Going to the Dentist — Virtually
BY DANIELA HERNANDEZ
Inside a South Los Angeles classroom filled with plastic dinosaurs, building blocks, stuffed animals and Dr. Seuss books, Mireya Rodriguez counted Hendryk Vaquero’s teeth and looked for cavities.
At just 4 years old, he’d already had nine stainless steel crowns and multiple fillings, and his gums showed signs of inflammation and infection. He’d lost a couple of baby teeth, including a capped tooth his mom pulled out after it started bleeding.
“Pero no llore,” said the boy, assuring Rodriguez in Spanish he didn’t cry.
This was only the second time the dental hygienist examined his teeth, many of which had rotted, in part because he was eating too many sweets and drinking milk before falling asleep. Later, a dentist at the Venice Family Clinic 16 miles away would pull up his records online and consult with Rodriguez on his case – without ever necessarily seeing the patient.
It was all part of a pilot “teledentistry” program, dubbed the Virtual Dental Home demonstration project, for low-income patients in California who don’t have access to regular dental care. Now, thanks to the success of the pilot and a new law signed by Governor Jerry Brown this week, similar services could reach many more kids like Vaquero.
The law, which takes effect on Jan. 1, requires Medi-Cal, the state’s insurance program for the poor, to pay for dental services delivered by teams of hygienists and dentists connected through the Internet.
California is among the first states to launch Medi-Cal-funded teledentistry services, which are intended to increase the options for patients in remote and underserved areas. Other states, including Oregon, Colorado, Hawaii and West Virginia, are interested in creating their own programs but are farther behind, advocates for the project said.
Often people without private insurance have been stymied by high costs and a shortage of dentists who treat the poor. Many also face language and transportation barriers, lack legal immigration status, are afraid of dentists or have a poor understanding of what causes dental problems.
“The only thing that they know is that they have to provide for their family and that’s the most important thing for them,” said Rodriguez, who conducted her exam of Hendryk earlier this year at the Volunteers of America Silva Head Start program. “You have to educate the parents.”
The new law spells out the types of training that hygienists and dental assistants must have and expands the procedures they can perform without onsite supervision by a dentist. They can decide which X-rays to take and install temporary fillings that help prevent decay from progressing. They will still need to consult with a dentist remotely by sharing records online and must refer patients when more sophisticated procedures are warranted.
“Technology has really allowed things that weren’t possible before,” said Shelly Gehshan, the director of the children’s dental policy team at The Pew Charitable Trusts. “But it’s not like flipping a switch.”
Before teledentistry can be used more broadly, the state will need to figure out the billing and payment structure for telemedicine services.
Dr. Paul Glassman, the dentist at the University of the Pacific in San Francisco who started the pilot, acknowledged this could be contentious: Providers will want to bill at the same rates as for in-person consultations, while Medi-Cal might opt for lower rates to control costs.
Expanding the program statewide could increase costs minimally in the short-term — by upward of $500,000 a year, according to a State Assembly Appropriations Committee analysis. If teledentistry takes off, the costs could be higher.
Already, the Medi-Cal budget for dental services is slated to grow from $682 million to roughly $940 million by June 2015 because of legislation signed in June 2013 that restored certain dental benefits for adults. It’s too early to estimate how much more teledentistry services would cost, said Department of Health Care Services spokesperson Tony Cava.
Advocates think the return on investment could be substantial. For every dollar spent on preventive services like the ones provided through the Virtual Dental Home demonstration project an estimated $50 is saved on more expensive, complicated procedures, said Dr. James Stephens, a Palo Alto dentist and president of the California Dental Association.
“It’s a no brainer,” he said. “It’s a way of getting people who are outside the system into the system…Preventive care costs so much less.”
Some dental organizations in other states have spoken out against letting hygienists, assistants and other mid-level providers do procedures typically reserved for dentists, questioning their qualifications.
But the California Dental Association, which represents 25,000 dentists, was generally behind the new California law because it gives people access to dental care who wouldn’t get it otherwise.
Dr. Burton Edelstein, a professor at Columbia University and the founding president of the Children’s Dental Health Project, a Washington, D.C.-based advocacy organization, said “quality of care can be just as good, or even better” in teledentistry if the benefits of better access are factored in.
In California and elsewhere, teledentistry has become more feasible in part because equipment and devices are smaller, more portable and less expensive than before. The federal health care law has also provided a boost with its emphasis on digital technology to improve care and reduce costs.
“This also bodes well for patients beyond Medi-Cal since most all of us wish we could take care of more of our healthcare without….[the] hassle of in-person office visits,” wrote Dr. Bob Kocher, a partner at venture capital firm Venrock and a former special assistant to the President for healthcare on the National Economic Council, in an email.
Out in the field, what matters is a gentle touch with patients — especially those who have never been to a dentist before or have had frightening experiences.
When Rodriguez examines children at Head Start — government-funded pre-schools — she usually brings them up to her work station in pairs. Meanwhile, their friends are singing and playing with each other and the teachers are in the background. It’s a fundamentally different experience than going to a dentist’s office.
“These kids are getting something that reframes their connection to dentistry,” said Terry Press-Dawson, the grant coordinator for several schools in Sacramento, some of which are participating in the Virtual Dental Home demonstration project. “They are connecting dentistry with something that is not scary — and that’s huge.”
After spending weeks coaxing Hendryk, the 4-year-old with serious dental problems, into an examination, hygienist Rodriguez was patient and respectful. She asked his permission as she took pictures of his teeth with a camera connected to a laptop and put fluoride on his teeth with a tiny disposable brush. She told him she was proud of him and complimented him on his shoes and Buzz Lightyear T-shirt.
And at the end of the exam, she gave him a baggie with a toothbrush, toothpaste, mouthwash and a two-minute timer so he could take care of his teeth at home with his mom’s help.
All the while, 5-year-old Abigail Velasquez was watching. She was up next. She said she’d never been to the dentist.
“We’re going to talk to mom so maybe mom can take you to a dentist when you’re done seeing us. Because it’s very important that you experience that,” Rodriguez told her. “Going to the dentist is quite an adventure.”
A version of this story ran in The Los Angeles Daily News earlier this year, before the bill had been signed by Gov. Jerry Brown.
DanielaH@kff.org
