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Milieu in Dental School and Practice

Teledentistry-Assisted, Affiliated Practice
for Dental Hygienists: An Innovative Oral
Health Workforce Model
Fred F. Summerfelt, R.D.H., M.Ed.
Abstract: The 2010 U.S. Patient Protection and Affordable Care Act (PPACA) calls for training programs to develop mid-level
dental health care providers to work in areas with underserved populations. In 2004, legislation was passed in Arizona allowing
qualified dental hygienists to enter into an affiliated practice relationship with a dentist to provide oral health care services for
underserved populations without general or direct supervision in public health settings. In response, the Northern Arizona Uni-
versity (NAU) Dental Hygiene Department developed a teledentistry-assisted, affiliated practice dental hygiene model that places
a dental hygienist in the role of the mid-level practitioner as part of a digitally linked oral health care team. Utilizing current
technologies, affiliated practice dental hygienists can digitally acquire and transmit diagnostic data to a distant dentist for triage,
diagnosis, and patient referral in addition to providing preventive services permitted within the dental hygiene scope of practice.
This article provides information about the PPACA and the Arizona affiliated practice dental hygiene model, defines teledentistry,
identifies the digital equipment used in NAU’s teledentistry model, give an overview of NAU’s teledentistry training, describes
NAU’s first teledentistry clinical experience, presents statistical analyses and evaluation of NAU students’ ability to acquire diag-
nostically efficacious digital data from remote locations, and summarizes details of remote applications of teledentistry-assisted,
affiliated practice dental hygiene workforce model successes.
Mr. Summerfelt is Assistant Professor, Department of Dental Hygiene, Northern Arizona University. Direct correspondence and
requests for reprints to him at Northern Arizona University, Box 15065, Building 66, Flagstaff, AZ 86011; 928-523-3623 phone;
928-523-6195 fax;
Keywords: mid-level dental health care practitioner, dental hygiene, teledentistry, affiliated practice dental hygiene, digital diag-
nostic data, underserved populations
Submitted for publication 8/8/10; accepted 12/29/10

he United States Patient Protection and Af- a minimum of eight hours chosen from pediatric,
fordable Care Act (PPACA), signed into law special health care needs, preventive dentistry, public
in March of 2010, greatly expands oral health health, or community-based dentistry.
care to eligible individuals and provides funding to Utilizing current teledentistry technologies,
train and employ alternate dental health care provid- oral health care providers can digitally acquire and
ers to work in areas with underserved populations.1 transmit diagnostic data to a distant dentist for triage,
In 2004, the Arizona Legislature approved a statute diagnosis, and patient referral. The Northern Arizona
allowing qualified dental hygienists to enter into an University (NAU) Dental Hygiene Department has
affiliated practice relationship with a dentist to pro- developed training for and successfully demonstrated
vide oral health care services for underserved popula- a teledentistry-assisted, affiliated practice dental
tions without general or direct supervision in public hygiene model, which has the advantage of digitally
health settings.2 Specific qualifications for the affili- linking all physically separated members of a tele-
ated practice dental hygienist include a) a minimum dentistry team to meet the federal government’s call
of five years of dental hygiene experience; b) active for an alternate dental health care workforce. This
engagement in dental hygiene practice for at least article provides information about the PPACA and
2,000 hours in the five years immediately preced- the Arizona affiliated practice dental hygiene model,
ing the affiliated practice agreement; and c) twelve defines teledentistry, identifies the digital equipment
additional hours of continuing education within the used in NAU’s teledentistry model, gives an overview
current triennial licensure renewal period, which of NAU’s teledentistry training, describes NAU’s first
must include four hours of medical emergencies and teledentistry clinical experience, presents statistical

June 2011  ■  Journal of Dental Education 733

Ad. that integrates electronic health records. The use of teledentistry presents as an 734 Journal of Dental Education ■ Volume 75. tions.2 U. a household income of less than 200 percent of the tion present in many rural communities have added federal poverty guidelines. Internet to link dental providers and their patients. and the American munications technology. two dentists will retire for each graduating within twelve months of initial treatment and that dental student and enrolling dentists as Medicaid an affiliated practice dental hygienist must consult providers will become more difficult due to burden. participating in the the rising number of ethnic minority and immigrant national school meal program. and the Dental Hygienists’ Association’s advanced dental hy. state. and acquire diagnostically efficacious digital data from standing orders established by an affiliated dentist. or local health care program. county. As an additional workforce alter. diverse and already undertreated populations. and summarizes details of remote That affiliated practice statute required that patients applications of teledentistry-assisted affiliated prac.3 Since 2001. Number 6 . graphics.S. velopment since 1994 when used in the U.S. Arizona SB 1400 amended § 32-1289’s emphasized the vastly disproportionate availability patient demographic to include a person of any age of oral health care among certain American popula. or residing in a feder- to the burden of providing oral health care for our ally designated Health Professional Shortage Area. seen by affiliated practice dental hygienists be eigh- tice dental hygiene workforce model successes. digital imaging. the PPACA provides $60 million to fund for the procedures affiliated practice dental hygienists fifteen projects designed to demonstrate the potential are allowed to perform under § 32-1289.7 Telemedicine.7-10 Although in de- In 2004. telecom- munity dental health coordinator. SB 1400 added additional language to § 32-1289 ditional considerations affecting future oral health requiring patients treated by an affiliated practice care availability include the facts that. over the next dental hygienist to be examined by a licensed dentist decade. members of a federal. the increasing elderly population. to dentistry.2. and enrolled in a national school meal program. prevalent in rural dental hygienists who are part of a digitally linked communities. Army’s 1289 that allowed qualified dental hygienists to enter Total Dental Access Project. and the professional health care isola. this article describes a teledentistry-assisted. uses telecommunications technology team to provide all of the preventive services within to send data.7. the American Dental Association’s com. giene practitioner. The foundations of teledentistry lie in telehealth and native. from a family with populations. or local health care program. analyses and evaluation of NAU students’ ability to ant to a written agreement.11 teledentistry has yet to into an affiliated practice to provide dental hygiene be accepted as a widely used or fully accepted adjunct services without general or direct supervision pursu. The PPACA cites as examples of alternate Teledentistry dental workforce models Alaska’s dental health aide Teledentistry is a developing area of dentistry therapist. state. administer- ing local anesthesia and nitrous oxide.4 service to a patient with a complex medical history The 2010 PPACA calls for mandatory pediatric or medication regimen. and audio and video images their scope of practice to members of underserved for diagnosis and consultation between participants and remote populations. teen years of age or younger. county. telemedicine technologies that have been practiced affiliated practice dental hygiene model that allows since the 1950s. effectiveness of new members of the oral health care team and to train and employ alternate dental health providers.2 See Table 1 are available.5 remote locations. written procedures. the affiliated practice dental hygiene by § 32-1289. who is either enrolled in a federal. with the affiliated practice dentist before providing some administrative requirements. physically separated by distance.2 Three The PPACA and Affiliated dental hygiene procedures—root planing. the Arizona Legislature passed § 32. surgeon general’s 2001 report on oral health had In 2009.1 To meet the tal hygiene services and consult with the affiliated increased need and ensure enough dental providers practice dentist in questionable cases.6 dentistry for eligible children up to age twenty-one Arizona’s affiliated practice dental hygienists and expands Medicaid to all who are at or below 133 are required to follow the standard of care for den- percent of the Federal Poverty Level. and placing Practice Dental Hygiene periodontal sutures—were specifically excluded from Prior to the 2010 federal health care reform.

000. Perform all procedures necessary for 1. Discuss patient’s home care proce- 2. varnishes as indicated according to tion and referral when appropriate. fluoride varnish. data. NAU acquired completed process evaluations in all related tech- two each of the following equipment: Open Dental niques including the ability to assemble and disas- office management software. teledentistry equipment for acquiring the diagnostic rays.7. ADA=American Dental Association. vices for the attendees. The dental hygiene students studied all ing the one-day event. Provide appropriate home care 3. portable hard disks. The cost of each teledentistry pack. and appropriate dental referrals for all Initial Student Training and participants. Because digital imaging management software. The students created patient records acquire diagnostically efficacious digital data from within TigerView and imported DXTRR’s digital remote locations. In April 2009. June 2011  ■  Journal of Dental Education 735 . Apply dental sealants to teeth ac.Table 1. 1. Note: Root planing. and NAU hosts an annual Kiddie Clinic to provide Dell projectors. Following the success of this first clinical test. administration of local anesthesia and nitrous oxide. prophylaxes. Provide tobacco cessation interven- 4. and a vehicle to decrease the records. dures. the Nomad Portable Handheld X-ray system and suc. Assess blood pressure. All of the equipment chosen dentists. radiographs. dental sealants. graphs according to ADA guidelines. Review medical and dental history. Volunteer community proximately $25. 5. Dell laptop computers. 6. The students learned how to export all of the phenomenon of professional isolation common to digital diagnostic data to store-and-forward storage rural and underserved areas. The Kiddie Clinic provides assisted. cavity and surrounding structures. using the Scan-X Duo image scanning unit. affiliated practice dental hygiene. Intraoral Digital Cameras. distance radiographs and intraoral images into the patient learning framework. affiliated and burned disks. including portable storage equipment. and how plans were made to improve both future student train- to capture intraoral images using the Acclaim Intra. Perform dental restorative charting cording to ADA and CDC guidelines. TigerView Professional semble all of the portable digital equipment. Expose and process dental radio. head-and-neck examinations. Administer topical fluoride gels and 3. dental hygienists. Scan-X Duo digital x. aminations for local children. The students learned to scan digital x. 3. ADA and CDC guidelines. Nomad Portable Handheld X-ray acquisition techniques typical to teledentistry. The digital x-rays were well of the manufacturer-supplied training materials for accepted by the volunteer Kiddie Clinic dentists. To develop the teledentistry-assisted. to test the teledentistry equipment. dental examinations. 2. the students easily learned the digital diagnostic data ray film scanners. taken on DXTRR mannequins with the Nomad. was ap. dental hygiene services and complete dental ex- age. Perform a caries risk assessment.12-18 devices such as thumb drives. and placement of periodontal sutures are specifically disallowed under § 32-1289. 2. Screen and photograph the oral a complete prophylaxis. ten senior dental hygiene students ac- Clinical Experience quired digital bitewing and occlusal radiographs NAU received the teledentistry equipment in from forty-six of the 117 Kiddie Clinic patients dur- March 2009. instruction. and NAU faculty members integrates seamlessly and has proven to be successful participate with the students to provide low-cost ser- in both local and remote applications of teledentistry. Each student received eight hours practice dental hygiene workforce model and add of teledentistry equipment training and successfully teledentistry skills to its curriculum. radiographic systems.9. Acclaim of their familiarity with general digital technologies. and they complemented both the diagnostic ease cessfully completed the manufacturer’s certification and increased clinic flow attributed to utilizing the examination. and recording of clinical findings. Procedures allowed for Arizona affiliated practice dental hygienists under § 32-1289 Patient Assessment Preventive Services Patient Education 1. CDC=Centers for Disease Control and Prevention emerging web-based intervention system. ing and evaluation methods of students’ abilities to oral cameras.

drive. students took x-rays with the portable digital equip- proper care and treatment. A computers. provided a much better image of the intraoral area Students learned to set up and manage the laptop than could have been attained by a visual exam. head-and-neck NAU Internal Review Board requirements were met. The pedodontist found the ment. The pedodontist reviewed the diagnostic data Eighteen of the service centers are located more and developed appropriate treatment plans for all of than a three-hour one-way drive from Flagstaff. students were given six hours of training with the claim Intraoral camera to be a very valuable asset. NACOG Head Start contracted with a Flagstaff were contacted directly by the pedodontist’s staff pedodontist to provide services for the Head Start to schedule appropriate treatment.500 preschool-age children Start Screenings. Number 6 . Training included com- Placing a new barrier sheath over the camera before prehensive study of the Nomad Pro Handheld X-ray use with each child negated the need to use a mouth system training manual and successful completion of mirror and light for the assessment examination and the manufacturer’s training certification examination. watched as the NAU now established patients of record with the NACOG- teledentistry coordinator and NAU dental hygiene contracted pedodontist and have had. As of July 2010. Kindercamp children include Head Start digital equipment and the diagnostic efficacy of and preschool children from the Flagstaff Unified students’ digital products acquired from simulated School District. and bitewings were acquired. and the Initial Field Trials use of the Stabe bite blocks prevented accidental biting damage to the phosphor x-ray film plates used The Northern Arizona Council of Governments for occlusal views. during NAU’s 2010 Annual Kiddie Clinic to evaluate zona KinderCamps conducted at Flagstaff elemen. a pilot Head Start community outreach program. and a Kiddie Clinic teledentistry-assisted. Discussions among the NAU giene services in his practice. (NACOG) Head Start program provides annual Following the two days of KinderCamp Head services to more than 1. Students onto a wall. pilot project to be successful and plans to include affiliated practice dental hygiene services to serve the teledentistry-assisted. children’s primary caregivers prior to the events. the Acclaim Intraoral cameras. or are receiving. On all from the general NAU vicinity.000 square miles of rural northern Arizona. the NACOG Head Start manager. affiliated practice dental hy- Head Start population. medical records. and the NACOG-contracted pedodontist led to an affiliated practice dental hygiene agreement. 736 Journal of Dental Education ■ Volume 75. and radiographs including occlusal views mary caregivers prior to any child being seen. Fluoride varnish was applied to each child’s teeth. tabs and Stabe bite blocks to gain experience ac- and the children enjoyed participating with their quiring digital x-rays with the portable equipment. and the projector was used to enlarge the intraoral images TigerView image management software. Medical history and permission. portable digital equipment. examinations. and appropriate consent forms were signed by pri- graphs. ten NAU senior dental hygiene the KinderCamp Head Start project proved the Ac. The children liked the Nomad x-ray device. children residing in the northern Arizona area. teledentistry coordinator. existing conditions. examinations because they could also see their teeth. The eighteen of the twenty-seven children seen during NACOG-contracted pedodontist had participated the 2009 Head Start KinderCamp screenings are in NAU’s 2009 Kiddie Clinic. affiliated practice demonstra- tion model. which made it easy for the affiliated worked with DXTTR mannequins using bitewing practice dental hygienist to see the intraoral images. the diagnostic data were forwarded at twenty-six local centers in four counties cover- to the NACOG-contracted pedodontist via a thumb ing 27. data including privacy and knowledge of the demonstration project. intraoral photo. the teledentistry A second demonstration project was conducted equipment was taken to United Way of Northern Ari. To ensure patient standing orders from the pedodontist. Preparation for the Project The public health screening atmosphere of In preparation. Demonstration Project For the initial NACOG project. The primary caregivers of the children 2009. and saw the potential for teledentistry-assisted. the adequacy of student training with the portable tary schools. In the children. The 2010 Kiddie Clinic popula- to-treat forms had been signed by the KinderCamp tion was children sixteen years of age and younger. the chief complaint. remote locations.

it was decided to simulated remote locations. the data from which were used face-to-face and clinic time was limited due to the as the control to compare with results from the two number of patients presenting. After the x-rays data during the demonstration project. appropriate number of digital data via the NAU Dentrix clinic management patients for data comparison. it was decided to present the received a similarly aged. Additionally. to blind the Conduct of the Project clinical participants as to the source of the incoming To ensure each of the three test locations digital diagnostic data. and the laptop learned to share the digital images with other tele. the patients proceeded to the Prior to the Kiddie Clinic. limit the data acquisition for this demonstration project to digital x-rays. were taken (Figure 1). Patients students. 2010 Kiddie Clinic: student taking x-ray June 2011  ■  Journal of Dental Education 737 . Dentrix software was installed on the dom number to either one of the two simulated remote laptop computers for acquiring and forwarding the locations or to the clinic x-ray lab. computers were linked to the NAU Dentrix data- dentistry team members via store-and-forward and base. Sixteen dental ect students set up the portable digital equipment in hygiene operatories were used by students for this two separate simulated remote locations adjacent to Figure 1. to radiology rotations utilizing NAU’s x-ray lab to Because dentists would be examining patients obtain digital x-rays.Students trained with the Acclaim Intraoral cameras the NAU Dental Hygiene Clinic. Other dental hygiene students were assigned real-time technologies. and volunteer dentists and dental were first grouped by age and then assigned by ran- hygienists. Both areas used by capturing digital images of their peers’ teeth and hard-wire access to the Internet. faculty. demonstration proj- dental hygiene clinic for services. a stratified-random software system already in place and familiar to all method of patient-by-age selection was used.

examined the results. two simulated remote locations was found (Z=-. Once seated. Students at each simulated remote location were asked to evaluate the digital x-rays as to whether were able to obtain statistically equal diagnostically they were diagnostically unacceptable.05.56). The data were analyzed with efficacy of the digital x-rays taken by dental hygiene PASW 18 statistical software.05. or diagnostically accept. 2010 Kiddie Clinic: student receiving remote data 738 Journal of Dental Education ■ Volume 75. No dental hygiene students at Remote Location 1 to the statistically significant difference was found between diagnostic efficacy of the patients’ (n=21) digital x- the diagnostic efficacy of x-ray images received from rays taken by the dental hygiene students at Remote Figure 2. The second objective was to compare the the dentists were asked to identify specific improvable clinical dentists’ (n=8) evaluation of the diagnostic aspects of the x-rays. and each operatory had a computer system Location 2. Number 6 . the patient’s ence in diagnostic efficacy of the x-rays taken at the digital x-rays were displayed via Dentrix (Figure 2). The first objective was to compare the clinical α=. project. ex- and standard monitor for viewing the clinic’s Dentrix amined the results. No statistically significant differ- software management data. able with no improvement necessary.577. Clinic dentists. Patients’ (n=20) x-rays dentists’ (n=8) evaluation of the diagnostic efficacy from Remote Location 1 were compared to patients’ of the patients’ (n=20) digital x-rays taken by the (n=26) x-rays from the NAU clinical x-ray lab. Additionally. with the portable equipment. students at the two simulated remote locations to the digital x-rays taken during Kiddie Clinic in the Analysis of Results NAU clinical x-ray lab (control) by other NAU dental hygiene students. α=. diagnostically efficacious digital x-rays after six hours of training acceptable but improvable. A Wilcoxon signed-rank test. p=. Again. unaware of the origin of the images. Wilcoxon signed-rank tests.

a blurred image due to either patient or operator mo- tion. These activities took place within training. unopened contacts. p=.604. the adequacy of their six-hour training with the Although not statistically significant. ate teledentistry-assisted. exposure adjustment control. A Likert-scale evaluation had more non-diagnostic and improvable results than found nine students rated the training excellent. failure to open interproximal contacts. Results of the diagnostic efficacy and/or placement.21). and of the patients’ (n=21) x-rays from Remote Loca. clinical lab were similar (Z=-1. and blurred images. In each of 2010. the Affiliated Practice Dental dental hygiene students used bitewing tabs and disposable Stabe bite blocks in each of the three Hygiene test locations rather than any type of reusable x-ray Between October 2009 and the end of June film-holding. using an x-ray film place. Error types by demonstration site location Film Placement Unopened Contacts Blurred Image Exposure Contrast Total Error Types Remote 1 1 6 1 2 10 Remote 2 0 6 0 1 7 Lab (Control) 0 5 0 1 6 June 2011  ■  Journal of Dental Education 739 .11). Students and faculty results than the lab (control). which might Flagstaff and at several remote Arizona sites including Table 2. See Table 2 for the image-set diagnostic hygiene curriculum. to ensure a Teledentistry-Assisted. affiliated practice dental Additional training and familiarity with the Nomad hygiene services for children participating in First Pro Handheld X-ray system might also reduce these Things First health care events at thirteen Coconino types of errors and will be addressed in future student County locations. the there was no statistically significant difference in the students (n=10) working in the simulated remote diagnostic efficacy between x-ray images acquired at locations were asked to provide their opinion on Remote Location 2 and the NAU clinical x-ray lab. the NAU teledentistry coordinator participated the three test locations. Exposure and contrast errors. software adjustment control. Diagnostic-but-im. A Likert-scale evaluation was efficacy from each location. and improper image contrast. Remote 1 portable x-ray equipment. Image-set diagnostic efficacy by location Non-Diagnostic Diagnostic Sets Diagnostic Sets Total Sets Image Sets Improvable Not Improvable of Images Remote 1 2 8 10 20 Remote 2 1 6 14 21 Lab (Control) 0 6 20 26 Totals 3 20 44 67 Table 3. indicating Following the demonstration project. See Table 3 for Applications of specific errors by demonstration site location. p=. with the Coconino County Maternal and Child Health ment device might have reduced errors due to film Program to provide oral screening and appropri- placement. Non-diagnostic and used to survey their opinion.Remote Location 1 and the NAU clinical x-ray lab have been caused by x-ray collimator proximity (Z=-1. For this demonstration project. placement.265. See Figure 3 and Table improvable results were caused by improper film 4 for the results of student and faculty responses. and Remote 2. and Remote 2 had more non-diagnostic one student rated it very good. collimator-aligning device. standard of conditions typical in remote areas where sterilization equipment might not be available. will also be addressed tion 2 and the patients’ (n=26) x-rays from the NAU in future training. members (n=82) were then asked to rate the value of provable results from Remote 2 and the lab (control) incorporating teledentistry skills into the NAU dental were equal.

thus eliminating the need for the hygienist could easily see large images of the intraoral children to first travel to Polacca. The diagnostic the need to move patients quickly through the pro. team and equipment to be flown in by helicopter. All of the remote areas were accessible by ing in the Kaibab area typically obtain dental services vehicle except Supai. including four children who appeared At each event.9% Good 14 17. In which is 225 miles east of Kaibab.4% Excellent 45 54. miles northwest of Flagstaff. highlighted specific advantages offered by the from digitally acquired data for these four patients teledentistry-assisted affiliated practice dental hy. apply fluoride varnish.0% 22.4% 2. for an initial examination and treatment plan.997. who diag- Because of the lack of sterilization equipment and nosed the need for immediate care. the Acclaim Intraoral cameras with disposable Hopi Health Care Center. triage. three children. the digital than simply screen. Kaibab is 231 tages for remote populations. and treatment plan Fair. 740 Journal of Dental Education ■ Volume 75.1% 17.26. n=82 Figure 3. concern to be viewed later by the dentist (Figure 4).3% 22. Student and faculty opinions on the value of teledentistry skills within the NAU curriculum Table 4. Grand Canyon. Student and faculty ratings of the value of teledentistry skills within the NAU curriculum Frequency Percentage Valid Percentage Cumulative Percentage Poor 2 2. _______________ X*__________________________________________________________ 5 4 3 2 1 Excellent Very Good Good Fair Poor *M=4. Number 6 . the NAU teledentistry coordinator did not allowed. the number of patients have an affiliated practice established with the Hopi and the time allowed made it impossible to do more Health Care Center pedodontist. the NAU teledentistry coordinator saw twenty- tists.6% Total 81 98. which required the teledentistry at the Hopi Health Care Center located in Polacca. the Kaibab Health of the dentist to diagnose. 183 children were screened and referred to den. sheath barriers proved very valuable in expediting the she instructed the NAU teledentistry coordinator to services. When the Paiute children tistry equipment as the circumstances of the event were seen. to the Flagstaff-based affiliated dentist.0% Williams. exemplifies one of the teledentistry-provided advan- giene model for remote populations.9% 55. During some events.4% 2. After reviewing the data.8% Missing 1 1. the team utilized the teleden. Therefore.2% Very Good 18 22. At the remote total. and 129 of the children received fluoride varnish. Page. data were then forwarded to the pedodontist at the cess. to need immediate care.5% 4. The Paiute Indians liv- and Supai. SD=0.2% Total 82 100. The time and cost savings represented by the ability One of the remote events. Fredonia. Kaibab. and make diagnostic data from the four children were forwarded appropriate referrals to the affiliated practice dentist.2% 44. a 450-mile round environment and knew when to photograph areas of trip.5% Fair 2 2. event. Projecting the intraoral images on the wall have the four children schedule immediate restorative again proved to be advantageous because the dental services with her.5% 2.

and refer patients assisted affiliated practices. and emerging technologies will only further health organization personnel. have shown their ability to set up. dentists. for appropriate treatment. NAU is providing informative acquisition equipment described is currently state of presentations and hands-on training for community the art. In addition to ongoing community dem. and transmit hygiene. presents one digital diagnostic data from the remote locations that mid-level practice model that can answer the call of are statistically as diagnostically efficacious as diag- the PPACA to provide comprehensive preventive oral nostic data obtained from an onsite dental hygiene health care and diagnostic services for the growing clinical laboratory. June 2011  ■  Journal of Dental Education 741 . as described in this article. The portable digital diagnostic data onstration projects. Initial training endeavors prove that teaching the data acquisition technolo- gies to dental hygiene students has been easily and Conclusion successfully accomplished: students. The teledentistry methodology practicing in Arizona. The success of the NAU described can be adapted to any model used for the teledentistry-assisted affiliated practice model has emerging mid-level oral health practitioner and pro- been well accepted by a growing number of Arizona vides a way for the mid-level practitioner to partici- community health organizations and oral health care pate as a digitally linked member of a complete oral providers. with only six hours of training. 2010 Kaibab Health Fair: student viewing intraoral image projected on wall There are currently forty affiliated practice population of underserved patients in both urban dental hygienists and five teledentistry providers and remote areas. triage. and dental the ability of distant dentists receiving the diagnostic hygienists interested in establishing teledentistry.Figure 4. Teledentistry-assisted affiliated practice dental manage remote patient service facilities. data to properly diagnose. health care team.

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