ALL HANDS ON DECK: Amber with son Christian. Although Amber is a dental professional, she still struggles with Christian cooperating at the dentist.

Telehealth in dentistry increases family understanding of dental home care & helps practitioners build rapport with patients before they even enter that "scary" place. The behavioral goal is to make dental visits fun & more comfortable for the patient.

TELEDENTISTRY A NEW PARADIGM TO IMPROVE ORAL HEALTH

BY DAVID FRAY, DDS, MBA AND AMBER LOVATOS, RDH, BSDH

"Christian, lay down." Christian shakes and sits up again. "Christian, lay down and open your mouth." Christian covers his mouth. "Christian, I need you to let the doctor take a look; just like you let me do at home."

 We all know too well the struggle we face when taking our child to the dentist, especially when having a child with a disability. Amber Lovatos, RDH, BSDH, is a dental hygienist and an assistant professor at The University of Texas Health Science Center at Houston (UTHealth) School of Dentistry. Her son Christian has autism. Amber concentrates her research on using technology in dentistry to facilitate and increase access to dental care. Although Amber is a dental professional, she still struggles with her son Christian cooperating at the dentist. As a parent and a dental hygienist, Amber understands the struggle that comes with making medical decisions for children. We can all agree that although our children may not want to go to the dentist, it is imperative that they receive regular dental care. Delaying visits to the dental office can lead to more severe issues such as dental decay, gum disease, and dental abscesses. These are all issues that will lead to more invasive dental treatment.

I am David Fray, DDS, an associate professor at UTHealth School of Dentistry, with family members from the disability and special needs population. During my 12-year tenure as Chief of Developmental Disabilities in Hawaii, we designed and initiated the "Virtual Dental Home" project based upon the concept of "teledentistry." Together with Amber, we collaborated as faculty in different departments within our school to create a teledentistry curriculum pilot program for dental and dental hygiene students at UTHealth School of Dentistry. This combined knowledge on how to use telecommunication facilitates improved oral health for people with intellectual disabilities. So how do we get our children the care they need, while increasing need, while increasing cooperation and providing a comfortable environment? We believe teledentistry is an integral component for the solution to that question.

You cannot receive traditional restorative dental care virtually, but you could potentially have an exam performed virtually and then have an allied healthcare provider provide preventive care in your home.

The use of telecommunication in medicine has become increasingly popular. People can now receive medical care from the comfort of their homes. If your child woke up with pink eye today, you could connect to a medical provider through a HIPAA-compliant app on your phone, have an exam, and a prescription sent to your pharmacy without having to leave your home or take off from work. The same technology can be useful in dentistry, but of course, with some limitations. You cannot receive traditional restorative dental care virtually, but you could potentially have an exam performed virtually and then have an allied health care provider provide preventive care in your home, including radiographs and behavioral support learning.

In Washington (both state and D.C.) and New York, dental hygienists under the supervision and direction of a dentist can visit patients in their homes and provide care. A dental hygienist brings mobile dental equipment: an intra-oral camera, a laptop with encryption for HIPAA security ("patient information protection software"), an X-ray machine and a portable dental unit used for cleaning teeth. The dental hygienist takes pictures and/or videos of the patient's mouth and sends them to a dentist using the HIPAA compliant teledentistry software. The dentist viewing the patient in real time can perform the exam virtually using the images and other assessment data collected by the hygienist. Once the dentist has performed the exam, the hygienist can provide preventive care and therapeutic care. Preventative care includes performing cleanings, applying fluoride, and silver diamine fluoride (SDF). SDF is a fluoride used to "arrest" decay (stop it temporarily) until the patient is able to visit a dentist. SDF application is noninvasive and painless. It also can turn teeth black only where there is active decay. Sometimes due to discoloration of teeth people choose to use SDF for back teeth while the front teeth are filled first.

How does receiving care at home help patients with disabilities? The dental office can be a scary environment, especially for the first few visits. Additionally, health providers can learn much from the family home setting. The home setting just feels safer than any dental office, especially if previous experiences were traumatic. What are the triggers that start adverse behavior? How do family members gain cooperation at home that can be duplicated in a dental office later? Just using a mouth mirror from a stranger will cause a reaction from some persons with intellectual disabilities. Family members can place the mirror and learn improved brushing techniques from the dental hygienist. Gradually the "bond of trust" transferred to the hygienist from the parent or caregiver will make the next steps of exam, X-rays and a cleaning possible.

This method of care known as incremental desensitization is based upon the work of Amber from UCLA many years ago. She demonstrated that behaviors do change over time when understood as communication that creates a desired result and incremental learning occurs.

Family members and dental team members can reinforce learning new desired behaviors. The best results are the formation of a plan guided by a behavioral professional such as a Board Certified Behavior Analyst (BCBA) with a behavioral support plan that includes specific step-by-step goals to learn to be a better dental patient.

Wow, that takes a lot of work! It can take many visits. The benefit to the dental team is that this incremental learning does not use valuable chair time at the office. Telehealth approaches increase family understanding of dental home care and result in the dental team understanding the person before ever entering that "scary" place. The person learns to trust the dental team hygienist and the office tour becomes a scavenger hunt for familiar dental items. Making dental visits fun is the behavioral goal.

There are limitations to teledentistry. For one, not all states have passed teledentistry legislation that permit dental exams performed virtually. Second, some states have teledentistry laws that limit the location for this innovative technology. Even if a dentist can perform an exam using teledentistry, it might be limit ed to locations such as health care facilities, schools, charitable organization, and the physicians' office. In states such as Arizona, there are limitations. A person could still receive care at a familiar location such as their school, but not at home. If you live in a state with no teledentistry legislation, you may not benefit from a "virtual" oral exam, but you may obtain a consultation depending on that state's Dental Practice Act and a participating supervising dentist.

Technology continues to advance the opportunity for better oral help.

The difference between an exam and a consultation is that an exam provides a diagnosis and a treatment plan. This theoretically allows a dental hygienist (if they provide care in a state that allows general supervision) to general supervision) to provide care for patients remotely. A consultation would be receiving a dentist's opinion and recommendation based upon information provided by the hygienist. As parents, we often have questions about our children's health and continuously take our child to the doctor for perceived ail ments that often prove to be benign. In situations such as these, parents can use their phones to take images of areas of concerns in their child's mouth and send it to their dentist. The dentist would then be able to guide the parent on whether or not a visit to the dental office is an immediate need.

Patients can also potentially use teledentistry to identify other concerns such as yeast infections in the mouth, often called thrush (oral candidiasis). This is important especially in patients who are at higher risk, such as patients with genetic disorders like Down syndrome, autoimmune disorders, and leukemia or lymphoma. While this practice is allowed in all states, parents must still protect their child's health care information. It is essential to ask the dentist to provide a HIPAA-compliant way to share their child's information – such as through a HIPAA teledentistry encrypted application. Many dentists now use these internet-based software applications.

While not all states are created equal when it comes to laws, technology continues to advance the opportunity for better oral help. Parents are advocates that can work with their dental professionals and elected representatives to expand the benefits of teledentistry to those individuals most in need of improved oral health.

NOTE: The opinions expressed in this article are those of the authors and do not represent The University of Texas Health Science Center at Houston (UTHealth) School of Dentistry. No part of this article is intended for the use or recommendation for any specific patient or treatment. All individuals with disabilities and their families are encouraged to have a dentist and dental home and rely on professional recommendations from those that know the unique person and their abilities.

ABOUT THE AUTHORS:

David Fray DDS, MBA is Associate Professor, University of Texas Health Science Center at Houston (UTHealth) School of Dentistry, Department of General Practice and Dental Public Health. Amber Lovatos RDH, BSDH is a Dental Hygienist and Assistant Professor at the University of Texas Health Science Center at Houston (UTHealth) School of Dentistry in the Department of Periodontics and Dental Hygiene.