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Increasing Access to Dental Care: "Taking A Toothache Out Using Teledentistry"

State: FL Type: Promising Practice Year: 2020

The Florida Department of Health in Marion County is located in Ocala, Florida.  According to the U.S. Census Bureau, the Marion County population is estimated to be 359,977 as of July 1, 2018. The county stretches over 1,584 square miles, making its land mass between the states of Rhode Island and Delaware. Children represent 18.6%, adults 18-64 represent 52.5% and seniors 65% are 28.9%. There are 50 schools receiving Title I funding for low income students. According to the Marion County Community Assessment 2019, 28.2% of Marion County children are in poverty, and the outlying areas of Reddick, Ocklawaha and Weirsdale with 34.4-37.6 in poverty. In addition, the Median Household Income was $40,295 in 2016, which was $8,605 less than the state average. Because of the large number of low-income families and the huge land mass of the county, there are multiple barriers to dental care. Working parents (mostly in low paying jobs) cannot afford to take off work to take their children to the dentist.  Residents, many with low education, are unaware of how oral health affects their overall health. Private transportation is unpredictable, and public transportation only travels inside the city limits not reaching the rural residents.

 In 2016 the school-based sealant program began with the goal to increase access to dental care for low income children in a financially sustainable model. In the first year, the objective was to establish a partnership with the Marion County School Board and provide services to the designated rural schools. Using portable equipment, the hygienist provided an assessment, fluoride varnish, oral hygiene instructions and sealants on permanent molars to students who returned their completed medical history and signed consent forms in designated schools. The first schools targeted were the Title I rural schools in the county, as they had the least access to care due to transportation. In 2017-2019 the objectives emphasized utilizing the same hygienist model while increasing the number of portable units and staff to reach more students. In June 2019, the objective was to increase access to care by providing teledentistry and dental cleanings. With the hygienist taking intraoral photos on each patient and using an asynchronized (store and forward) method, the dentist in the fixed clinic could review the photos and charting, complete a limited exam and thus authorize a dental cleaning and make recommendations for follow up care.

The teledentistry pilot program began in June, 2019 in day cares, churches and Boys and Girls Clubs. This increased access to care in other venues. A hurdle to implementation of teledentistry was to provide the services in a standardized and timely manner. Since this was achieved, the program was implemented in the Marion County Public School system.  Its outcome has been slower to realize because to expand services in the schools, the program needed a third hygienist and portable unit and camera. The unit was purchased along the camera, but it took nearly a year to find a hygienist to work. The new hygienist will start in January 2020, which will allow a third hygienist in the school program. This will compensate for the longer time per student needed to provide the additional services (intraoral photos and dental cleaning) so that they can still see a comparable number of students. Specific factors that have led to success were to obtain the intraoral photos, store and forward, and load them in the dental software, thereby overcoming the technology obstacle. Also, a good relationship with the Marion County School Board who approved the new memorandum of agreement was critical to the success of the project. The public health impact is that the project is providing better access to care in reaching Title I children in rural and city schools. Since the addition of teledentistry more children are signing up to be seen since they are getting their teeth cleaned and seen by a dentist (without the dentist being physically present at the school). Children are getting greater dental care and follow up care is being readily identified. Oral hygiene instructions are taught to the children and a follow up note goes home with each student. A phone call is made to parents not only for children in pain and swollen but for basic restorative needs. The website is marion.floridahealth.gov.

This school-based sealant program is a portable program, providing services by hygienists in the Title I schools in Marion County and Head Start. Marion County has two federally qualified health centers and the Florida Department of Health, and 4-5 private offices that accept Medicaid. Only the federally qualified health centers and the health department offer dental care on a sliding fee based on income. According to census.gov/quickfacts/marioncountyflorida, Marion County has an estimated population of 359,977 people of which 18.6% are children under 18 years old. This extrapolates to 66,956 children under the age of 18. According to the wellflorida.org Marion County Community Health Assessment 2015-2016, 28.2% children live in poverty. It is estimated that 34,000 households received public assistance 2009-2013. Fifteen percent of adults 25 years and older do not have a high school diploma. The average time to travel to work is 25 minutes for private cars and 100.8 minutes on public transportation. Multiple areas of the county with low income families live greater than 20 miles from the supermarket.

Healthy People 2020 identifies multiple school-based sealant programs. During the baseline years (1999-2004) 25.5% children received a sealant on a permanent molar. The Healthy People 2020 goal increases that number to 28.1%. There were no teledentistry entries in Healthy People 2020. The Florida Board of Dentistry requires a patient to have an exam by a dentist every 13 months for the hygienist to perform a dental cleaning. This greatly limits access to care for Marion county low income families because there are few providers who take Medicaid or sliding fee based on income. All the providers except one are in the Ocala City limit; the other one is slightly out of the city limit. For the rural areas, there are no dental resources close to home. Families must travel 25-40 miles one way to go to a dentist that takes their Medicaid or sliding fee. This school-based sealant program takes dentistry to the children in areas where there is no access to care. The program started with these rural areas and has increased the number of schools each year. In 2018-2019 the program served 25 of the 50 Title I schools in the county and served 2,320 children and provided 8,289 services, including 5,119 sealants. In addition, the LHD operates a separate school-based program for the Head Start and Early Head Start children, which has a dentist and assistant model due to Head Start requirements. Four hundred and three head start children were served with an approximately 1,226 services provided.  June-July 2019 in the pilot program, 52 teledentistry exams were performed with 178 child and 43 adult (12 and older) dental cleanings in day cares, churches and Boys and girls Clubs in the county.  Memorandum of Agreements (MOA's) had to be established for each site, which took some time to write and have them reviewed by legal teams for each entity.

 The main barrier to implementing teledentistry in the past was the internet band width required to access electronic dental record. Several discussions were held with Patterson Dental, the Eaglesoft electronic dental record company, and it was determined that the platform for the Eaglesoft system was too large to initiate and maintain off-site access through either a VPN or cloud-based method. Other options had to be explored. There are two teledentistry modes, one for synchronized live feed intraoral photography and verbal communication and the other is asynchronized where the data is stored and forwarded. This program chose to utilize the asynchronized mode. An informational flier, medical history and consent and notice of privacy practices packet is sent home to all children. Principals at most of the schools, make at least one all-call” school alert to let parents know the fliers have been sent home. This helps alert the parents to look for the fliers and to let the parents know the principal supports the program. Forms are collected 1-2 weeks later and reviewed. Any medical issues are reviewed and if necessary, a call home to the parent is done. The hygienists operate under a signed dental protocol that is standardized. Each hygienist takes a series of intraoral photos starting the upper right quadrant, followed by upper left, lower left and lower right quadrants. Intraoral photos are also taken of the soft palate, throat area, cheeks and the tongue and floor of the mouth area. The hygienists also have a standardized dental record they complete on each child, recording existing conditions, soft tissue findings, plaque score, and record if the child has pain. Sealants are prescribed per the Basic Screening Survey (BSS) defined by the Association of State and Territorial Dental Directors (ASTDD) which defines the oral health indicators and sealant protocols. After recording the oral health conditions, the hygienist performs a dental cleaning, sealants, fluoride varnish and oral hygiene instructions. Finally, the hygienist sends a letter with the student to the parent describing their oral health conditions and what treatment was completed. The letter encourages the student to see a dentist either right away or in 6 months. The contact information is listed for the two federally qualified health centers and the health department dental clinic on the form. The hygienists return to the dental clinic, download the intraoral photos to a secured drive and then complete their charting and recording of services in Eaglesoft and complete the encounter form for billing. The office assistant then uploads all the intraoral photos to each of the dental records and the dentist reviews the photos, charting and completes progress notes. Parents of children who have pain or swelling are called immediately by the hygienist to let them know of the situation and give them resources to obtain care. A follow up call is made by the office assistant to those parents and any parent of a child with early dental needs. Letters are sent via mail if the child has dental conditions in previous school-based visits that were never addressed. Documentation is made for all calls and letters. Thus, follow up care is identified, communicated to the parent and every effort is made to assist the parent in obtaining the necessary care. There is no cost for the school-based program to any child. The school-based program bills Medicaid, Kid Care and there is a recurring federal grant that helps cover children without insurance. Referrals are made for children needing sedation. Many of these parents are extremely thankful to have the assistance in getting the follow up care and referrals.

The school-based sealant program's goal to increase access to dental care for low income children in a financially sustainable model. In the first year, the objective was to establish a partnership with the Marion County School Board and provide services to the designated rural schools. Using portable equipment, the hygienist provided an assessment, fluoride varnish, oral hygiene instructions and sealants on permanent molars to students who returned their completed medical history and signed consent forms in designated schools. The first schools targeted were the Title I rural schools in the county, as they had the least access to care due to transportation. In 2017-2019 the objectives emphasized utilizing the same hygienist model while increasing the number of portable units and staff to reach more students. In June 2019, the objective was to increase access to care by providing teledentistry and dental cleanings. With the hygienist taking intraoral photos on each patient and using an asynchronized (store and forward) method, the dentist in the fixed clinic could review the photos and charting, complete a limited exam and thus authorize a dental cleaning and make recommendations for follow up care.


The steps of implementation were as follows:

  1. Create a memorandum of agreement with the Marion County Public School Board and update yearly. A separate MOA is needed for each entity, such as churches or day cares since they are not administered by the School Board. This is very important for communication so that everyone know their responsibilities and liability.
  2. Create a signed protocol authorizing the delegable duties that can be performed under the supervising dentist.
  3. Obtain a student count from the School Board Liaison and order consents and fliers. This program uses Pride, which is the prison-based printing company.
  4. Purchase portable patient chair and ProSeal II unit. This program purchased the chairs and portable unit through Patterson Dental which is a distributor for Dental Health Works. When the dental cleanings started this summer the two existing ProSeal units were retrofitted with a quick connect outlet so that the hygienists could use a cavitron. The new unit was ordered with both the quick connect outlet and an additional electrical outlet.
  5.  Obtain lap top computers and in 2019 intraoral cameras to use in the field. The Sirona Schick USBCam4 was chosen as it was compatible with Eaglesoft.
  6. Install a stand-alone Eaglesoft work station on the lap top computer. This work station does not communicate with the main Eaglesoft server.
  7. Order all mirrors, explorers and dental cleaning instruments, cavitrons and cavitron tips. Order all supplies for sealants, dental cleaning, fluoride varnish, fluoride gel for the rare child that has a contraindication for the varnish, take home kits with toothbrush, floss and tooth paste, oral hygiene instructions. Also order any models needed to explain oral hygiene instructions. A portable eye wash and emergency equipment is needed. The program does not take an AED since the schools have them.
  8. Distribute the consent packets to the schools approximately 2-3 weeks ahead of the visit. We found that sending them all out for the entire year caused a lower response than sending them out two weeks ahead of the school visit.
  9. Collect the returned consents. Many times, the school office assistant will create a list of the students by classroom and by schedule for the middle school children. This helps with locating the children and minimizing classroom interruptions. Obtain a liaison for that school to help with communication and locate a volunteer, if possible, at the school who will help with getting the children to and from class.
  10. Review the medical histories and consents to make sure they are complete and follow up on any concerns.
  11. The office clerks enter the children in Eaglesoft and print out their Medicaid, Kid care insurance. This is attached to the medical history/consent and the child dental record to go with the hygienists to the schools.
  12. Using a van, transport all items to the school and set up equipment and supplies in the designated room at the school. This should be a room that is large enough to handle the equipment and supplies and able to be secured when not in use. No patient information is left at the school when not in use.
  13. Provide services to the children based upon the agreed schedule with the school liaison. 
  14. Secure area, return to the fixed dental clinic, down load the intraoral photos into a designated secured drive, chart services in Eaglesoft, complete encounter form. Meanwhile instruments are properly sterilized for future use. This program ordered additional instruments so that there could be extra for the next day.
  15. The office assistant uploads the intraoral photos into the Eaglesoft chart at the clinic and the dentist reviews the photos, charting and makes notes. She also scans in all the consents, medical history and child dental record to the individual Eaglesoft record before giving them to the dentist. This provides extra assistance to make sure nothing is misplaced.

The hygienist calls any parent/guardian of a child in pain or has swelling that afternoon. Once the dentist reviews the records and makes notes the office assistant follows up with those parents to answer any questions and facilitate scheduling or referral. She sends a letter if the child has urgent dental needs and she was unable to make contact. She also calls the parents of children with identified early needs (no pain or swelling at this time). When a hygienist sees a child a subsequent year and they note that the follow up care was never completed, a letter is sent home to the parent identifying the problems and again listing places where care could be obtained.  Once the dentist has reviewed and follow up calls/letters are completed and documented in the progress notes of the dental record, the paperwork is scanned as a bulk file to a patient record with the name of the school and date. This provides back up before the paperwork is shredded.

The criterion for school selection was to target the rural schools first. Therefore, the schools in the Reddick, Ocklawaha, Weirsdale, Dunnellon, Ft. McCoy, Belleview areas were first. Once the program finished those schools and time permitted contact was made to schools inside the city limits.

The timeframe for the program was Spring 2016 to begin the Memorandum of Agreement. Equipment was ordered in Summer 2016. Additional equipment was added the 2017-2018 to accommodate a second hygienist.  The teledentistry pilot program MOA's were started in Spring 2019 and the program started Summer 2019. Finally, additional equipment was added 2019 for a third hygienist.

The LHD is the Florida Department of Health in Marion County. The stakeholder is the Marion County Public School Board with each of its 50 Title I school children and families.

The LHD fosters a relationship with the Marion County School Board (stake holder) by communicating with the School Board Liaison via phone and email in creating and updating the MOA each year in the Spring for the next year. Before school starts, the LHD provides the Liaison a list of the school visits planned for the coming year. The LHD provides an informational email and PowerPoint explaining the program in detail, its importance in prevention of oral health problems to the Liaison. The Liaison then sends the email and PowerPoint to the individual principals. The Liaison communicates to the LHD as necessary any questions or concerns. The LHD notifies the school principal and the Liaison of any incident report needed for the school.

Startup costs and funding are as follows: the ProSeal II units cost $5,622 per unit. The Ultralite patient chair with scissor base, arm rest slings and carrying case is $1,388. The basic operator stool is $274. The straight attachment for the electric motor on the ProSeal is $536.24. Cavitron Select SPS 30K Ultrasonic scalers with reservoir are $2,585 each. The quick connect on the ProSeal is $32 and the electrical outlet is $72. Cavitron tips cost $113.74 each, mirrors are $.91 each and explorers with periodontal probes cost $25.45 each.  Hand scalers vary in price from $14-$25 each. The hygienists preferred head lamps ($400 each) rather than floor LED lamps.  The supply cost per student visit averages to $2.75 if no sealants are needed. The supply cost of a student visit with 4 sealants in addition to the cleaning, fluoride varnish is $6.25. The cost of a student visit with 8 sealants in addition to the above services is $7.39. This program provides a take home goodie bag with a new toothbrush, floss and tooth paste with a cost per student of $.65. Other costs including autoclave bags, water, lab coats, hand sanitizer, gauze, floss and masks are approximately $26.46 per school. Printing costs are approximately $.32 per student packet and will vary depending on how many students are enrolled in a school. The Health Department purchased a dental van in the second year that made transportation easier, since the equipment must be moved school to school.

 The school-based sealant program's goal to increase access to dental care for low income children in a financially sustainable model. The first objective was to establish a partnership with the Marion County School Board and provide services to the designated rural schools. The second objective was to increase the number of portable units and staff to reach more students. The third objective was to increase access to care by providing teledentistry and dental cleanings. With the hygienist taking intraoral photos on each patient and using an asynchronized (store and forward) method, the dentist in the fixed clinic could review the photos and charting, complete a limited exam and thus authorize a dental cleaning and make recommendations for follow up care.

 The data sources used are State reporting systems. Performance is measured by how many students seen and how many services provided for each hygienist. Sealant retention rates are also measured, although this difficult because they do not necessarily see all the same children each year. Finally, revenue for the sealant program is reviewed. The program should be self-sustainable.

  1. In 2016-2017 one hygienist with a dental assistant to help with charting treated 1,666 children, providing 7,321 services at 11 Title I schools. The dentist with assistant treated 309 Head Start children, providing 1,236 services.
  2.  In 2017-2018 one full time and part time (1 day per week) treated 2,230 children, providing 7,935 services at 18 Title I schools. The dentist and assistant treated 228 Head Start children, providing 799 services.
  3.  In 2018-2019 school year on full time hygienist and part time (4 days per week) treated 2,268 children, providing 8,093 services. The dentist and assistant treated 403 Head Start children, providing 5,496 services.
  4. In June-July 2019 the pilot teledentistry program staffed with one full time hygienist and one part time hygienist (2 days per week) and a dentist one hour per day at the fixed clinic treated 106 children, providing 876 services.

Since our goal of increasing access to dental care for low income children through a financially sustainable model, was successful, the only modifications made were to increase hygienists and portable units. Teledentistry started in June 2019. It seemed good public health practice to provide dental cleanings to the children in addition to their sealants and to provide a limited exam using asynchronized teledentistry. This service has increased quality of care in having the oversight of a dentist and has facilitated follow up care for the children.

This program has learned several lessons in the past 3 years. The program found that is was more efficient to have each hygienist complete their own charting and data entry in Eaglesoft. This gave greater accountability and reduced errors in patient identification and in charting.  Another lesson learned was that the hygienist team needs to work together. They are off-site without a supervisor on premises, so they must be very responsible and thorough in every detail. They interact with the school personnel and they need to be diligent to complete the tasks as necessary but flexible to adapt to the school schedule, room accommodation, volunteers, etc. A huge lesson learned is that there is a shortage of Florida dental hygienists and it can take many months to a year or more to hire a qualified hygienist. Therefore, the program must adapt until a suitable hygienist can be found. Another lesson learned was to be persistent in finding solutions. For example, dental cleanings were deemed highly important for the students, rather than continuing to provide sealants on top of the teeth and fluoride varnish. It took many months of asking the right questions before a solution could be found.  Florida dental law requires that patients be examined by a dentist every 13 months for the hygienist to provide dental cleanings. Technology could not support a live feed teledentistry connection in Eaglesoft, the electronic dental record. Research into Medicaid fees revealed an asynchronized teledentistry code. Discussions with the program's local IT department and the online Eaglesoft technology support determined that the platform for Eaglesoft was just too large host in the field. Through those discussions a stand alone work station was proposed. The transportation issue was resolved by purchasing a van dedicated to dental. It also has an advertising wrap on the outside which promotes good oral health.

Lessons learned in partner collaboration were to make sure the Marion County School Board Liaison was informed well in advance of the school start date. School principals and school staff question the Liaison and they need to be able to respond accordingly. The Memorandum of Agreement (MOA)needs to be reviewed and signed in the spring for the coming year. This avoids the last-minute rush during the summer as meetings are usually every month or two. A lesson learned for the school summer programs, Boys and Girls clubs, churches and day cares was to provide services an MOA had to be written and approved by both legal parties. This can be a lengthy process and should be done well in advance. The MOA's can be written to renew each year unless changes are needed and that will help expedite the process next year.

The revenue collected in 2018-2019 by the school-based program was $193,762.90. Hygienist salaries and benefits are relevant to each program and are not included here. However, in the June 2019 JADA 150 (6) article Hospital inpatient admissions for nontraumatic dental conditions among Florida adults, 2006-2016”, there were 163,906 dental related ED visits in 2014 with total charges of $234.4 million.  Early dental care is the key to prevention of future nontraumatic dental conditions. Limited exams completed through teledentistry allows a dentist to complete early detection of cavities and oral health diseases. Dental cleanings, fluoride varnish, oral hygiene instructions and sealants provide preventive dental care.  This school based program is using technology and mobility to take preventive dental care to the areas where it is most needed, thereby increasing access to care.

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