By Anne Blythe

Shaun Matthews, an evangelist for telehealth in the United States and abroad, was giving a presentation to the International Association of Dental Research on a Zoom call last week when he learned that North Carolina lawmakers had just approved a bill formalizing the use of teledentistry.

As part of his presentation on “The Rise of Teledentistry in Clinical Practice: An Inevitable Response to a Global Pandemic or a False Dawn,” Matthews mentioned work he had done in North Carolina while at the UNC-Chapel Hill dental school.

During his Zoom segment, Jane Weintraub, former dean of the UNC Adams School of Dentistry and the woman who recruited Matthews to Chapel Hill from Great Britain, dropped a message into the chat discussion for her colleague.

She had just received word that Senate Bill 146, an act establishing standards for the practice of teledentistry in North Carolina, was sailing through the General Assembly with broad support in both chambers.

On Friday, Gov. Roy Cooper signed the bill into law.

Matthews, a clinical professor in Oral and Maxillofacial Surgery and Hospital Dentistry at the Indiana University School of Dentistry since August 2020, swelled with pride.

For two of his five and a half years at the dental school in Chapel Hill, Matthews was director of telehealth while juggling his clinical and teaching work.

Teledentistry, Matthews and other supporters say, can help expand basic oral health care to people in areas where it can be difficult to see a dentist, to underserved children and to the aging. With special cameras, audio and visual technology, clinicians can do consultations and some follow-up visits with patients remotely, often saving the patient the cost of traveling to the appointment and the need to take time off from work.

Power of telehealth

During the pandemic, telehealth visits rose sharply, especially in the spring of 2020. In an Oct. 2020 report posted on the Centers for Disease Control and Prevention website, a team of scientists concluded that there was a 154 percent increase in telehealth visits during the last week in March compared to the same time frame in 2019. 

“Telehealth could have multiple benefits during the pandemic by expanding access to care, reducing disease exposure for staff and patients, preserving scarce supplies of personal protective equipment, and reducing patient demand on facilities,” the researchers concluded. “Telehealth policy changes might continue to support increased care access during and after the pandemic.”

Some estimates put the adoption of telehealth even higher. The management consulting firm McKinsey estimates that beyond an initial explosion of telehealth use in early 2020, telehealth use has stabilized at 38 times higher than pre-pandemic levels.

“After an initial spike to more than 32 percent of office and outpatient visits occurring via telehealth in April 2020, utilization levels have largely stabilized, ranging from 13 to 17 percent across all specialties,” the McKinsey authors found. 

In the early days of the pandemic, when Matthews was still in North Carolina, he worked with Weintraub and others at the Adams School of Dentistry to create the Carolina Dentistry Virtual Oral Health Care Helpline.

COVID-19 had spread across the country and state with a vengeance.  

The UNC dental school had held its second teledentistry summit in early March of 2020, hoping to persuade others that the use of such technology could expand oral health care access to underserved populations and remote parts of the state.

When many dental offices across North Carolina were forced to close except for emergency services, Matthews and others built on their teledentistry models to set up a system in which people who perhaps cracked a tooth or had some other oral health issue could call into the hotline.

Putting ideas into action

If necessary, the caller could get a virtual assessment through a video or Zoom call.

In the first month, 337 telephone calls were answered, according to an article the dental school colleagues published in the Journal of the American Dental Association about the hotline. Dental pain was the reason that more than half of the people called. Seventy-nine of the callers received consultations from virtual providers, the authors stated, and 33 of those callers did not require follow-up.

Using teledentistry to connect dentists and oral health care providers to their patients virtually during the pandemic underscores many of the benefits that advocates have been touting for years.

They include:

  • Virtual consultations in which dentists can assess a patient quickly and remotely to determine whether to recommend medicine, a trip to an emergency clinic, hospital or their dental offices.
  • Saving patients the expense of travel and unnecessary time off from work for a check-up after an operation if it can be done online.
  • Through the use of intraoral cameras, a hygienist or nurse can share images from inside the mouth of a patient they’re seeing at a nursing home, school or other remote site and discuss a treatment plan with a dentist.

Hygienists and local anesthesia

Zachary Brian, director of the North Carolina Oral Health Collaborative, has long advocated for teledentistry as a way to provide more public health care at schools, nursing homes, rest homes and facilities for people with special needs.

North Carolina dental hygienists have been urging dentists and others in this state to give them the freedom to clean teeth and screen patients for cavities and other problems even if a dentist is not in the room or office with them.

Masked male dentist and masked female hygienist drill inside a patients mouth
Dentist Bill Milner of Access Dental Care and hygienist Mary Elizabeth Andreyev extract a patients broken tooth at Moses Cone Infectious Disease Clinic. Photo credit: Anne Blythe

Additionally, they have argued that they could take X-rays, apply sealants, and in some cases prevent further tooth decay with silver diamine fluoride outside the physical presence of a dentist.

In early 2020, the state legislative rules commission amended the scope of practice for licensed hygienists in North Carolina, making it possible for them to work without a dentist on-site in federally qualified health care centers, some public schools, and special-needs and some elder-care facilities.

The new law establishes standards for the practice of teledentistry that will make it possible for hygienists to work in such facilities without a dentist there with them.

The law also authorizes registered hygienists to administer local anesthetics, another expansion of their scope of practice in a state that is among the most restrictive in the country for what a hygienist can do outside the presence of a dentist.

North Carolina hygienists now will join the ranks of their peers in 44 other states and Washington, D.C., already authorized to give injections. The change, Brian said, could help improve efficiency and perhaps reduce the cost of care.

“This is an important step toward a more equitable oral health landscape in North Carolina,” Brian said in a statement.

There are challenges, though.

There’s a paucity of broadband infrastructure in much of rural North Carolina, making telehealth visits less likely in just the regions such programs could better serve.

Questions remain, too, about whether insurers will continue to cover teledentistry and other online health care visits after the pandemic.

The stakeholders who brought together lawmakers from both parties to show broad support for teledentistry in North Carolina say it was important to bring many to the table and educate them about the public health benefits and business advantages for dentists.

The North Carolina Dental Society played a crucial role, too.

“It is always great to see bipartisan support for common-sense health care reform,” Ben Popkin, political strategist for the Foundation for Health Leadership and Innovation, said in a statement.

‘Over the moon’

Matthews, the former UNC dental school professor recruited to Indiana University to help advocate for telehealth in the Hoosier State, was still jazzed several days after the North Carolina law was adopted.

“I am absolutely thrilled, over the moon,” Matthews said during a telephone interview.

The Indiana governor signed a bill into law in April that authorizes dentists, hygienists and other health care providers to use telehealth with their patients, a change that came, in part, because of Matthews.

Though approval of the law in North Carolina came several months after the Indiana action, Matthews said this state’s establishment of standards for the practice of teledentistry is a step further.

“To hear it literally coming through hot off the presses as I was giving my presentation was so impressive,” Matthews said.

Weintraub, who has been busy looking up teledentistry activities in the corporate world now that this state will be able to offer it as a service, summed up the law after the international conference.

“This bill is a major step forward in aligning our state with the rest of the country to improve the accessibility and efficiency of dental care,” Weintraub said in a statement. “It clarifies the provision of teledentistry that benefits those who can’t easily get to a dental office because of geography, disability, a pandemic, or who desire greater convenience.

“It makes it possible for people to obtain preventive services from qualified dental hygienists in many community settings without on-site dentist supervision.  NC is one of the last states to allow trained dental hygienists to provide local anesthesia. The first state did so 50 years ago in 1971.”

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Anne Blythe

Anne Blythe, a reporter in North Carolina for more than three decades, writes about oral health care, children's health and other topics for North Carolina Health News.