Virtual Dental HomeVirtual dental home system

Background.—The traditional office- and clinic-basedoral health care delivery system cannot meet the needs ofa large segment of the US population. The resulting dispar-ities in services has led the Institute of Medicine to call forexpanded research and the development of delivery sys-tems using new methods and technologies to work innontraditional settings, using non-dental professionalsand expanded roles for existing dental professionals. Thevirtual dental home offers a way to deliver oral health ser-vices where people live, work, play, go to school, andreceive social services. The populations serviced rangefrom children in Head Start Centers and elementary schoolsto older or disabled adults living in residential care ornursing home settings. The Pacific Center for Special Careat the University of the Pacific has developed this modeland completed the first phase of its existence.

Definitions.—The virtual dental home is a community-based oral health delivery system wherein people receivepreventive and early interventional therapy (Fig 1). It usescurrent telehealth technology to link practitioners in thecommunity with dentists in remote office settings. Commu-nity practitioners include registered dental hygienists inalternative practice (RDHAPs), registered dental hygienistsworking in public health programs (RDHs), and registereddental assistants (RDAs). They are led by a geographicallydistant dentist. The system relies on the advanced trainingand community-based practice of these allied oral healthprofessionals. The goal is to keep patients healthy byproviding education, triage, case management, preventiveprocedures, and early intervention therapeutic services. Ifmore complex dental treatment is required, the virtualdental home connects patients with dentists. The conceptis based on the health home and provides the same ingre-dients but is led by a dentist rather than a medical practi-tioner. This option is a way to provide oral health servicesto underserved populations and avoids the costs associatedwith neglecting dental disease (Fig 2).

Procedures.—The RDHAP, RDH, or RDA collaborateswith a dentist who makes diagnostic and treatment deci-sions. The geographic gap between the community profes-sionals and the dentist is bridged using advancedtechnology. The RDHAP, RDH, or RDA uses portable imag-ing equipment and an Internet-based dental record systemto collect electronic dental records. These include radio-graphs, photographs, charts of dental findings, and dentaland medical histories. The information is uploaded toa cloud-based software system (Denticon) for the

collaborating dentist to review. The dentist then creates aplan for dental treatment, which is carried out by the dentalauxiliaries on site and in accordance with their practice reg-ulations. Services include health promotion and preventioneducation, dental disease risk assessment, prevention pro-cedures (applying fluoride varnish and dental sealants, ordental hygienists doing dental prophylaxis and periodontalscaling), using interim therapeutic restorations (ITR) underthe supervision of the dentist for carious teeth until theycan be addressed by the dentist, and tracking and support-ing the patient’s need for and compliance with additionaland follow-up dental services. If the patient requires ser-vices only a dentist can provide, the RDHAP, RDH, or RDArefers the patient to the dental office. The patient arriveswith a health history and consent arrangements completed,a diagnosis and treatment plan in place, and preventionpractices and procedures already having been performed.This makes the dental visit more successful and tends tolead to more utilization of dental resources by the patient.

Status and Results of Phase 1.—Phase 1 is completeand has accomplished many important milestones:

� Developed the project concept and design� Created and implemented all the components and infra-

structure of the virtual dental home system� Created the legal framework for the project� Created or adapted the technology hardware and soft-

ware systems� Developed the training materials and methods, site pro-

tocols, and operational guidelines� Conducted a study validating the ability of dentists to

make treatment decisions after reviewing digital oralhealth records without a personal evaluation of thepatient

� Enlisted and trained providers and sites in nine commu-nities in California In addition, a Health Workforce PilotProject (HWPP) has been approved through CaliforniaOffice of Statewide Health Planning and Developmentto authorize two new duties for allied dental personnel:making the decision about which radiographs to take, ifany, to facilitate an oral evaluation by a dentist andplacing ITRs.

The virtual dental home project has clearly demon-strated that it is possible to successfully conduct acommunity-based, geographically distributed, collabora-tive, telehealth-facilitated system of delivering dental care.Patients enrolled in the project are being seen in various

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Fig 1.—The virtual dental home concept model (Pacific Center for Special Care, University of the Pacific School of Dentistry,ª 2012). (Cour-tesy of Glassman P, Harrington M, Namakian M, et al: The virtual dental home: Bringing oral health to vulnerable and underserved popula-tions. Calif Dent Assoc J 40:569-577, 2012.)

settings, including elementary schools in low-income com-munities, Head Start centers, residential facilities for per-sons with developmental disabilities, long-term carefacilities for vulnerable elder patients, and a communityclinic. Eight RDHAPs and one RDA have been trained in tele-health technology and their expanded duties. Over 750

Fig 2.—The virtual dental home: Cost of providing care versus cost of neof Dentistry,ª 2012). (Courtesy of Glassman P, Harrington M, Namakianand underserved populations. Calif Dent Assoc J 40:569-577, 2012.)

e40 Dental Abstracts

patients have received a telehealth-enabled consultationwith a dentist, and RDHAPs have provided over 300 prophy-laxes for children and adults and over 500 applications offluoride varnish. More than 170 ITRs have been successfullyplaced. Dentists believe that nearly half of the patients seenso far can be kept healthy through the services of the virtual

glect (Pacific Center for Special Care, University of the Pacific SchoolM, et al: The virtual dental home: Bringing oral health to vulnerable

dental home. Oral health services have been integrated intothe activities of institutions such as schools, group homes,and long-term care facilities. Dental literacy is beingincreased, along with a greater willingness on patients’part to comply with referrals, daily oral hygiene practices,and nutrition beneficial to oral health. In addition, the valueof expanding the roles of all members of the dental teamand training them to work in a new, unique system ofcare has been shown.

Clinical Significance.—It is likely that thenew system of care will provide better oralhealth for underserved and vulnerable popula-tions who have not been reached successfullythrough traditional methods. In addition, thecost of providing care through a virtual dentalhome will likely be less than for other models.The roles and reach of dental professionalshave been expanded, and telehealth-enabled

collaboration and communications systemshave been established. The data being collectedduring this trial will support regulatory andreimbursement changes that are needed topermit the spread of this model to other areas.It is expected that within several years it willbe possible to see the viability and effectivenessof this significant new approach for improvingand maintaining the oral health of underservedpopulations. This model is making a difference.

Glassman P, Harrington M, Namakian M, et al: The virtual dentalhome: Bringing oral health to vulnerable and underserved popula-tions. Calif Dent Assoc J 40:569-577, 2012

Reprints available from P Glassman, Arthur A Dugoni School ofDentistry, 2155 Webster St, San Francisco, CA 94115

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