By Anne Blythe
Dr. Shaun Matthews rolls his chair closer to the computer in his UNC-Chapel Hill dental school office and clicks on a video of him talking with a patient whose jaw he recently reconstructed.
Meghan Welty is a special-needs teacher from Morganton and is Matthew’s Exhibit A for how a teledentistry program could help North Carolina improve access to oral health care.
The state ranks 37th in the country for the number of dentists per capita and much of the paucity is tied to how few providers set up practices in the state’s more rural counties.
“Most dentists are heavily concentrated in five counties,” Matthews said, referring to Pitt and Orange, where the state’s two dental schools are, as well as Buncombe, Mecklenburg and Wake.
Teledentistry uses technology to connect clinicians with patients outside their offices and is extolled as a cost-efficient way to expand basic care to low-risk patients in underserved areas, especially children and seniors who have to rely on others for transportation to appointments. Matthews and Welty also see it as advantageous for professionals and others with jam-packed schedules.
For Welty, a 29-year-old native North Carolinian with rheumatoid arthritis, it’s a six-hour trip to Chapel Hill and back to see Matthews, the oral surgeon who has given her hope for eating food again that isn’t pureed, mashed or cut into tiny pieces.
Before her surgery in June 2018, Welty’s jaw had deteriorated so much from arthritis she could open her mouth no more than 14 millimeters, a painful predicament that severely limited her diet.
Since then, Welty’s care team has monitored her progress, routinely measuring her jaw mobility, checking on her scars and the facial paralysis plaguing her right after surgery.
There are times when Welty needs to meet with caregivers in person. That can necessitate taking a whole day off from work, gas money on top of the price of the visit, too.
Now she’s an advocate for adding dentistry to the growing list of health care provided remotely.
Matthews, the director of telehealth for the UNC School of Dentistry, wanted to check Welty’s progress during a week last year that was one of the busiest times of the school year.
“I asked him if there was any other time …” Welty recalled, “and he told me about this conference.”
Oral health providers, lawmakers, policy-shapers and telehealth program pioneers gathered for a teledentistry summit at UNC in October, and Matthews offered the special-needs teacher a chance to help him teach others. All Welty had to do was click an email link during her lunch break and the live-stream consultation began, giving her virtual access to two places at one time. She never left her classroom.
“It’s amazing,” Welty said.
In addition to saving on the time and cost of travel, Welty could see the before and after jaw scans posted by Matthews for conference attendees more clearly online than she ever had during on-site appointments.
Welty has continued to improve. On last measurement she could open her mouth 40 millimeters, a little more than an inch and a half, making it possible for more variety in her meals. One thing she enthusiastically awaits is biting into corn on the cob this summer.
“It’s just not the same experience when you have to cut it off,” Welty said.
Building a support team
As Welty looks forward to the fresh summer staple, Matthews is excitedly pitching teledentistry to different audiences.
He cites statistics in the N.C. Oral Health Collaborative’s recent “Portrait of Oral Health in North Carolina” to bolster his point.
- Twenty-one percent of North Carolina adults age 65 and older have lost all their teeth.
- Thirteen percent of the kindergartners had untreated tooth decay.
- Though many of the state’s more rural counties have no more than one or two dentists, Camden, Hyde and Tyrell have none.
“The figures clearly demonstrate that we are in an oral health crisis,” said Matthews, shaking his head in dismay.
A native of Barbados who came to Chapel Hill four years ago from Great Britain, Matthews did his dental and medical training in Scotland and England. At Charing Cross and Kings’s College hospitals in London, he specialized in treating TMJ syndrome and is proud of the interdisciplinary team he brought together to treat the disorder.
Here in North Carolina he is focused on building a team to educate others about teledentistry, and he might have some powerful support with the executive director of the North Carolina Dental Society on board.
“Teledentistry and telehealth are not about replacing what exists,” Matthews assured. “It’s about enhancing it.”
Teledentistry can take several forms.
Livestream face-to-face consultations between a dentist and patient, a hygienist and dentist or general practitioner and specialist in different locations. Technology makes it possible to add in parents or family members for group consultations, too.
“Store-and-forward” consults that make use of intraoral cameras to get images that can be stored and forwarded with records and other patient data to a supervising dentist for review and formation of a treatment plan. That treatment might be something a hygienist is trained to do or require referral to a specialist.
Hygienists limited by law
But in North Carolina, there are barriers.
The hygienists on the frontlines of routine dental visits, the ones who clean teeth, check gum health, take X-rays and more, are prohibited for the most part from working inside someone’s mouth unless a licensed dentist is on site.
There are public health hygienists who can clean teeth and help with preventative care in schools and places served by state and local health departments when a dentist is not there, but state lawmakers have cut that workforce by more than half since 2009 — shrinking it to 24 hygienists from the 54 on board 10 years ago.
The number of licensed hygienists has grown steadily over the past 40 years to 6,153 in 2017, but they’re dispersed around the state in roughly the same areas as the 5,112 dentists.
Sommer Wisher, president of the NC Dental Hygienists’ Association and executive director of Wake Smiles, said hygienists might be willing to establish or work in satellite offices in underserved counties if North Carolina allowed them to provide more care outside the direct, on-site supervision of a dentist. Teledentistry could help, she said.
“They really would have to change the scope of practice laws,” Wisher said, noting North Carolina’s practice limitations are among the most restrictive in the country.
Additionally, broadband access in rural and mountainous North Carolina would have to be expanded and improved. The North Carolina Broadband Infrastructure Office estimated in 2018 that at least 637,671 North Carolinians, largely in rural areas, lacked broadband service at the Federal Communications Commission’s minimum speeds.
But two bills have been introduced this session that could help improve rural broadband.
Role of student debt
Alec Parker, executive director of the North Carolina Dental Society, a powerful player in shaping oral health care laws, says it’s important to invest in that kind of infrastructure and teledentistry programs.
New dental school graduates in North Carolina enter the job market with student loan debt only slightly lower than the $287,000 national average, a financial burden that stymies most from setting up new practices or moving outside urban areas where they can make more money at the start.
Parker recalled completing dental school in 1979 and being able to buy property and immediately start a solo practice in Asheville, where he practiced for nearly 28 years before moving to the N.C. Dental Society in 2006.
“That is not really an option for graduates at this point,” Parker said.
That’s why he’s become an advocate for teledentistry and amending laws that limit hygienists’ scope of practice, changes he thinks dentists are ready to buy into gradually as long as patient safety and quality care are of utmost importance.
A law adopted last year orders the state Department of Health and Human Services to submit a report to the Joint Legislative Oversight Committees on Health and Human Services and Medicaid and NC Health Choice by Oct. 1 that includes recommendations for improving access to dental care in rural North Carolina.
Parker said he expected teledentistry to be a part of that report which could help fuel scope of practice changes next year.
“Where we’re focusing our efforts right now is we’re trying to make some of these changes to hygienists and dental assistants in tier one counties,” Parker said, referring to the state’s most distressed counties.
In the meantime, Parker will join other oral health care advocates on trips to Rochester, N.Y., and California in the coming months to see established teledentistry programs.
Paul Glassman, who’s at the Arthur A. Dugoni School of Dentistry at the University of the Pacific in San Francisco and sometimes hailed as “the father of teledentistry,” will be one of the tour guides.
He gave a presentation at the UNC summit last fall and spoke recently in a telephone interview about the Virtual Dental Home project that has served as a model for other states and could, too, for North Carolina.
In California, specially trained hygienists and dental assistants went to schools, nursing homes and other sites convenient to people who might otherwise not see a dentist.
They performed basic procedures — such as deciding which X-rays to take or installing temporary fillings to stop an already decayed tooth from further deterioration — while consulting with dentists miles away.
That project led to changes in California five years ago when then-Gov. Jerry Brown signed a bill into law requiring Medi-Cal, the state’s insurance program for the its neediest, to pay for such services.
Teledentistry programs have been launched in Oregon, Colorado, Ohio, Minnesota and elsewhere, too.
“It’s pretty clear this is starting to get some momentum,” Glassman said. “This is a significant opportunity for improving the oral health care of North Carolina.”
Correction: This article originally stated that North Carolina ranked 47th in the country with 42 dentists per 100,000 people. That is an older number. An update done by the American Dental Association in 2018, found here, shows there are now 52 dentists per 100,000 per capita in North Carolina.