed to keep the project going.
  • Onsite clinics at school eliminate many barriers to care that family experience.
  • Store-and-forward teledentistry expanded services to populations with substantial unmet dental needs.
  • Oral health of SMILES patients improved.
  • Patients highly endorsed SMILES teledentistry care and ITRs.
  • Parents and staff were very appreciative when children receiving ITR and SDF from a dental hygienist in schools.
  • Dentists exhibited initial hesitancy in treatment planning ITRs. However, the hesitancy was reduced with reassurance from dentist leaders.
  • Financial sustainability requires reducing inefficiencies and optimizing visits.

 

The Oregon Virtual Dental Home

In 2016, the Oregon Health & Sciences University School of Dentistry (OHSU) began a Virtual Dental Home (VDH) program which incorporated a demonstration of the ability of Expanded Practice Dental Hygienists (EPDH) to place ITRs.Citation59 The demonstration was approved by the Oregon Health Authority as Dental Pilot Project #200.Citation60 They partnered with Dr Paul Glassman and Capitol Dental, an Oregon DCO to use the VDH system in schools and pre-schools in predominantly rural, low-income, communities with residents with primarily Hispanic backgrounds.

The outcomes of the Pilot Project resulted in legislation, SB1550 (2020), which authorized an expanded practice dental hygienist to perform Interim Therapeutic Restorations (ITRs).Citation61 A collaborative agreement is required between a dentist and an expanded practice dental hygienist to include the additional scope of practice for placing ITRs.

Capitol Dental, now a division of InterDent, has continued to use and spread the VDH model in other areas of Oregon.Citation62

The Hawaii Virtual Dental Home

The Hawaii State Health Department has recognized the challenges that many people in Hawaii face in accessing oral health services and maintaining good oral health. The 2015 Hawaii Smiles Report indicated that Hawaii had the highest prevalence of tooth decay among third graders in the United States – far above the national average, with almost 1 out of 4 third graders

in Hawaii having untreated tooth decay and about 7% of Hawaii’s third-grade children in need of urgent dental care because of pain or infection.Citation63 The report also noted the disparities in dental care and dental disease based on income, race/ethnicity, and location, with children in Kauai, Hawaii, and Maui counties being more likely to have experienced tooth decay than children living in Honolulu County.

In 2017 and 2018, Dr Paul Glassman at the University of the Pacific School of Dentistry received funding from the Hawaii Dental Service Foundation to work with the Hawaii State Health Department Hospital & Community Dental Services Branch to start a Virtual Dental Home system in conjunction with the West Hawaii Community Health Center (WHCHC) FQHC. In that project, the first VDH system in Hawaii, the WHCHC served children at the Kealakekua Head Start preschool, Kailua‐Kona’s Tutu and Me preschool, and WIC at Kealakekua.

In 2019, the VDH system was expanded to Maui County with funding from the Hawaii Dental Service Foundation and the Hawaii Medical Service Association (HMSA). This funding supported Hui No Ke Ola Pono (HNKOP), one of five Native Hawaiian Health Care Systems, in bringing the VDH system to Hawaii. HNKOP’s VDH systems has served children enrolled in WIC, Early Head Start and Head Start programs, as well as adults in long-term care facilities. In May 2019, Maui’s Mayor, Michael P. Victorino, issued a Mayor’s Proclamation and declared the day to be “Maui Teledentistry (Virtual Dental Home) Pilot Project Day”.Citation64

In 2021, the Hawaii Dental Service Foundation extended their support to fund a VDH system on the island of Kauai. Partners in that project have included Dr Paul Glassman as a consultant, the Hawaii State Health Department Hospital & Community Dental Services Branch, Na Lei Wili Area Health Education Center, Baird Dental is a private dental office located in Kapaa on the island of Kauai, Child & Family Service which manages Early Head Start and Head Start Centers on Kauai, and the Hawaii State Department of Health’s Women, Infants and Children (WIC) program on Kauai. This program is unique in demonstrating the ability for multiple community partners to collaborate with a private dental practice to develop and run a VDH system.

These VDH systems on multiple islands in Hawaii are raising awareness about the ability of different kinds of dental delivery system to partner with community organizations and use the VDH system to improve oral health in Hawaii.

The Idaho Virtual Dental Home

In 2019, the Idaho Department of Health and Welfare Oral Health Program (IOHP) received a $1.6 million grant from the federal Health Services and Resources Administration (HRSA) to address oral health workforce needs of designated dental health professional shortage areas (dental HPSAs).Citation65 The project, which used Dr Paul Glassman as a consultant, called the Project to Address Oral Health Access and Workforce, was designed to test strategies aimed at improving the oral health of individuals living in Dental HPSAs. It is notable that 42 out of 44 Idaho counties are designated Dental HPSAs, according to the Bureau of Rural Health and Primary Care in the Idaho Department of Health and Welfare (IDHW).

One important goal of the HRSA grant was to support adoption of the Virtual Dental Home system of care. The IOHP provided subgrants to three organizations for this purpose. One private dental practice used the model to reach people and improve oral health for residents of nursing homes and residential facilities for people with disabilities. Another subgrantee worked on using the VDH model to improve operations of a free clinic that depends on volunteer dentists to staff their clinic and accept referrals for in-office care. The third, the Dental Hygiene Department at Idaho State University, incorporated the VDH in the educational program for dental hygiene students.Citation66 This program has now become sustainable because it was successfully incorporated into dental hygiene student curriculum and serves as a valuable and recognized educational experience.

In October 2021, the IOHP convened an Oral Health Summit where the activities and results of the projects were described, and a broad stakeholder coalition was able to comment and provide advice for further development.Citation67 Armed with the results of Idaho’s first Oral Health Workforce Assessment, the attendees were able to consider the importance of the strategies presented and their ability to address the severe shortage of access to dental care faced in most of Idaho.Citation68

One important development that was highlighted was the recent enactment of the Virtual Care Access Act in Idaho which was signed into law March 22, 2023.Citation69 This Act allows healthcare providers, including dental providers, to provide care to patients via both synchronous and asynchronous telehealth. This includes establishing a new patient–provider relationship.

The Iowa Virtual Dental Home

The University of Iowa College of Dentistry partnered with the Community Health Centers of Southeastern Iowa (CHC SEIA) to bring the Virtual Dental Home care system to residents of two nursing facilities in Iowa.Citation70 They worked with Dr Paul Glassman to plan, train and support the staff of CDC SEIA and the nursing facilities in the implementation of the VDH system.

The project, funded by the Delta Dental of Iowa Foundation, uses the VDH system, in which asynchronous teledentistry is used to bring diagnostic and preventive services to nursing home residents on site. Their implementation of the VDH system enables dental hygienists to capture dental records including intraoral photographs, x-rays, and other information and provide preventive services in these nursing homes. Dentists then follow-up by conducting dental examinations virtually. When follow-up treatment is needed, the CHC SEIA staff and the nursing home work together to get the patient scheduled for treatment at the CHC SEIA clinic.

Prior to the pandemic, the CHC SEIA clinic had been available to serve the residents of these nursing homes. However, they found that only about 10% of the patients they saw at the nursing home came into the clinics, the rest of them (~90%) had not been receiving any dental care. Now they are bringing care to those individuals. Although this project faced many obstacles as a direct result of the COVID-19 pandemic, care has now resumed in the nursing homes.

The research team at the University of Iowa College of Dentistry is studying the impact of the program on residents’ access to care, as well as implementation successes and challenges for community health centers and nursing home staff. They have indicated that this information will be used to help inform other clinics in Iowa, many of whom have expressed interest and want to use this model, to extend the reach of their clinics into the community.

The Maine Virtual Dental Home

The Children’s Oral Health Network of Maine has started a statewide demonstration of the Virtual Dental Home system in Head Start programs across the state.Citation71 Working with Dr Paul Glassman, they have developed partnerships with oral professionals, dental offices and clinics and Head Start pre-schools in six regions of Maine.Citation72  is a workflow diagram from the Maine Virtual Dental Home model.

Figure 2. The Maine VDH model.

Figure 2. The Maine VDH model.

 

The goal of the Maine VDH, through an emphasis on school integration, primary care integration, and workforce development, is to deliver 75% of care that children need on-site in their schools or childcare settings. The Children’s Oral Health Network of Maine is convening and supporting a broad network of nonprofit dental clinics, dental hygienists, and local Head Start and other early childhood programs and settings who are eager to implement the VDH model in Maine. The Maine VDH pilot is initially focused on serving children in Head Start programs and then extending into school and primary care settings.

The Children’s Oral Health Network of Maine secured initial funding for the development of this statewide system from the Association of Maternal & Child Health Programs.Citation73 They were also able, with the support of both of their state Senators, Senator Susan Collins and Senator Angus King, and Representative Chellie Pingree, to obtain the first in the nation direct federal budget allocation of $650,000 to support Maine’s Virtual Dental Home project.Citation74 Videos of these Senators and Representative discussing this allocation and the VDH system are available on a page of the UCSF California Oral Health Technical Assistance Center.Citation75

At the time of this writing, the Maine VDH system is in the third year of development. Through a system of training and technical assistance, policy monitoring and advocacy, and a state-wide learning collaborative, the VDH system is developing and growing across the state.

The Future of Teledentistry and Virtual Dental Homes

In addition to the many current uses of teledentistry and VDH systems, there are continuing developments in technology and delivery systems that will provide increased opportunities to expand oral healthcare systems. One example is an AI supported dental scan that allows consumers to use their mobile phones to get a preliminary report of their visible dental conditions and then be linked to dental care providers for further evaluation and care.Citation76 This and similar technology developments will be readily adopted in an era when consumers expect to be able to interact with healthcare systems remotely. It will drive greater consumer involvement and interest in oral health.

Another example of expanding oral health systems supported by technology is the use of non-dental personnel with technology support playing a role in oral healthcare delivery. A program in New York equipped community health workers (CHWs) with a technology support system used to support behavioral interventions with parents of young children.Citation77 California’s Advancing and Innovating Medi-Cal (CalAIM) program, a long-term commitment to transform and strengthen Medi-Cal, now includes provisions to pay for services of CHWs in healthcare delivery.Citation78,Citation79 An example of the use of CHWs in oral healthcare delivery is described in a companion article in this issue of the California Dental Association Journal on the use of CHWs in Home Visiting Programs at the Front End of an Oral Health System: Background and Program Design.Citation80

One additional example of the expanding use of teledentistry and VDH systems is a developing program to keep people with disabilities healthy in community sites and reduce the need for sedation and general anesthesia to provide oral health treatment. This program is described in a companion article in this issue of the California Dental Association Journal on Shortening-The-Line: Reducing the Need for Sedation and General Anesthesia for Dental Care for People with Disabilities.Citation81

Discussion

It is clear from the research, policy advancements and examples of implementation work presented here that the VDH system of care is attracting wide attention in the U.S. As the evidence and results of demonstrations across the country continue to expand, interest is growing. This expanding body of work and experience indicates that the VDH system will become an important source of oral health care for many people in the U.S. population that currently face many challenges accessing oral health care and having and maintaining oral health.

Ongoing research and the supported adoption and demonstrations of the VDH system in multiple states described here are contributing to the body of knowledge about what factors facilitate or inhibit adoption of this system. Although there has been widespread adoption and policy support, there are many barriers that remain. These include the need for expanded awareness about the value of this model of care. They also include the need to address the uneven policy environment between states. In addition, they include the need for training, implementation support, and technical assistance since these models present different challenges and requirements compared to dental care in a dental office or clinic environment.

All these developments and the future trends described above point to the conclusion that the use of teledentistry and virtual dental homes will continue to expand and become a larger part of oral healthcare systems in the future.

Summary

There is increasing recognition of the value of teledentistry and the Virtual Dental Home (VDH) system of care. This paper provides background on terminology and “use cases”, illustrating situations where teledentistry supported systems of care have been adopted, have addressed barriers to accessing oral health services, and have improved oral health of traditionally underserved groups.

This paper also documents growing policy support for the use of teledentistry supported care systems and VDH models from professional dental organizations, state legislative bodies and administrative agencies. Many public and private regulatory and payment systems now support establishing patients as patients of a dental provider using teledentistry and paying for oral health services that are provided using teledentistry supported care systems and virtual dental homes.

This paper also describes multiple initiatives and demonstrations of VDH systems that have taken place or are underway in California, Colorado, Oregon, Hawaii, Idaho, Iowa, and Maine. These states and others are demonstrating that the (VDH) system provides all the essential ingredients of a “health home” but does so using geographically distributed, telehealth-connected teams. As distinct from “dental home” systems that regard the dental office as the “home”, this model reaches people who do not regularly visit dental offices by bringing services to them. Teledentistry in general and the VDH system in particular are providing opportunities to expand the reach of oral health services and improve the oral health of the population.

The VDH system emphasizes prevention and early intervention services in community settings while linking to and expanding the involvement of dental offices and clinics. The use of teledentistry and the VDH system is expanding, as is policy support and implementation experience.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Adam Lampe

Adam Lampe is a second-year dental student at California Northstate University College of Dental Medicine in Elk Grove, California. Adam earned a B.A. in Anthropology from UC San Diego. In 2018, Adam’s abstract Drinking Away Success, which discussed adolescent alcohol abuse, was published in the Building Bridges journal.

Sevinch Djalilova

Sevinch (Sevi) Djalilova is a second-year dental student at California Northstate University College of Dental Medicine in Elk Grove, California. She earned a B.S. in Biological Sciences from the University of the Pacific. In 2020-2021 she was the recipient of a research training grant by the Pacific Southwest Center of Excellence in Vector-Borne Disease (CDC & UC Davis School of Veterinary Medicine) for the “Culex Tarsalis Insecticide Resistance” project.

Paul Glassman

Paul Glassman is a Professor and Associate Dean for Research and Community Engagement at the California Northstate University College of Dental Medicine in Elk Grove, CA and Professor Emeritus at the University of the Pacific, Arthur A. Dugoni, School of Dentistry in San Francisco, CA. He has served on many national panels including the Institute of Medicine’s (IOM) Committee on Oral Health Access to Services which produced the IOM report on Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Dr. Glassman has had many years of dental practice experience treating patients with complex conditions and has published and lectured extensively in the areas of Hospital Dentistry, Dentistry for Patients with Special Needs, Dentistry for Individuals with Medical Disabilities, Dentistry for Patients with Dental Fear, Geriatric Dentistry, and Oral Health Systems reform. Dr. Glassman has been PI or Co-PI on over $35 million in grants and contracts over the last 30 years devoted to community-service demonstration and research programs designed to improve oral health for people with disabilities and other underserved populations. Dr. Glassman is a pioneer and has led the national movement to improve oral health using telehealth-connected teams and Virtual Dental Homes.

Valerie Phillips

Valerie Phillips is as Assistant Professor and Director of the Office of Research and Community Engagement at California Northstate University College of Dental Medicine. She graduated with her BS in Dental Hygiene from Oregon Institute of Technology in 1987 and from Eastern Washington University with a MS in Dental Hygiene in 2013. In 2022 she became licensed as an RDHAP in California.

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References