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It’s Time to Think Differently About Access to Dental Care

It is impossible to find a dentist today that claims to have too many patients (1). Yet at the same time there are thousands of people in the United States who don’t have access to dental services (2). Let’s call this a systems paradox. From the dental school curriculum to the way in which the average dental practice is managed, our profession’s systems are built in lockstep and are often out of sync with ever changing social and cultural mores. Some of the most warmly held practices in dentistry such as the standard six-month hygiene recall have been called into question from an evidence-based perspective.(3) Dentistry is moving towards a risk-based approach to managing dental disease.(4) In that paradigm, each dental patient’s needs are determined by their level of risk and as such the appropriate amount of resources/care can be allocated. The Field of Dreams (5) strategy of “if you build it, they will come” has not been an economically and operationally viable model for increasing access to dental services in rural and other underserved areas. Unlike the dental patient that routinely comes to bricks and mortar practices, the underserved population is heavily skewed by higher rates of chronic disease, higher percentages of the elderly, higher rates of unemployment, underemployment and poverty, lower rates of dental insurance, and greater dependence on public insurance coverage.(6) With the ubiquity of the smartphone and the ease with which individuals of all socioeconomic strata can access communications technology, a Star Trek (7) strategy of “beam me up, Scotty” has emerged as an alternative model for increasing access to dental services. Teledentistry, our profession’s version of Captain Kirk’s teleporter, leverages communication technology in order to create bidirectional communication between those who seek dental services and those who provide them, literally bringing the treatment room within reach of the living room.

The American Teledentistry Association (ATDA) defines teledentistry as “the use of electronic information, imaging and communication technologies, including interactive audio, video, data communications as well as store and forward technologies, to provide and support dental care delivery, diagnosis, consultation, treatment, transfer of dental information and education, where the originating site of care is the location at which the oral health professional is licensed.” (8) The American Dental Association provided the profession a comprehensive policy statement on teledentistry in 2015, in which they laid out a broad framework for its practice and highlighted the need for insuring that ethical and regulatory standards are maintained.(9) With any innovation, commercialization soon follows. Subsequent to the publication of the ADA Policy Statement, there has a been a proliferation of commercial entities providing teledental services and a number of serious allegations have been leveled against some of these companies.(10) Unfortunately, there has been much heat and very little light shed on best practices for teledentistry. Our profession would be well-served to bring together the brightest innovators from industry, academia and government to discuss the current reimagination of clinical practice (11) via teledentistry rather than litigate them in the courts. Both State Medical and Dental Boards have recently learned an expensive lesson about exercising their responsibility to protect the public at the expense of free trade.(12,13)

Regardless of where one stands on the issue of elective doctor-directed at home clear aligner teleorthodontic treatment, there is a tremendous opportunity for the dental profession to gain valuable insights from the teleorthodontic industry into how we can utilize our existing workforce to increase access to basic dental services in rural and other underserved areas. Over 60 percent (1,972) of the counties in the United States do not have an orthodontist’s office.(14) A national network of affiliated state licensed dentists and orthodontists have treated patients via the teleorthodontics platform provided by SmileDirectClub during a 3.4-year period and served 1,655 counties out of the 1,972 underserved US counties.(15) This represents an 84% geographic increase in access to elective orthodontic care in the US. In comparison, only 66.3% of the US population is currently receiving fluoridated water.(16)

Teledentistry is in its infancy but clearly has the potential to make a tremendous impact on the way in which patients will access their dentist in the future.

THIS EDITORIAL WAS SOLICITED AND THEN LATER REJECTED BY THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION. PLEASE SEE BELOW:

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1. Vujicic M. Solving dentistry’s “busyness” problem. J Am Dent Assoc. 2015;146(8):641-643. doi:10.1016/j.adaj.2015.06.001
2. Gupta N, Vujicic M, Yarbrough C, Harrison B. Disparities in untreated caries among children and adults in the U.S., 2011-2014. BMC Oral Health. 2018;18(1):30. doi:10.1186/s12903-018-0493-7
3. Patel S, Bay RC, Glick M. A systematic review of dental recall intervals and incidence of dental caries. J Am Dent Assoc. 2010;141(5):527-539.
4. American Dental Association. Center for Scientific Information, ADA Science Institute. Caries Workgroup, ADA Council on Scientific Affairs. https://www.ada.org/en/member-center/oral-health-topics/caries-risk-assessment-and-management (Accessed September 2, 2018)
5. Costner K, Madigan A, Jones JE, Brown D, Whaley F, Liotta R, Lancaster B, et al. 1999. Field of dreams. Universal City, CA: Universal.
6. Langelier M, Rodat C, Moore J. Case Studies of 6 Teledentistry Programs: Strategies to Increase Access to General and Specialty Dental Services. Rensselaer, NY: Oral Health Workforce Research Center, Center for Health Workforce Studies, School of Public Health, SUNY Albany; December 2016.
7. Roddenberry G. 1967. Star Trek. Culver City, CA: Desilu Studios.
8. American Teledentistry Association. Available at: https://www.americanteledentistry.org/facts-about-teledentistry/ (Accessed September 2, 2018)
9. American Dental Association. Comprehensive ADA Policy Statement on Teledentistry. Trans.2015:244.
10. American Dental Association News. ADA discourages DIY orthodontics through resolution. November 10, 2017. Available at:
https://www.ada.org/en/publications/ada-news/2017-archive/november/ada-discourages-diy-orthodontics-through-resolution (Accessed September 2, 2018)
11. Ackerman MB. Reimagining clinical practice: Teleorthodontic technology and its impact on workflow, workforce and access to care. J Am Coll Dent. 2018;85(2):26-29.
12. LeBuhn R. How Will the U.S. Supreme Court’s Decision in North Carolina Dental Affect the Regulation of the Professions? J Am Coll Dent. 2015;82(3):18-20.
13. United States Court of Appeals For The Fifth Circuit. Teladoc Inc., et al. v. Texas Medical Board, et al. No. 16-50017.
14. U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (2017). National Plan and Provider Enumeration System (NPPES). Research report. Washington, D.C.
15. American Teledentistry Association. Research Brief. Available at:
https://www.americanteledentistry.org/teleorthodontics-and-access-to-care-at-least-84-percent-of-underserved-us-counties-now-have-access-to-orthodontic-treatment/ (Accessed September 2, 2018)

16.Centers for Disease Control. Community Water Fluoridation.  Available at: https://www.cdc.gov/fluoridation/statistics/2014stats.htm (Accessed September 2, 2018)

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