Accepted Manuscript

Feasibility Assessment for Using Telehealth Technology to Improve Access to Dental

Care for Rural and Underserved Populations

Amy B. Martin, DrPH, Joni D. Nelson, PhD, Grishma P. Bhavsar, PhD, James
McElligott, MD, David Garr, MD, Renata S. Leite, DDS, MS

PII: S1532-3382(16)30114-2
DOI: 10.1016/j.jebdp.2016.08.002
Reference: YMED 1136

To appear in: The Journal of Evidence-Based Dental Practice

Received Date: 18 August 2016

Accepted Date: 29 August 2016

Please cite this article as: Martin AB, Nelson JD, Bhavsar GP, McElligott J, Garr D, Leite RS, Feasibility
Assessment for Using Telehealth Technology to Improve Access to Dental Care for Rural and
Underserved Populations, The Journal of Evidence-Based Dental Practice (2016), doi: 10.1016/
j.jebdp.2016.08.002.

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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 ACCEPTED MANUSCRIPT

Feasibility Assessment for Using Telehealth Technology to Improve Access to Dental Care for
Rural and Underserved Populations

Amy B. Martina, Joni D. Nelsonb, c, Grishma P. Bhavsard, James McElligotte, David Garrf,
Renata S. Leiteg
a
DrPH, Division of Population Oral Health, James B. Edwards College of Dental Medicine,

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Medical University of South Carolina, Charleston, SC, USA
martinamy@musc.edu
b

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PhD, Division of Population Oral Health, James B. Edwards College of Dental Medicine,
Medical University of South Carolina, Charleston, SC, USA
dunmeyej@musc.edu

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c
PhD, South Carolina Office of Rural Health, Columbia, SC, USA
d
PhD, Department of Health Sciences, College of Health and Human Development, California
State University, CA, USA

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grishma.bhavsar@csun.edu
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e
MD, Center for Telehealth, Medical University of South Carolina, Charleston, SC, USA
mcellig@musc.edu
f
MD, Area Health Education Center (AHEC), Medical University of South Carolina,
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Charleston, SC, USA

garrdr@musc.edu
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g
DDS, MS, Department of Stomatology, James B. Edwards College of Dental Medicine,
Medical University of South Carolina, Charleston, SC, USA
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leiter@musc.edu

Corresponding Author:
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Amy B. Martin, DrPH

Director, Division of Population Oral Health
Associate Professor, Department of Stomatology
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James B. Edwards College of Dental Medicine

Medical University of South Carolina
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173 Ashley Avenue

Basic Sciences Building, Room 127
Charleston, SC 29425
843-792-8270 (telephone)
843-792-7809 (fax)
martinamy@musc.edu

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Abstract

Background. South Carolina Dental Association members were surveyed on telehealth

knowledge, need and interest in using it for access to care improvements.

Methods. Dependent variables were Medicaid patient population size (less or greater than 10%),

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career stage (early/middle and advanced), and National Health Service Corps participation (yes
or no). Practice and provider characteristics were screener questions. Data were collected

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electronically and analyzed with SAS. Descriptive and bivariate analyses were conducted.

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Results. Most (69.3%) reported some or no teledentistry knowledge. Distribution of needing
consults were: endodontics (40.2%), oral-maxillofacial surgery (37.9%), orthodontia (30.7%),
periodontics (28.4%), and pediatrics (12.5%). Consultations for diagnosis (72.9%) emergencies

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(56.7%) and continuing education (53.3%) were most frequently identified telehealth uses.
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Medicaid patient population size was the only dependent measure with statistical significance.
Compared to <10% Medicaid, >10% was more likely to (a) frequently need consults for
orthodontics (25.5% v. 43.4%, p=0.0043) and pediatrics (5.9% v. 29.0%, p<0.0001); (b) use
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telehealth for children with special healthcare needs (44.1% v. 65.8%, p=0.0017), complex
health conditions (54.3% v. 78.1%, p=0.0004), conditions exacerbated by unmet dental needs
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(44.6% v. 65.8%, p=0.0022); and (c) use telehealth for extending practice to underserved
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populations (14.6% v. 33.8%, p=0.0004).

Conclusions. Despite need for telehealth knowledge improvement, sufficient interest exists.
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Further study will determine if demand for teledentistry is in balance with consultant availability.

Practical Implications. It has been suggested that access to care improvements require capacity
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expansions in private practices. States will need to engage dental communities determine if
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teledentistry is an effective solution.

Keywords: Teledentistry; reimbursement; dental provider;

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Introduction
Telehealth encompasses the electronic exchange of patient information, usually clinical,

from one geographic location to another for interpretation and/or consultation among authorized

healthcare professionals.1, 2 Telehealth has been used in the past to provide unique technological

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health services that aid in improving health including: diabetes and cardiovascular disease,3

behavioral and mental health illnesses,2, 4 educational trainings for faculty and clinical staff,

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medical home based care1 and a cadre of medical specialties consultations for critical care

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situations.1 Increased discussions and applications of telehealth for oral health care have been

explored within the last decade, given the attention brought by the 2000 Surgeon General’s

Report for Oral Health in America.5

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The first recognized application of telehealth usage for oral care was by the US Army in

1994 where dental consultations and diagnoses were received by members of the service at a
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distance of 100 miles or more.6 Since that time, telehealth has been used in a variety of oral
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health demonstration projects within the US.2 Teledentistry, through emerging applications for
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distance dental care, has become an acceptable use for telehealth that fulfills many, otherwise

unmet oral health needs.7, 8

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The Institute of Medicine’s report, “Improving Access to Oral Health Care for

Vulnerable and Underserved Populations,”9 recommends teledentistry as a way of ameliorating

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traditional geographic access to care barriers for rural and underserved communities, although its
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application for definitive treatment remains elusive under most states’ dental practice acts. As

such, contemporary use of teledentistry appears to be limited to using dental auxiliaries and

primary care providers in remote locations to conduct screenings, treatment planning, and limited

diagnostic, preventive, and restorative services within their scopes of practice.10 California may

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be the exception as evidenced by its Virtual Dental Home11; its replication, however, has

encountered legal and practical challenges in states with more restrictive practice acts.12

Additional published barriers to the adoption of telehealth technologies by dentists

include training deficiencies, insufficient networks to support the application, overall low use of

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technology, and reimbursement concerns.13 Telehealth terminology can be confusing and distort

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dentists’ understanding of the use and resource requirements of telehealth.13 As such, gauging

the readiness for and understanding of telehealth among the dental community is essential prior

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to developing a teledentistry network.

As an effort to advance potential clinical applications of teledentistry, we conducted a

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statewide feasibility assessment that included the identification of potential consulting
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specialists, pilot demonstration applications, and reimbursement and regulatory issues in South

Carolina. Our goal was to understand the interest and need for the usage of telehealth technology
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by professional dental health providers in South Carolina (e.g. general dentist, pediatric dentist,
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oral surgeon, etc.).

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Methods
Survey Development
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Our survey was developed as a derivative of an instrument previously used by the

principal investigator to assess the readiness of rural hospitals and primary care practices for care
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delivery through telehealth.14 The survey design team represented members from the state dental
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association, the state’s public health and dental academic programs, the South Carolina Area

Health Education Consortium and an established rural telemedicine program. The survey design

team assisted with instrument content and modifications. The target audience was South

Carolina Dental Association membership, which represents more than 80% of practicing dentists

in the state.

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Respondents were given a brief introduction to the purpose of the survey in an electronic

format. A question was added about knowledge of telehealth applications in the practice of

dentistry, however the bulk of the survey questions focused on two domains: 1) need for

telehealth technology; and 2) interest in using telehealth technology for dental care delivery. We

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intended our independent variables to be practice and dentist characteristics, which included:

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dental specialty type, primary practice type, career tenure, proportion of the patient population

that was Medicaid-enrolled; and having past or present participation in the National Health

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Service Corps. Our choice in independent variables stemmed from an assumption that dentists

serving rural, underserved, safety net populations would be more likely to use telehealth to

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bridge access gaps, as their primary care peers have done.15
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With regard to the second domain, respondents were asked to identify the frequency of

needing specialty consultants in the areas of endodontics, oral and maxillofacial pathology,
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radiology, and surgery, orthodontics, pediatric dentistry, periodontics, prosthodontics, and other
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specialties. Frequently needing consultations was defined as once a week or more.

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To assess the potential capacity for consultation services usage and facilitation,

respondents were asked about their interest in using consultants and/or their willingness to serve
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as consulting clinicians to help improve dental care delivery. Respondents were asked to

consider their willingness to seek telehealth consults, or serve as consultants, in the context of
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high priority patient populations, which included people with HIV/AIDS, long-term care
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residents, people with behavioral health diagnoses, children with special health care needs,

patients with complex medical conditions or who are immunosuppressed, people with medical

conditions for which unmet dental needs can exacerbate, and other. Figure 1 provides a

summary of abbreviated questions asked in the teledentistry feasibility survey assessment. The

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study was deemed not to be human subjects research by the researchers’ Institutional Review

Board.

Survey Administration

Surveys were administered electronically in 2013 through the South Carolina Dental

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Association. Of the 46 counties, 44 have some type of dental health professional shortage

designation.16 Targeted dental specialties included general dentistry (n=1,513), pediatric

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dentistry (n=97), oral surgery (n=97), periodontics (n=91), endodontics (n=75), and orthodontics

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(n=128). We included both dichotomous and open-ended questions within the survey to allow

respondents to include additional descriptive information.

Data Analysis
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All data were collected through EpiInfo17 and analyzed using SAS.18 Frequency analyses

were used to reveal response percentages per survey item. The unit of analysis was individual
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respondents, not individual dental practice facilities. We conducted descriptive and chi-square
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analyses, with the latter framed by the distribution of respondent characteristics (independent
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variables).

Results
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Description of Respondents. We had an overall survey response rate of 19.5% (n=384).

Most respondents (78%, n=277) identified as general dentists with the remaining evenly
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distributed across pediatric dentistry (3.9%, n=14), oral surgery (4.5%, n=16), periodontics
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(2.8%, n=10), endodontics (2.5%, n=9), orthodontics (4.5%, n=16), and others (3.7%, n=13).

The majority of respondents were in private practice (91.5%, n=325). More than 80% (n=285)

reported being advanced in their career, followed by 10.1% (n=36) and 8.7% (n=31) as middle

and early career professionals, respectively. Most (65.4%, n=232) reported less than 10% of their

patients were Medicaid beneficiaries with another 16.1% (n=57) between 10% and 30% of their

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patients were enrolled in Medicaid. Only 14 respondents reported having ever participated in the

National Health Service Corps.

Given the distribution of respondent characteristics, our chi-square analyses of dependent

variables (need/interest and potential use) was limited to stage of career, which were

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dichotomized as early and mid career versus advanced, and proportion of practice that was

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Medicaid (<10% versus greater than 10%). Specialty type served as an inclusion criteria for

those initiating telehealth consults and dentists who potentially could serve as consultants.

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Consult initiators were defined as general and pediatric dentists (n=291) and potential

consultants as all respondents.

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Knowledge of Telehealth Use in Dentistry. Of the 384 respondents, 309 dentists indicated
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the degree to which they believed they were knowledgeable in the practice of dentistry using

telehealth technologies. Using a likert scale, most respondents reported they were either
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somewhat or not at all knowledgeable about teledentistry, as presented in Figure 2.

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Estimating Need and Interest. General and pediatric dentists (n=264) responded to
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questions about initiating a specialty consult using telehealth. The largest number of respondents

indicated a need for endodontics and oral and maxillofacial surgery consultations. Table 1
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illustrates the significant differences that were observed for frequently needing consultants by

size of Medicaid practice. Respondents with greater than 10% of patients enrolled in Medicaid
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reported higher rates of frequently needing consults for orthodontics (p=0.0043) and pediatric
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dentistry (p<0.0001) whereas those with less than 10% Medicaid reported higher rates of

frequently needing periodontics consults than practices with smaller proportions of Medicaid

(p=0.0221). No statistically significant differences were observed for frequently needing

consults by stage of career for each of the specialty areas examined. Chi-square analyses were

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not conducted for oral and maxillofacial pathology and radiology, prosthodontics, or other

specialties due to low numbers of responses.

Potential Use of Telehealth Consultant. General and pediatric dentists (n=259) answered

questions about potential use of telehealth for care consultations. The most frequently identified

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priority population for whom the respondents said they would use telehealth consultations were

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patients with complex medical conditions or who were immunosuppressed (n=158), patients

with medical conditions that can exacerbate due to unmet dental needs (n=131), and children

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with special health care needs (n=130). Respondents whose patient populations were greater

than 10% Medicaid reported higher rates of potential telehealth use when caring for the three

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aforementioned special populations (Table 2). As with estimating need and interest, no
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differences were observed with stage of career and potential use of telehealth consultations.

Improving Care Delivery. General and pediatric dentists were asked how they would use
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telehealth resources, if available, to improve practice and care delivery. They were asked to
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choose from a list of ten patient care related functions, as delineated in Table 3. More than half
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reported they would use telehealth for diagnostic and emergency consultations and continuing

education. Another third indicated they would potentially use it for patient follow-up after oral
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surgery. Respondents’ whose practices had a larger proportion of Medicaid-enrolled patients

were more likely to provide an affirmative response to using teledentistry to extend their
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practices to underserved populations than those with smaller such populations (p<0.004). No
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chi-square analysis was conducted for stage of career because it had not demonstrated

significance for the other dependent variables.

Conclusions

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Despite the need to improve knowledge about how telehealth can be used to improve

access to dental care, there appears to be sufficient interest among dentists who responded to the

survey in the potential use of telehealth. Specialties with greatest need, and therefore

opportunity, for telehealth in South Carolina were endodontics and oral and maxillofacial

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surgery. Patient populations identified as potential beneficiaries of teledentistry were

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immunosuppressed patients and children with special health care needs. Diagnostic and

emergency consultations were identified by most respondents as potential applications for

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teledentistry. The survey has provided valuable information to policymakers and the South

Carolina Dental Association as the state explores how telehealth can be used to improve access

to dental care and oral health disparities.

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Further study of the survey will examine who is likely to serve as a consultant in a

statewide teledentistry platform and if the demand for the service is in balance with the
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availability of potential consultants. The demand for dental care services continues to surpass the
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capacity of our declining dental health workforce. Our approach to this formative study was to
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focus on the potential for a teledentistry demonstration project. Teledentistry is a promising

telehealth technology resource that can be a valuable asset to help improve oral healthcare
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delivery and reduce oral health disparities for specific populations. The use of teledentistry can

have a significant positive impact on people receiving safety net services and can help reduce the
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adverse impact of unmet oral health care needs.

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Practical Implications

The United States healthcare system is transforming into an enterprise that is positioned

to achieve the Triple Aim19 of improved population health and quality of care while saving costs

to the system. Policymakers and consumers are beginning to recognize that oral health has been

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excluded from essential public policies such as the Affordable Care Act in ways that adversely

impact access and affordability of care.20, 21 The American Dental Association Health Policy

Institute (ADAHPI) has provided its members with useful analyses that should help facilitate

dentists’ inclusion in the national discourse about improving the quality and efficiencies of

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dental care. In July 2015, ADAHPI published a video22 that delineated the market trends, forces,

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and opportunities that will shape the profession. While the video does not mention teledentistry

specifically, the trends, forces, and opportunities align with the potential benefit telehealth can

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bring to the practice of dentistry.

Before espousing telehealth as one solution for access to care disparities, dental leaders

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should carefully explore the clinical, business, and political levers and challenges. Specifically,
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describing the care and cost efficiencies teledentistry can bring is an essential state-level

conversation. Such a discussion should be contextualized by states’ practice act and

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reimbursement environments. Finally, dental leaders should examine in what ways teledentistry
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aligns with dental consumerism and expectations of care.

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As state dental leaders explore teledentistry and examine the aforementioned questions,

they should consider engaging the nation’s 12 Regional and 2 National Telehealth Resource
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Centers (TRCs)23 funded by the Office for the Advancement of Telehealth, which is a part of the

Health Resources and Services Administration, U.S. Department of Health and Human Services.
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TRCs are funded to improve access to health care in rural and underserved areas by advancing
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the adoption of telehealth technologies and supporting provider communities in their application.

They have a plethora of resources on their websites to educate providers about reimbursement

models, legal and regulatory issues, marketing, and other operational functionalities. TRCs are

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adept at connecting local clinicians with telehealth networks, academic and consulting partners,

and resources to develop telehealth solutions.

Modernizing dental practice in ways that are responsive to consumers but in balance with

healthcare transformation requires innovative approaches to addressing unmet needs. The

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national capacity for providing dental care to underserved communities has been estimated to be

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7 to 8 million people out of the 23 to 24 million who will actively seek dental care on an annual

basis.24 It has also been suggested that improving access to dental care for rural, underserved and

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safety net patients will require growth in capacity in private practice settings. States will need to

determine if teledentistry is an effective tool for bridging access to care gaps.

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Acknowledgements

Appreciation is extended to Dr. Jim Mercer, Board Chair at time of study, and Mr. Phil Latham,

Executive Director, at the South Carolina Dental Association for their contributions to survey

development and distributing it among their members. We would also like to thank Mrs. Kathy

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Schwarting of Palmetto Care Connections for assisting with survey development.

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Funding: Our project was funded in 2012 by the Health Resources and Services Administration

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(Grant Number T12HP24722). The funder had no role in the study design, data collection,

analysis, documentation of findings or submission for publication.

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References

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10. Marino R, Ghanim A. Teledentistry: a systematic review of the literature. Journal of

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for policy and strategy. J Calif Dent Assoc. 2012;40:605-611.

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14. Martin AB, Probst JC, Shah K, Chen Z, Garr D. Differences in readiness between rural
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Table 1. Frequently Needing Consults by Size of Medicaid Practice (n=264)

Proportion of Practice that is Medicaid

P-value
Less than 10% Greater than 10% Total

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N % N % N %

Endodontics 79 42.0% 27 35.5% 106 40.2 0.3297

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OM Surgery 66 35.1% 34 44.7% 100 37.9 0.1441

Orthodontics 48 25.5% 33 43.4% 81 30.7 0.0043

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Pediatrics 11 5.9% 22 29.0% 33 12.5 <0.0001

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Periodontics 61 32.5% 14 18.4% 75 28.4 0.0221
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P-value set at 0.05.
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Table 2. Affirmative Responses to Using Outside Consultants if Available through Telehealth by

Special Populations (n=259)

Greater than
Less than 10%
10%
Special Population
P-value

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N % N %

People with HIV/AIDS 53 28.5% 29 39.7% 0.0804

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Long-term care residents 55 29.6% 29 39.7% 0.1162

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People with behavioral health
69 37.1% 36 49.3% 0.0716
diagnoses

Children with special healthcare needs 82 44.1% 48 65.8% 0.0017

Patients with complex medical

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conditions or who are 101 54.3% 57 78.1% 0.0004
immunosurpressed
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People with medical conditions for

which unmet dental needs can 83 44.6% 48 65.8% 0.0022
exacerbate
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Other 21 11.3% 12 16.4% 0.2636

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P-value set at 0.05.

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Figure 1: Summary of abbreviated questions asked in the teledentistry feasibility survey assessment
Survey construct
categories
Dental practice and
practitioner characteristics
(Asked of all respondents)
Estimating the need for
telehealth technology for
oral health improvement
(Asked of all respondents)
Assessing the interest in
utilizing telehealth
technology for dental care
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delivery
(Asked only of potential
consultants)
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Questions
What is your dental specialty?
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Are you a faculty at MUSC College of Dental Medicine (Full/Part Time or Adjunct)?
In what county is your primary dental practice?
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Currently in South Carolina, Medicaid is the only third party payer that reimburses for
telehealth services. Approximately what percentage of your patients are Medicaid
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beneficiaries?
In a typical year, how many times do you need to consult with any of the following
specialists on a treatment plan or patient care issue?
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When providing services to, or developing treatment plans for, patients with complex
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needs, would you use outside consultants if they were made available to you through
telehealth services?
If telehealth resources were available to you, in what way(s) do you see your office
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using them to improve practice and care delivery?
Please indicate your interest or willingness to participate in a potential demonstration
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project that has funding to support telehealth technology to improve quality and access
to dental care for any of the following complex patient populations
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If telehealth services were available and reimbursable to facilitate your consultation
services to primary care providers (general and pediatric dentists) for the purpose of
developing care plans, would you be willing to serve as a consulting clinician for any
of the following patient populations?
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Figure 2. Responding Dentists’ Degree of Knowledge on Dental Practice Using Telehealth

(n=309)

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Table 3. Potential Applications of Telehealth to Improve Practice and Care Delivery

(n=291)

<10% >10% Total

N % N % N % P-value
Administration (meetings) 40 20.8% 15 18.8% 57 19.6% 0.5446

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Continuing education
(CME, Other) 106 55.2% 38 47.5% 155 53.3% 0.4670
Consultation (diagnostic or

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second opinion) 140 72.9% 61 76.3% 212 72.9% 0.2703
Laboratory (telepathology) 54 28.1% 24 30.0% 81 27.8% 0.4568
Follow-up care with patient

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who have had oral surgery 69 35.9% 32 40.0% 103 35.4% 0.0522
Emergency consultation 109 56.8% 50 62.5% 165 56.7% 0.0503
Triage 38 19.8% 18 22.5% 58 19.9% 0.5000

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Remote monitoring of oral
health for hard to reach
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patients 39 20.3% 25 31.3% 66 22.7% 0.0619
Extending your practice to
underserved populations,
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such as through a school

based program 28 14.6% 27 33.8% 56 19.2% 0.0004
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Other 12 6.3% 2 2.5% 15 5.2% 0.4438

P-value set at 0.05.
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