Telehealth technologies have high potential to improve oral health in Arkansas. Teledentistry is now widely used by orthodontists across the state, but not yet by most Arkansas dentists.
Teledentistry is the examination, diagnosis, and treatment of dental patients remotely. Most often it involves the use of specialized cameras to capture high quality digital videos or photos of patients’ teeth. The data is then securely transmitted live or recorded to dental practitioners.
Dr. Lindy Bollen, director of Arkansas's Office of Oral Health says, if used more widely, the practice has the potential to provide dental care to more patients. Bollen gives one example of the benefits of dentists being able to review pictures of patients from afar.
"Using an intraoral camera and taking pictures, snapshots that the hygienist could share with the doctor and say, 'I think there’s some decay here,' instead of the patient driving into the office."
The time-saving potential of teledentistry could be significant, as well as its ability to reach patients who lack access to brick-and-mortar dental facilities, says Bollen.
"But [it will take] changing the minds of providers and the public all at the same time, so it's an evolution in the process."
Because it's not possible to fill a cavity or perform a root canal remotely, some dentists have been slow to consider the examination and diagnostic possibilities offered by teledentistry. Dr. Michael Zweifler pioneered teledentistry in Arkansas from his practice in Little Rock. He's practiced dentistry for 36 years and says the technology was helpful in his consultations with a practice in Clarendon.
"Being an 80-mile trip each way, I was working a couple days a week to help them develop their dental program or bring it to a new level. It was so much easier for me to be here in Little Rock and be able to look at the images of teeth that were going to be seen. For example, on Monday I would be able to talk and see pictures of the teeth I was going to be seeing on Tuesday, so I was able to communicate with the staff over there over the phone so that we could schedule those patients in a very efficient manner."
According to the American Telemedicine Association, visits to dental offices have been in steady decline since 2003, so telehealth systems to connect providers with patients has become an important tool for improving the oral health of patients across the country.
Zweifler has seen advances in camera technology, and subsequently the quality of the images provided, improve significantly over the years. Internet access, while still not universally available in Arkansas, has also become more common in rural areas. But the use of data encryption has been the biggest key to unlocking the potential of both telehealth and teledentistry protected for patients protected by HIPPA.
"Patient privacy is of the utmost importance," says Zweifler. "Improvements and refining of the ability to transport digital or medical information in an encrypted form was really the turning point that made teledentistry and telemedicine possible. Before that, you wouldn’t dare transfer medical information from point A to point B without someone being able to hop in there and have the patient's confidentiality violated. That was really the turning point with the newer technology."
These advances have resulted in the growth of telemedicine, but wide deployment of teledentistry by states has lagged. In 2015, Arkansas enacted a telemedicine parity law requiring coverage for telemedicine by Medicaid, private insurance, and state employee health plans. In 2017, Deborah Ferguson, a Democratic member of the Arkansas House of Representatives, who is a licensed dentist, sponsored a telemedicine bill passed by the legislature as Act 203. The measure sets standards for telemedicine. For example it mandates providers cannot initiate a relationship with a patient remotely, using an internet questionnaire, email, or text. The act encompasses teledentistry, but specific dental practices are not named in the bill.
"Dentistry is more like surgery. It’s really very different than a medical visit," says Ferguson. "Really when we wrote the telemedicine bill, I, even as a dentist, did not write it with dentistry in mind. We were specifically thinking about physician/APRN visits."
Despite that, Ferguson does see some potential benefits of teledentistry for children in Arkansas.
"What I would really like to see done, which I think teledentistry could facilitate, I would like to see a requirement that every child, before they started school,to have a dental screening. You know one of the biggest reasons kids miss days of school is for dental pain."
Across the country, state legislatures are working to keep up with the rapidly advancing fields of telemedicine and teledentistry. Laws regulating the requirements for medical professionals the circumstances under which patients can receive services vary from state to state. In Arkansas, the law requires a face-to-face meeting between a dentist and patient before the use of any telecommunications, which may be one reason teledentistry has been slow to catch on. As part of Act 203, the Arkansas Board of Dental Examiners has some flexibility to change those requirements, but no rules specifically governing teledentistry have yet to issued by the board.
Dr. Marc Ackerman, the Director of Orthodontics at Boston Children's Hospital, founded the American Teledentistry Association last year. The association's mission is to educate dental professionals, public policy makers and patients about the scope of teledentistry and tele-orthodontistry. Ackerman keeps tabs on trends across the country and says laws like those in Arkansas reflect those in several other states which are being challenged in federal court.
One such case in Alabama alleges that state's dental board violated federal anti-trust laws by creating rules which prohibit a national company from using teleorthodontics to sell mail-order clear plastic aligners.
"What I’m saying is when you look at what's gone in these three states, Arkansas, Alabama, Georgia, and many other states have entered the fray, it's more like protectionism and almost collusion to price fix in the market."
While the courts untangle the legal ramifications of new applications of teledentistry, Ackerman says patients will be even further delayed in receiving the benefits that could be offered. Arkansas Public Media reached out to one rural public school district which is in the early stages of using teledentistry. They weren't willing to comment, but stated in an email that they were "working out the kinks" in their system.
Ackerman believes it's just a matter of time before teledentistry becomes more mainstream because he thinks insurance companies will support the cost-saving potential.
"Because they want to improve the quality of care, and they also want to improve the economics of care, teledentistry is going to become front and center, so I think we have a lot to look forward to."
As telemedical laws are more clearly defined and the technology continues to improve, more patients and providers, including dentists, experts say, may use it.
KUAR Reporter Daniel Breen contributed to this report.
This story is produced by Arkansas Public Media, a statewide journalism collaboration among partner stations KUAR, KUAF, KASU and KTXK, and community partners AETN, and the Butler Center for Arkansas Studies. Arkansas Public Media’s series on oral health in Arkansas is funded through a grant from the Delta Dental of Arkansas Foundation, and with the support of its partner stations. You can learn more about Arkansas Public Media’s reporting at arkansaspublicmedia.org.