Teledentistry in Arizona
Initial Development

Arizona Department of Health Services
Office of Oral Health
November 2009

Acknowledgements
Arizona Department of Health Services, Office of Oral Health
150 North 18th Ave. Suite 320
Phoenix, AZ 85007
602‐542‐1866
Julia Wacloff, R.D.H., M.S. Chief, Office of Oral Health
Julie M. W. Tang, D.M.D., M.P.H. Grant Technical Advisor

Partners:
Arizona School of Dentistry and Oral Health
Hopi Health Care Center Dental Program
Northern Arizona Council of Governments Head Start
North Country HealthCare
Northern Arizona University Dental Hygiene Department
Scottsdale Healthcare & Community Health Services Neighborhood Outreach Action for Health Programs

This publication and the project described herein were made possible by Grant Number
T12HP07705 from the U.S. Department of Health and Human Services, Health Resources and Services
Administration
Its contents are solely the responsibility of the authors and do not necessarily represent the official views of Health
Resources and Services Administration or Arizona Department of Health Services.
Permission is given to photocopy this publication or to forward it, in its entirety, to others. Requests for permission
to use all or part of the information contained in this publication in other ways should be sent to the above address.

Teledentistry in Arizona
Initial Development
Table of Contents
A. Introduction and Background Information ………………………………..

1

1. Introduction ………………………………………………………………

2

2. The Basics of Teledentistry ……………………………………………

3

3. The First Teledentistry Providers in Arizona …………………………

7

B. Teledentistry Technology: Lessons Learned ……………………………..

14

1. Teledentistry Hardware and Software ………………………………...

15

C. Care Delivery Supported by Teledentistry: Lessons Learned …………

23

1. Teledentistry in a School-Based Preventive Program ………………

24

2. Increased Service Delivery Using Teledentistry …………………….

30

3. Care Coordination Supported by Teledentistry ………………………

35

4. Teledentistry for Care of Patients with Special Needs ………………

42

5. Training of Dental Hygiene Students in Teledentistry ………………

48

6. Teledentistry at a Free Annual Kiddie Clinic …………………………

52

7. Teledentistry for Head Start & Community Outreach ………. ……..

55

8. Introducing Teledentistry through a Business Model ………………

58

9. Teledentistry Communication …………….……………………………

66

D. Future Efforts ……………………………………………………………………

69

1. Future Efforts to Advance Teledentistry in Arizona ………………….

70

E. Appendices ……………………………………………………………………...

72

Appendix A: Regulations ……………………………………………………

73

Appendix B: Reimbursement ……………………………………………….

75

Teledentistry in Arizona
Section A
Introduction and
Background Information

1

Teledentistry in Arizona
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In 2006, Arizona Department of Health Services, Office of Oral Health (OOH) was awarded a
Health Resources and Service Administration (HRSA) grant: Grants to States to Support Oral
Health Workforce Activities. The grant funded the OOH project to increase access to dental
care for underserved and at-risk populations through teledentistry.
This manual describes the experience of the
grant project, reports the progress made by the
first five teledentistry providers in Arizona, and
shares the learned lessons in the installation
teledentistry hardware/software and use of
teledentistry technology in supporting dental care.
Efforts will continue among the five Arizona
teledentistry providers to integrate the technology
into their programs to provide quality and efficient
care to their patients. With a new HRSA grant
awarded to the OOH for 2009-2012, OOH will
also continue to advance teledentistry in Arizona.
This teledentistry manual offers a resource for
providers, agencies/organizations, community
groups, program administrators, decision-makers,
funders, and other partners and stakeholders of
oral health care to learn together. The manual offers building blocks for further development of
teledentistry as a viable approach to improving access to dental care for the underserved and
at-risk populations.
The OOH would like to acknowledge and thank the following contributors in their support and
development of this manual:


Health Resources and Services Administration, Bureau of Health Professions, Grants
to States to Support Oral Health Workforce Activities, Grant No. T12HP07705



The five initial teledentistry providers in Arizona:



o

Hopi Health Care Center Dental Program

o

Northern Arizona Council of Governments Head Start

o

Northern Arizona University Dental Hygiene Department

o

North Country HealthCare Dental Services in collaboration with A.T. Still
University, Arizona School of Dentistry and Oral Health

o

Scottsdale HealthCare & Community Health Services System Neighborhood
Outreach Action for Health Program

Arizona Department of Health, Office of Oral Health staff and consultants
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Teledentistry – Definitions and Descriptions
Teledentistry is a developing area of dentistry that integrates electronic health records,
telecommunications technology, digital imaging, and the Internet to link dental providers and
their patients. Several definitions and descriptions of teledentistry are found in the literature and
in communications, each highlighting aspects of teledentistry:
•

Teledentistry is the practice of using video-conferencing technologies to diagnose and
provide advice about treatment over a distance.1

•

Teledentistry uses computermediated technology for treating
individual patients at a distance.2

•

Teledentistry, through the use of
telecommunication and
computer technologies, provides
interactive access to specialist
opinion that is not limited by the
constraints of space and time. 3

•

Teledentistry harnesses the realtime capability of modern
telecommunications to allow offsite dentists of any specialty to
assist their colleagues in
providing care.4

•

Teledentistry has come to mean the use of electronic information and
telecommunications technologies to support long-distance clinical oral health care,
patient and professional health-related education, public health, and health
administration.5

•

Teledentistry is using the Internet to consult with an expert. This consultation could be
direct (between the patient and the expert) or indirect (between the patient’s doctor and
the expert).6

•

Teledentistry will be the clinical dimension of the new patient-doctor relationship. A
definition of telemedicine helps identify the emerging realm of teledentistry: “…the
combined use of telecommunications and computer technologies to improve the
efficiency and effectiveness of health care services by liberating caregivers from
traditional constraints of space and time and empowering consumers to make informed
choices in a competitive marketplace”7

Teledentistry’s roots lie in telemedicine; therefore, teledentistry fits into several definitions of
telemedicine. For example, the Association of American Medical Colleges (AAMC) described
3

telemedicine as the use of telecommunications technology to send data, graphics, audio, and
video images between participants who are physically separated (i.e., at a distance from one
another) for the purpose of clinical care.8 The American Telemedicine Association defined
telemedicine as the use of medical information exchanged from one site to another via
electronic communications to improve patients' health status.9 The federal government, in its
1997 Telemedicine Report to Congress, defined telemedicine as the use of electronic
communication and information technologies to provide or support clinical care at a distance.10
Dentistry can look to telehealth and telemedicine to incorporate some of the necessary lessons
that will aid teledentistry’s evolution into new health delivery models.

Teledentistry Services
Teledentistry can be integrated in general dental practice and specialty practices. Teledentistry
services would be part of a larger investment by health care practices, organizations, and
institutions in information technology or the delivery of clinical care. Like telemedicine,
teledentistry can provide different types of programs and services for the patient. The following
teledentistry services could evolve from current telemedicine practices:11


Specialist referral service involves a specialist assisting a general practitioner to
diagnose and manage a patient. This may involve a patient "seeing" a specialist over a
live, remote consult or the transmission of diagnostic images and/or video along with
patient data to a specialist for viewing later. (Almost 50 medical subspecialties
successfully use telemedicine for referrals.)



Patient consultation uses telecommunications to provide medical and dental/oral
health data, which may include audio, still or live images. Data is exchanged between a
patient and a health professional for use in rendering a diagnosis and treatment plan.
This may originate from a remote site to a “home” dental office/clinic. Communication
may use a direct transmission link or the Internet.



Remote patient monitoring uses devices to remotely collect and send data to a
monitoring station for interpretation. Telemedicine has used remote monitoring for "home
telehealth" applications (e.g., monitoring specific vital signs or other indicators for
homebound patients) and to support nursing visits.



Professional education provides continuing education credits for health professionals
and delivers special health education seminars for targeted groups in remote locations.



Consumer medical and health information includes the use of the Internet for
consumers (patients) to obtain specialized health information and on-line discussion
groups to provide peer-to-peer support.

Teledentistry Delivery Mechanisms
The different ways of how providers and patients can connect shows several delivery
mechanisms to provide the teledentistry services described above. Telehealth and telemedicine
have used the following delivery mechanisms, which could be developed to support teledentistry
services:11

4



Networked programs link hospitals and clinics with outlying clinics and community
health centers in rural or suburban areas. The links may use dedicated high-speed lines
or the Internet for telecommunication links between sites.



Point-to-point connections using private networks. These connections are used by
hospitals and clinics that deliver services directly, or contract out specialty services to
independent providers, at ambulatory care sites.



Primary or specialty care to the home connections involves connecting primary care
providers, specialists and home health nurses with patients using single line phonevideo systems for interactive clinical consultations.



Home to monitoring center links are used for patient monitoring, home care and
related services that provide care to patients in the home. Often normal phone lines are
used to communicate directly between the patient and the center although some
systems use the Internet.



Web-based e-health patient service sites provide direct consumer outreach and
services over the Internet. Under telemedicine, these include sites that provide direct
patient care.

Potential Benefits of Teledentistry
Teledentistry offers innovative prospects in the delivery of dental care and has the potential to
enhance the current practice of dentistry. However, teledentistry has been underused as a
means of diagnosis and referral in dentistry. Through the exchange of clinical information over
distances, teledentistry can facilitate the delivery of dental care in areas underserved by dental
practitioners, and therefore overcome social and geographic barriers. A greater number of
patients can be assessed and treated. Teledentistry has the potential to achieve the three
fundamental benefits of telehealth and telemedicine:11
•

Improved access – For over 40 years,
telemedicine has brought healthcare services to
patients in distant locations improving access and
allowing physicians and health facilities expand
their reach.

•

Cost efficiencies – Adopting telehealth and
telemedicine technologies have shown to reduce
the cost of healthcare and increase efficiency
through better management of chronic diseases,
shared health professional staffing, reduced
travel times, and fewer or shorter hospital stays.

•

Patient demand – The greatest impact of
telemedicine is on the patient, their family and their community. More than 15 years of
studies have documented patients’ satisfaction and support for telemedical services that
offer access to providers and reduce the need to travel long distances.

Teledentistry has the ability to improve access to care, improve the delivery of health care, and
lower its costs. Teledentistry can be a much needed resource for dental consulting, referral for
specialized care, dental mentoring, dentist-laboratory communications, and continuing
education.12-19
5

_______________________________________
References:
1.
2.
3.
4.

5.

6.

7.

8.
9.

10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Cook J. ISDN video conferencing in postgraduate dental education and orthodontic diagnosis.
Learning Technology in Medical Education Conference 1997 (CTI Medicine). 1997:111–6.
Curts, EK. Exploring teledentistry – a new horizon in dental care? AGD Impact. 2009;37(7):34.
Available at: http://www.agd.org/publications/articles/?ArtID=5798
Joshi V. Teledentistry: E-consultations. Dentistry Magazine. 9 February 2002. Available at:
http://www.dental-consults.com/dentistry.html
Berndt J, Leone P, and King G. Using teledentistry to provide interceptive orthodontic services to
disadvantaged children, Am J Orthod Dentofacial Orthop. 2008;134(5):700-6. Available at:
http://www.nidcr.nih.gov/Research/ResearchResults/ScienceBriefs/Archive/archive2008/December/
Teledentistry.htm
Douglas Manning, Florida State Oral Health Improvement Plan (SOHIP) Teledentistry Workgroup
Chair, in the 2006 Florida Department of Health white paper Teledentistry as a Method to Improve
Oral Health Access in Florida.
Glenn T. Clark, DDS, MS, Teledentistry: what is it now, and what will it be tomorrow? J Calif Dent
Assoc. 2000;28(2):121-7. Available at:
http://www.cda.org/Library/cda_member/pubs/journal/jour0200/now.html
Bauer JC, Brown WT. The digital transformation of oral health care: teledentistry and electronic
commerce. J Am Dent Assoc. 2001;132(2):204-9. Available at:
http://jada.ada.org/cgi/reprint/132/2/204
Chen JW, Hobdell MH, Dunn K, Johnson KA, Zhang J. Teledentistry and its Use in Dental
Education. J Am Dent Assoc. 2003;134(3):342-46.
American Telemedicine Association Website. Telemedicine defined. Available at:
http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3333. Accessed on October 22,
2009.
Telemedicine report to Congress: executive summary. January 1997. Available at:
www.ntia.doc.gov/reports/telemed/execsum.htm. Accessed October 22, 2009.
American Telemedicine Association. What is telemedicine & telehealth? Available at:
http://www.americantelemed.org/files/public/abouttelemedicine/What_Is_Telemedicine.pdf
Kopycka-Kedzierawski DT, Billing RJ. Teledentistry in inner-city child-care centers. J Telemedicine
and Telecare. 2006;12(4):176-82.
Sfikas PM. Teledentistry: legal and regulatory issues explored. Am Dent Assoc.
1997;128(12):1716-18.
Foke LE. Teledentistry: an overview. Tex Dent J. 2001;118(1):10-18.
Golder DT, Brennan DA. Practicing dentistry in the age of telemedicine. J Am Dent Assoc.
2000;131(6):734-44.
Allokian M. The neglected epidemic and the surgeons general report: a call to action for better oral
health. Am J Public Health. 2000; 90(6):843-5.
Chang SW, Plotkin DR, Mulligan R, et al. Teledentistry in rural California: a USC initiative. Calif
Dent Assoc J. 2003;31(8): 601-8.
Zeigler J. Telemedicine starts to pay off. Bus Health 1995;13(10):47-50.
Phase I clinical teledentistry evaluation, S.E. Dental Service Support Area. Available at:
http://tdent.tatrc.org/ldl/nfpaper.htm. Accessed March 29, 2000

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Teledentistry in Arizona

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Five Arizona Teledentistry Provider Sites
As of November 2009, five dental service delivery sites in Arizona are using teledentistry
technology. These are the first Arizona teledentistry providers (see map below):
1. Hopi Health Care Center Dental Program (Hopi)
2. Northern Arizona Council of Governments Head Start (NACOG)
3. Northern Arizona University Dental Hygiene Department (NAU)
4. North Country HealthCare Dental Services in collaboration with Arizona School of
Dentistry and Oral Health (NCHC/ASDOH)
5. Scottsdale HealthCare & Community Health Services, Neighborhood Outreach Action
for Health Program (NOAH)

●

Polacca

2

3
4

5

7

4

1

These Arizona teledentistry providers, located in rural and urban areas, are in the early stages
of developing their teledentistry models. With the support of the HRSA workforce grant (20062009), teledentistry equipment, hardware and software programs, were purchased and installed.
One of the sites went live with the technology in 2008; the other four sites went live in 2009. All
providers will further integrate teledentistry technology into their dental practice and explore
approaches to service delivery (e.g., community outreach efforts). These providers, using
multiple sites to deliver dental services, have different practice settings such as a portable
school-based program, a school-based fixed dental clinic, a community-based health center,
and a private dental practice. The five teledentistry providers have identified barriers and
indicated that more support and time are needed to advance teledentistry in their programs and
practices.

A Framework for Teledentistry
The initial efforts for the first Arizona teledentistry providers varied in their focus of using the
technology to build capacity in their program’s dental service delivery. Each of the five
providers contributed to learning one or more aspects of teledentistry and together supported
the following framework for teledentistry.

Home Dental Facility
Health
Services
Delivery
Infrastructure

Clinical Staff
Patient Population
Clinical Services
Teledentistry Coordinator

Health
Information
Technology
Infrastructure

Imaging
Radiography

Hardware

Assessment
Monitoring

Extraoral Camera

Consultation

Intraoral Camera

Treatment Plan

Digital Radiographic Equipment
Portable X-Ray Unit

Care Coordination

Software
Dental Practice Management
Software
Imaging Software

Referral
Consumer Education
Professional
Continuing Education

Satellite Dental Facility
Clinical Staff
Patient Population
Clinical Services

A diagram for each of the initial Arizona teledentistry models is presented below. The
models will evolve for each provider as teledentistry advances for their program.
8

Hopi Health Care Center’s Teledentistry Model
The Hopi Health Care Center (HHCC), an IHS Service Unit, is
a critical access hospital that offers diverse services including
dental care to 28,000 eligible patients. The HHCC is centrally
located on the Hopi Reservation. The HHCC School-based
Preventive Dental Program, in full operation since September
2008, uses teledentistry to support diagnostic, preventive and
temporary restorative care for children in all six elementary
schools on the Hopi Reservation. The Teledentist is a pediatric
dentist and the Teledentistry Coordinator is a dental hygienist
with a MPH (a Commissioned Corp Officer with the USPHS, IHS Division). At each school,
children are provided with dental services onsite (include x-rays, intraoral photographs,
prophylaxis/scaling, fluoride applications, dental sealants, temporary fillings, oral hygiene
instruction, oral health education, and sport mouthguards). Further care is coordinated with the
HHCC dental clinic. The mobile dental program relocates to each of the six schools. The
following is HHCC’s teledentistry model.
Hopi Health Care Center (HHCC) – IHS Service Unit:
HHCC Dental Clinic

HHCC Dental Program

Information
Technology

14-chair dental clinic
1 Pediatric Dentist (Teledentist); 4
General Dentists; 2 Dental Hygienists;
13 Dental Assistants; 1 Receptionist
(all FTEs)
Visiting specialists, volunteer dentists
and dental/dental hygiene students
Clinical services include preventive,
restorative, oral surgery, prosthetic,
periodontal, and endodontic care.

HHCC has its own
IT Department to
support
teledentistry.
The Center uses a

medical system
(RPMS) to
manage patient
scheduling and
billing.

Care Coordination
Teledentistry Hardware

Extraoral Camera
Acclaim Intraoral Camera
NOMAD Portable X-ray Unit
ScanX Duo Digital Imaging System

HHCC School-Based
Preventive Dental
Program coordinates
care for all elementary
school children with
the HHCC Dental Clinic.

Teledentistry Software
Tigerview (imaging software)
Open Dental (practice management
software)

HHCC School-Based Preventive Dental Program Serves 6 Schools on the Hopi Reservation:
Portable dental
equipment is brought to
the schools, allowing for
two dental operatory setups at the school facility.

School Based Preventive Program

A dental hygienist collects
oral health data that includes
charting, digital radiographs
and intra-oral films.
The data is stored and
forwarded to the HHCC
pediatric dentist for diagnosis
and treatment planning.

Northern Arizona
University dental hygiene
students and faculty also
provide school-based
preventive services.

Clinical services include
diagnostic, preventive, and
temporary restorative care.

9

Northern Arizona Council of Governments Head Start’s
Teledentistry Model
Northern Arizona Council of Governments
(NACOG) Head Start program is a non-profit
organization providing comprehensive
programming to low income children (birth to age
five) and families throughout Apache, Navajo,
Coconino and Yavapai counties. NACOG Head
Start provides services to over 1,585 preschool
age children and 124 prenatal moms, infants and
toddlers at twenty-six local centers in the four
county areas. The program is centrally managed
from Flagstaff, AZ. NACOG Head Start’s service
area covers 27,000 square miles of rural northern Arizona not including the Navajo Nation.
While eight of the centers are located within a thirty minute drive from Flagstaff, many centers
are located one to more than three hours of drive time from Flagstaff (one-way travel). Currently
children living in Navajo or Apache counties who require specialized services from a pediatric
dentist must travel to either Flagstaff or Phoenix for care. The following model is NACOG Head
Start’s first initiative to integrate teledentistry into its program to address pediatric dental care.
Remote (Local) Site
in NACOG Rural Service Area

Pediatric Dental Office
in Flagstaff, Arizona
Pediatric dentist
(contracted by NACOG Head
Start) receives referral from
remote site.

Local general dentist
refers Head Start child to
pediatric dentist in
Flagstaff.

Oral health assessment
scheduled in remote
(local) location by
trained staff.

Trained dental staff
travel to remote site and
collect oral health data
using teledentistry
equipment. Staff store
and forward data to
pediatric dentist.

Pediatric dentist examines
the oral health data
(radiographs, intra-oral films,
charting, etc.) to diagnose,
complete treatment plan, and
determine treatment
schedule.

Pediatric dentist travels to remote site
to treat the child (has an arrangement
to use a local provider’s office).
Pediatric dentist provides treatment to
multiple children during the visit.

A parent and child having to drive to Flagstaff for a dental examination and one subsequent
treatment visit with the pediatric dentist may mean 12+ travel hours and two missed work days
with additional transportation cost. NACOG’s teledentistry model reduces these barriers to care.

10

Northern Arizona University’s Teledentistry Model
Utilizing technologies that currently exist, a board
certified and licensed dental hygienist can collect
and digitally transmit all subjective and objective
diagnostic data to a distant dentist for diagnosis
and prescription of dental hygiene services.
Northern Arizona University (NAU) dental hygiene
students are being trained to use such teledentistry
technology to acquire and transmit charting, intraoral films, radiographs, etc. to a distant supervising
dentist. The NAU faculty dentist will receive all of
the digital diagnostic data (including the student's
dental hygiene diagnosis), make a dental
diagnosis, develop a dental hygiene treatment plan
with the distant student, and provide appropriate referrals. Dental hygiene services will then be
provided under direct faculty supervision by the student. The patient will be referred as directed
by the distant dentist. Teledentistry broadens the scope of dental hygiene practice by allowing
properly trained dental hygienists to provide services to new and existing patients of record in
underserved communities. The following is NAU’s teledentistry model.

11

North Country HealthCare and Arizona School of Dentistry & Oral Health’s
Teledentistry Model
North Country HealthCare (NCHC) provides
comprehensive, preventive primary care, dental care,
outreach programs, and training/education services to
people of Northern Arizona. Ten NCHC sites accept
Medicaid and offer a sliding fee-scale. Patients range
from the very young to seniors, including individuals with
special needs as well as the mentally and physically
challenged. The NCHC and Arizona School of Dentistry
and Oral Health (ASDOH) at A.T. Still University have
established a collaboration to integrate teledentistry for
the care of patients with special needs and for
professional development. ASDOH maintains a Special Care Dental Clinic. Teledentistry will be
used to support the care of patients with special needs, allowing NCHC providers to consult with
specialists at ASDOH. NCHC is also a training site for the Lutheran Medical Advanced General
Dentistry Program, ASDOH and Northern Arizona University Dental Hygiene Program.
Teledentistry will be integrated into the training for residents/students and to provide
professional continuing education that targets the NCHC telemedicine network/satellite sites.
The following NCHC/ASDOH model illustrates the integration of teledentistry:
Health Service and Information Technology (IT) Infrastructure
- North Country HealthCare Dental Clinics
- A.T. Still University IT Department
- AZ School of Dentistry & Oral Health Special Dental Care Clinic
- North Country HealthCare Health IT Director
North Country HealthCare
Dental Services
Teledentistry Coordinator
Dr. Kimberly Barnes
Dental Clinic Director
3 Dental Clinics and 5 Staff Dentists
Patients
Children & adult patients
including patients with complex
medical conditions & special needs
Clinical Services
Full scope of dental care
Training/Rotations at North
Country Dental Clinic
Lutheran Medical Advanced General
Dentistry Residents
Arizona School of Dentistry and Oral
Health Students
Northern Arizona University Dental
Hygiene Students
Additional Providers/Facilities
Telemedicine provider network at
ten NCHC satellite sites

Hardware
Acclaim Intraoral Camera
ScanX Duo Imaging System

Imaging
Radiography
Assessment
Monitoring

AZ School of Dentistry & Oral
Health at A.T. Still University
Teledentistry Coordinator
Dr. Maureen Romer
Director of Special Care Dentistry
Special Care Dental Clinic
Provides comprehensive dental care
to patients with special needs
throughout the state.

Consultation
Treatment Plan
Care Coordination

ASDOH Faculty
Provides consultations to staff
dentists, residents and students.

Referral
Consumer
Education
Professional
Continuing
Education
Software
DENTRIX
(practice management
software)

12

ASDOH Dental Students
Rotations at North Country
HealthCare will include training in
treating patients with special needs
and teledentistry
Professional Continuing Education
Provides presentations and training
workshops.

Neighborhood Outreach Action Health Program’s Teledentistry Model
Scottsdale HealthCare, a hospital system, operates two health
care centers as part of its community outreach, the
Neighborhood Outreach Action for Health Program (NOAH). A
dental clinic is set up in each center as NOAH’s commitment
to integrate oral health into primary care. All children seen in
the adjacent medical clinic are given a dental appointment
after their well-child visit. NOAH provided 2,500 preventive
dental visits in 2008-2009. Initially, teledentistry will be
integrated into the NOAH system: (1) to share radiographs and
intra-oral photographs with specialists for patient referrals, and
(2) for care coordination with the two NOAH dental clinics to
improve time management and efficiency for care delivery
since the dentists are part-time at both sites. Currently, NOAH
is calibrating the dental team’s use of teledentistry: the
affiliated practice dental hygienist collects oral health data for
the dentist to diagnose and complete a treatment plan. As
NOAH dental services expand, teledentistry will become an
integrated part of community outreach efforts. The following model illustrates NOAH’s initial
teledentistry integration into its school-based and school-linked dental services.
NOAH Health Service Infrastructure
NOAH is part of the Community Outreach for the
Scottsdale Healthcare Hospital System. The entire
hospital infrastructure is available for support services.

NOAH Information Technology Infrastructure
The Scottsdale Healthcare hospital system‘s
Information Technology Department provides
support to the NOAH clinics and teledentistry.

Hardware

School-linked Dental Clinic at
Paiute Neighborhood Center
Clinical Staff
Affiliated Practice Dental Hygienist
Part-time Dental Hygienist
Part-time General Dentists
Dental Assistant
Patient Population
Prior 10/2009: children age 0-18
As of 10/2009: Children <age 21
Clinical Services
Preventive & restorative care
Support Services
Transportation (taxi) for families

Acclaim Intraoral Camera
NOMAD Portable X-ray Unit
ScanX Duo Imaging System

Imaging
Radiography
Assessment
Treatment
Plan
Monitoring
Consultation
Care
Coordination
Referral
Software

Tigerview (imaging software)
Open Dental (practice management
software)

School-based Dental Clinic at
Palomino Elementary School
Clinical Staff
Affiliated Practice Dental Hygienist
Part-time Dental Hygienist
Part-time General Dentists
Dental Assistant
Patient Population
Prior 10/2009: children age 0-18
As of 10/2009: Children <age 21
Clinical Services
Preventive & restorative care
Support Services
Transportation (taxi) for families
Portable Dental Equipment
Participation in the state’s dental
sealant program

Additional Dental Care Providers for Referrals
Oral Surgeon / Orthodontist / Pedodontist for sedation services

13

Teledentistry in Arizona
Section B
Teledentistry Technology:
Lessons Learned

14

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Seeccttiioonn B
B
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Technology and Equipment for Designing a Teledental Model
There is not a recommended list of equipment, hardware or software for designing a teledental
model. As with many technologies today, there is an array of choices. Having so many choices
can be better; resulting in improved performance, functionality and price competition. Choosing
equipment and technology requires objective detailed research on the part of the purchaser.
The decision of which approach to take will depend on many factors including: budget,
technology infrastructure, and type of dental services to be delivered. These factors will
determine the choices of teledentistry equipment, hardware and software.
Teledentistry is about delivering data from one point (spoke site) to another point (hub site)
using telecommunications technology. There is a wide-variety of technologies available to
users which can go into the design of a model. These technologies are constantly changing
and advancing. When making decisions of what to include in the model one should choose
systems and equipment that are not soon to be obsolete and can be easily integrated and
adapted with current and emerging technologies.
Components that factor into designing a teledental model include: information technology (IT)
infrastructure, networks, telecommunication services, data security, real time video conferencing
vs. store and forward communication, and comfort with technology. The following attempts to
review the necessary minimal components in the establishment a teledental model and factors
to consider when choosing the technology.
1. Information Technology (IT) Infrastructure
IT infrastructure of telecommunications equipment and staff will play a critical role in the
success of the teledental model and will impact the selection of methods and technologies.
To be successful in implementing a teledental model, having a team approach and building
on all resources is critical. Having a strong IT Infrastructure will ensure that the technical
structures that support such a model, such as IT staff, networks, computer systems,
software and hardware, will enable and support the basic requirements that are needed for
the operation of a successful model.
2. Networks
Networks will play a critical role in the transmission of patient data. There are two basic
types of computer networks; a local area network (LAN) and a wide area network (WAN). A
LAN, also known as the Intranet, connects computers in a building, agency or company
together. This allows computers the ability to communicate with each other and also share
equipment such as printers, servers, and routers. A Wide Area Networks or WAN, also
known as the Internet, connects LANs to other LANs so they can communicate. Computers
may be connected using wired or wireless telecommunication connections and a device

15

known as a router. Other networks to consider include: private networks, public networks
and virtual private networks (VPN).
3. Telecommunication Services
Telecommunication services refer to the media used to link computers together. These may
be supplied by a wired service or a wireless service. The availability of these services will
vary by locale, with fewer options available in remote areas. In addition, the costs of these
services vary greatly; the higher the speed of data transmission the higher the associated
costs. The most common telecommunication services are through telephone lines, twistedpair cable, coaxial cable, and fiber-optic cable. Others include infrared light, radio waves,
satellites, and additional wireless communication equipment.
4. Data Security
Models should address data security to ensure that data is kept safe from corruption and
that access is controlled to ensure data integrity. Software and hardware systems allow for
encryption of data to prevent data from being stolen. Hardware based security systems are
more secure than protection provided by operating systems that can be vulnerable to
outside attacks by viruses and hackers. Backups are also included as part of data security
to ensure that data is not permanently lost and can be recovered at moment’s notice.
Data security for teledentistry must address Health Insurance Portability and Accountability
Act (HIPAA) compliance. Each model must consider whether or not they fall under the
umbrella of the HIPAA. This will help to determine the scope of data security needs. HIPAA
provides guidance on most privacy and security issues in health care and seeks to
streamline electronic medical record systems while protecting patients, improving health
care efficiency, and reducing fraud and abuse. HIPAA’s privacy rule deems that any
“individually identifiable health information” in any form or medium is to be protected health
information (PHI). This information includes, but is not limited to: name, address; date of
birth; social security number; payment history; account number; health care provider and/or
health insurance plan. HIPAA’s privacy rule applies to health providers including dental
providers, health plans, and health care clearinghouses that transmit PHI in any form or
medium, including electronic, paper, or oral.
Telehealth encounters and consultations are transmissions of protected health information.
Protected health information can potentially be sent anywhere in the world in a matter of
seconds. HIPAA requires that health care providers protect this individually identifiable
health information. Therefore telehealth systems should have security measures such as
encryption and dedicated lines where possible that are part of the system. Moreover, HIPAA
requires that health care providers obtain consent prior to using or disclosing protected
health information to carry out treatment, payment or other health care operations. Before a
teledental encounter or consultation takes place, the patient must be made aware of and
give his or her consent to the fact that teledentistry involves the electronic transmission of
his or her protected health information.
5. Real Time Video Conferencing vs. Store and Forward Communication
Technologies that use real time interaction require broadband connections which is a
complex and costly technology. Store and forward communication can be managed
successfully with relatively low cost intermediate data storage devices. Such devices
include but are not limited to: hard drive, flash drive, jump drive, CD, or DVD. Flash drives,

16

which are removable and rewritable intermediate devices, continue to increase in storage
capacity ranging from a few megabytes to multiple gigabytes. Some flash drives allow for
multiple write and erase cycles and have 10 year data retention warranties. Flash drives
can be used to transport and store personal files such as digital x-rays, patient data, extraoral photos, and videos. Some flash drives allow for excellent data security using biometrics
and encryption. All these factors must be thoroughly researched when selecting
technologies.
6. Comfort with Technology
When considering technology, account for training and adaptability to current operators’
levels of comfort with new and emerging technologies. In addition, as users of the
technology are replaced, systems need to be in place for continued training of new staff.
Additionally, training may need to be considered as upgrades are made to systems.

Teledental Application Software
Teledental application software allows the user to accomplish tasks necessary for the
acquisition and organization of patient health information. There are two necessary application
software components: dental management software and imaging software. The following are
factors to consider when choosing application software.
1. Dental Management Software
Dental management software is a tool used to in the delivery of dental services. It allows for
the electronic collection and exchange of patient data and the management of typical office
or company activities. There are four components to consider when choosing management
software.


Dental records – allows for the collection of data critical in the clinical management of
patients, including patient charts and histories.



Dental billing – may be a factor in choice of software. The billing and revenue
component of management software allows for the management of patient financial
records.



Appointment scheduling – management of appointments and scheduling can be a
part of the management software. The software is designed to track patients from
the moment they are entered into the system and also tracts missed, rescheduled,
and canceled appointments.



Reporting Requirements – Most dental management software has built in reports. If
custom or ad hoc reports are required, accommodations must be made to factor in
those reports.

Site Choices: After exploring several dental management software packages, Open
Dental was chosen through close consultation with IT staff. Open Dental has several
advantages for use in these sites. Open Dental is licensed under the GNU, General
Public License (GPL), the standard open source license. This license ensures that the
software will always remain free increasing sustainability for sites. The GPL requires
that the database structure and source code be available and freely modified. This

17

allows sites to modify the database according to their specific needs. In addition, Open
Dental also allows an unlimited number of copies to run on computers without any
licensing restrictions or dongles. It utilizes MySQL as the database which is also free
software. Open dental will also provide for installation, support and free upgrades for one
year. These functions provided for in Open Dental have not been identified in other
proprietary dental management software companies. Transfer of image files occurs
through store-and-forward technique utilizing CD’s, flash drives or secure email. Dental
management records can be accessed via Virtual Provider Network (VPN).
2. Imaging Software
In order to view digital images captured through digital radiography, a software program is
needed. Some management software comes with the built in imaging software and some
management software requires a separate purchase. The selection of imaging software will
depend on the management software and its ability to bridge or connect with the
management software.
Site Choice: Televere’s TigerView Professional package was selected because of the
ability to integrate with the existing dental hardware and its capability of bridging to Open
Dental software. In addition, TigerView was an affordable option that offers state-of-theart digital imaging with predefined templates and the ability to enhance, zoom, magnify
and measure images. TigerView also provides for installation, on-site training and
comprehensive technical support.

Teledental Equipment
This manual is not intended to be an all inclusive list but rather a set of basic components that
were used in the teledental prototypes. Equipment requirements will depend on the dental
services to be delivered and the facility being equipped. Hub sites will be different from spoke
sites. Hub sites may only require viewing technology, whereas spoke sites require the
capabilities of capturing digital photos and implementing dental procedures. There are many
choices of manufacturers and models and it is not the intent of this manual to promote or
recommend one over the other.
The following are basic characteristics to consider when selecting teledental hardware and
software technology.


Accessibility - the level of access to the vendor is critical in terms of training, support,
upgrades and maintenance. Vendor access will factor into the overall price of the item.
The more support required by the user results in higher associated costs.



Compatibility- teledental technologies should be compatible with current in-office
systems including operating systems, software, hardware and equipment.. For
example, if purchasing particular software one needs to consider the current operating
system and the software’s ability to bridge or communicate with other in-office software.



Scalability – the technology should be capable of migrating into expanded capabilities
without requiring total replacement. Additionally, features and functions should be
available as options rather than impacting the base cost of the technology.

18



Reliability – or the ability of a technology to perform and maintain its functions is vital in
delivering dental services. Networks and equipment should work as intended and the
user should be assured that the equipment will perform as needed without operational
error. If and when equipment requires maintenance, the system should insure that it
can be reliably serviced with minimal downtime.

Teledentistry sites require some or all of the following basic equipment:
1. Extraoral Digital Camera
Extraoral cameras are used for the digital acquisition of photos of the face, lips, profile, and
anterior teeth. They are good for documentation of lip lesions and trauma. They are also
effective as a reference to linking the patient’s photo with their record. Extra-oral cameras
come in many forms from the very simple point and shoot models to more complex
professional models. The more complex the camera model; the more expensive the
camera.
2. Intraoral Digital Camera
Intraoral wand cameras are used for digital documentation of intraoral features. They are
especially effective because of the high intensity light and magnification capabilities.
Qualities to consider when purchasing an intraoral camera include: weight, built in lighting,
handling ease, auto-focus capabilities, and integration with dental imaging software.
Intraoral cameras are used for capturing still pictures of individual carious lesions, soft
tissues, hard to reach areas, and are excellent for locating early white spot lesions. Some
cameras also allow for capturing video images.
Choice of Sites: The camera of choice for the teledental sites was the Air Techniques’
Acclaim USB Intraoral Camera. It provided for superior clarity and sharpness of intraoral
photos. It is a single hand manipulation and also its flexible shape makes it easily
portable.
3. Videoconferencing System
Videoconferencing systems will not be discussed in this volume as the teledental models did
not advance to the point of implementing live video conferencing.
4. Digital Radiographic Equipment
There are 3 ways to obtain digital radiographs:


Converting traditional radiographic films to digital images via a film scanner.



Photostimulable phosphor (PSP) plates or phosphor plate technology – radiographs
are taken using a phosphor plate to store the image, the plate is then fed through a
scanner and read by a laser which produces an image which is viewable on a
computer.



Sensors known as CCD (charged-coupled device) powered device or direct digital
technology – radiographs are taken using digital sensors and the image is
immediately shown on a computer screen.

19

Pros and Cons: Scanning traditional radiographs requires all the elements of traditional
radiograph processing which includes chemicals, processors and supplies. The portability
of this equipment is not conducive to moving from site to site. Phosphor plate technology is
somewhat slower than sensor technology in that it requires an additional step of running the
plate through the scanner and in some cases erasing the plate. However, phosphorus plate
technology is less expensive from start-up costs to replacement costs. At the time of this
project the phosphorus plate technology allowed for greater adaptability to child size
radiographs. In addition, it was much less costly to replace phosphorus plates than sensors
when damaged.
Site Choices: The PSP technology was selected for use at all partner sites.
Specifically, Air Techniques’ ScanX Duo was chosen for acquisition of intra-oral digital
radiographs. The ScanX uses the phosphor storage plate as the receptor. The ScanX
system works with existing x-ray equipment and provides for an easy, fast, and flexible
system that can deliver diagnostic-quality images in a complete range of sizes. These
plates mimic a traditional dental film and are available in sizes 0, 1, and 2. These sizes
are much more compatible with younger children which is the primary population served
at the partner sites. It provides for an ultra-thin, wireless, flexible film that is reusable
thousands of times. It is relatively inexpensive and could easily be replaced once funding
is no longer available. Because of its size and weight the ScanX is very portable.
Providers can easily transport the equipment as needed. The ScanX also provides for
in-line erase, thereby saving time and eliminating the extra step that is required of some
systems.
5. Portable Dental Radiographic System
A portable x-ray source is needed at remote sites that are not equipped with traditional
dental x-ray equipment.
Site Choices: Portable x-ray technology was needed for two sites. The Nomad Portable
Hand-Held X-Ray was chosen. In addition to cost as a major factor, the Nomad offers
cordless operation, a rechargeable battery pack which allows more than 100 exposures
on one battery charge. It comes in an easily transportable case with pull-out handle and
wheels and weighs only nine pounds.
6. Laser and Fluorescence Caries Detection Devices
There are current and emerging technologies such as laser fluorescence that are designed
to assist the dentist in interpreting visual cues in detecting dental caries. Findings of studies
however indicate that these technologies result in the detection of early carious lesions that
may result in an increased likelihood that a potentially sound surface will be filled.1 2 3 4 For
purposes of this project these devices were not used.
7. Computer
1

. Bader JD, Shugars DA, Bonito AJ. Systematic reviews of selected dental caries diagnostic and
management methods. J Dent Educ 2001; 65(10):960-968.
2
Bader JD, Shugars DA, Bonito AJ. A systematic review of the performance of methods for identifying
carious lesions. J Public Health Dent 2002;62(4):201-213.
3
. Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence device for
detecting caries. JADA 2004;135(10): 1413-1426.
4
Zandoná AF, Zero DT. Diagnostic tools for early caries detection. JADA 2006;137(12):1675-1684.

20

Every teledentistry site, whether a spoke or hub site, must be equipped with a computer.
The computer can be either a laptop or desktop computer. Laptop computers are much
simpler to transport and store than desktop computers. The following is a list of minimal
computer requirements. It is important to note that these minimal requirements may
become obsolete at any moment:


CPU Speed: 2.8 GHz Pentium 4



Operating System: Windows 2000 Service Pack 4 or Windows XP Service Pack 1
w/Microsoft knowledge base KB822603 update



System RAM: 1 KB



Hard Drive: 80 GB



CD-ROM Drive: 48x



Video Display Adapter: 64 MB RAM



USB Ports: Must be USB 2.0.

Along with the many choices of equipment and technologies, the purchaser must be aware that
the standard of today may be the dinosaur of tomorrow. Many of the pieces of equipment,
technology and software discussed above may become obsolete or have gone through several
upgrades by the time this reaches the reader.

Definitions
Below are definitions used throughout the manual.
Broadband – Refers to telecommunication in which a wide band of frequencies is available to
transmit information.
Bandwidth – Is a primary factor in the performance of a network. Wider bandwidth allows for
greater information carrying capacity. Bandwidth is supplied by wires, cables, radio waves or
satellite transmission. The more sophisticated the bandwidth, the more complex the
telecommunication can be. Bandwidth is also positively correlated with cost.
Standard phone lines can support some teledental applications but higher bandwidth
technologies are required for more advanced procedures.
Hub site – Is the location of the teledental consulting provider receiving the electronic data.
Media – Refers to the material used to link computers together via a network.
Real time – The interactive, two-way transfer of information and oral health data, occurs at two
sites simultaneously: the hub site and the spoke site.
Spoke site – Is the location where the patient is receiving the service and from which the data
is being transmitted.
Store and forward – The transfer of patient data from one site to another through the use of an
intermediate station. The intermediate station is a data storage device such as a hard drive,

21

flash drive, jump drive, CD, or DVD. The patient data is is sent to an intermediate station where
it is kept and sent at a later time to the final destination.
Teledentistry – The practice of health care delivery, diagnosis, consultation, and treatment with
the transfer of oral health data through interactive audio, video or data communications that
occur in the physical presence of the member.
Videoconference – Is a live connection that provides transmission of images and text between
people located in separate facilities for the purpose of communication. The connection can be
site to site or among multiple sites. In its most advanced form, it can provide transmission of fullmotion video images and high-quality audio between multiple locations.

22

Teledentistry in Arizona
Section C
Care Delivery Supported by Teledentistry:
Lessons Learned

23

Teledentistry in Arizona
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Chapter contributed by:
Hopi Health Care Center Dental Program

BACKGROUND
The Hopi people occupy more than 1.5 million acres of reservation land they call home. The
land is beautiful and vast, set on three Mesas across desert terrain in northern Arizona. Most
families living on the reservation receive some type of government assistance and the majority
of children are eligible for Medicaid.
Children on the Hopi reservation experience a much higher rate of tooth decay than the national
average. The 1999 Indian Health Service (IHS) Oral Health Survey revealed that in the service
area where the Hopi people live, 65% of the children age six to fourteen had tooth decay
experience. This service area ranked as
having the second worst rate of tooth
decay of all IHS areas in the United
States. A 2007-2008 local assessment
showed that of 355 children, ages five to
twelve, 87% did not have a current dental
exam (within the past 18 months), 84%
needed dental sealants, 78% had
untreated tooth decay, and 27% had
urgent treatment needs (e.g., having an
abscess).
Oral health services for the Hopi people
are provided by the IHS at the Hopi Health
Care Center (HHCC) in Polacca, Arizona.
The HHCC Dental Program has a 14-chair
operatory clinic currently staffed by four full-time general dentists, one full-time pediatric dentist,
two full-time dental hygienists, thirteen dental assistants, and one receptionist. The dentist
provider-to-patient ratio is well below the IHS recommendation and national average.
Typically, Hopi children have episodic care and do not visit the dental clinic until there appears
to be an immediate need. The lack of regular preventive care, early diagnosis and treatment
often result in more invasive dental procedures and poor prognosis for the affected teeth.
Furthermore, Hopi children and families experience barriers to accessing oral health services.
These barriers include lack of adequate number of dental providers, geographical distance, and
lack of transportation. Limited communication between the dental clinic and patients (or their
parents/caregivers) makes care coordination and scheduling difficult because not all patients
have telephones and there is no mail delivery to their residence.

24

High tooth decay rates, episodic dental care visits, barriers to accessing dental services and risk
factors demanded careful assessment and evaluation of the dental services delivery system and
additional solutions to improve the oral health of the Hopi children. This led to the HHCC Dental
Program establishing a mobile school-based preventive dental program.

SETUP AND ACTIVITIES
A Pilot School-based Dental Program
Prior to 2008, elementary schools on the Hopi reservation transported students by bus to the
HHCC dental clinic for preventive care. Organized by grades, a group of approximately 30
students was brought to the dental clinic and stayed from 9 a.m. to 1 p.m. before returning to
the school. During the 4-hour period, each student had a dental visit for 30 to 45 minutes
receiving a prophylaxis (teeth cleaning), dental sealant placement, and fluoride application. All
elementary schools on the reservation were
concerned that this arrangement required a child to
miss too many hours of classroom time. The
HHCC Dental Program was also concerned with
missed classroom time, as well as students who did
not get preventive care due to being absent or not
having a permission slip, the limited amount of
services due to the time constraints, and the very
low number children returning for a complete
examination and restorative treatment. The dental
clinic was able to provide care to only 63% of the
total students from the five schools transporting
them; one school declined to transport the children
to the clinic due to missed school time.
In 2008, the Hopi Health Care Center (HHCC) submitted a proposal to the Inter Tribal Council of
Arizona (ITCA) requesting portable dental equipment to develop a new school-based program
and was awarded. A pilot school-based dental program was initiated in March 2008 at one of
the Hopi elementary schools. The goals of the pilot were to: 1) determine how the program
needs to be managed, 2) determine how the scheduling of students could be efficient, 3) identify
the challenges in transporting and setting up of portable equipment, and 4) identify missing
components for a comprehensive program.
The pilot program had only one portable dental operatory setup and utilized one dental hygienist
and two dental assistants from the HHCC Dental Program. The dental hygienist is a
Commissioned Corp Officer with the U.S. Public Health Service (USPHS), IHS Division and
provides dental care under federal guidelines on Indian reservations. The IHS is
congressionally mandated to provide oral health services to members of federally recognized
tribes on sovereign land following federal guidelines regarding services provided, state
licensure, and billing issues. Services provided at the pilot school consisted of dental
screenings, prophylaxes/scalings, dental sealants, and fluoride applications. Each parent
received a follow-up letter in the mail with recommendations to visit the HHCC dental clinic to
provide his/her child with a complete examination. HHCC does not require an advance
appointment for a dental exam; parents can bring their child and walk-in for an examination.

25

Use of Teledentistry
In 2008, the HHCC Dental Program collaborated with the Arizona Department of Health
Services Department, Office of Oral Health (OOH) to participate in the teledentistry project. The
HHCC Dental Program recognized the advantage of using teledentistry technology for the
school-based preventive dental program. Teledentistry, using information technology and
telecommunications for consultation, education and dental care, and exchanging clinical
information and intraoral images over remote distances, would have a good fit to the operation
of the school-based program. The Hopi Health Care Center Dental Program was chosen to be
a teledentistry provider and the grant provided a portable digital x-ray unit, intraoral camera,
digital film, digital film scanner, and dental imaging and management software for the schoolbased preventive dental program.

Expansion of the School-Based Program
With the school-based program receiving additional portable dental equipment and teledentistry
equipment, the program was expanded to provide greater access and higher efficiency in
delivering dental preventive services. A justification was presented to the HHCC administration
to hire an additional dental hygienist based on
revenues generated from increased dental
services delivered to Medicaid children. The
new dental hygienist and the current dental
hygienist would provide periodontal treatment in
the dental clinic and staff the school-based
program. As a result, the HHCC administration
approved the hiring of a full-time dental
hygienist.
In September 2008, a comprehensive schoolbased preventive dental program was
launched. An agreement between schools and
the HHCC was put into place making the schools an extended setting for the HHCC Dental
Program to deliver services. In order for a school-based program to work, there needs to be an
understanding with all those involved. A Memorandum of Agreement (MOA) was established
with each school outlining the school’s responsibilities for participation in the program. School
responsibilities included: provision of a space for delivering treatment and secured storage of
equipment when not in use; coordination between students and the program flow for the day;
access to school internet services; and follow up with parents for consent forms and for
additional dental care needed by their children.
The expanded staff for the school-based preventive dental program now includes:
 A teledentist who is the pediatric dentist at the HHCC dental clinic.
 A primary provider of preventive dental services who is a dental hygienist and a
Commissioned Corp Officer of USPHS, IHS Division. The dental hygienist also serves
as the HHCC teledentistry coordinator who spearheaded the development of the schoolbased program and its use of teledentistry.
 Dental hygiene students from Northern Arizona University, along with a faculty member,
who provide preventive services in the program.
 A dental assistant who rotates to the school program on a volunteer basis.

26

The expanded school-based program will target five to fifteen year old Native American school
children in all six elementary schools on the Hopi reservation. Enrollment for all of the Hopi
elementary schools is approximately 790 students.
During the school year, the school-based dental program operates two days per week.
Consent forms are sent home in advance. Students with consent are seen for dental preventive
services by grade and classroom. Approximately 15 to 20 students are seen each day (from 9
a.m. to 3 p.m.) and each child is seen for approximately 45 minutes to one hour. Typically, each
student receives one dental visit at the school site for the preventive services unless additional
follow-up is needed. Other treatment needs are scheduled at the HHCC dental clinic. When the
school-based program has treated all students with parental permission for preventive dental
care, the mobile program then moves to another school.
Each school has a designated area to set up the program’s portable equipment. The equipment
is set up into three stations – two for treatment and one for x-rays and intraoral photographs.
The portable dental and teledentistry equipment
is stored on-site at each school.
Children rotate through the x-ray station and then
to one of the treatment stations. Children receive
the following services from the school-based
dental program: x-rays, intraoral photographs,
examinations supported by teledentistry (the
dental hygienist collects the oral health
assessment data and the teledentist completes
the diagnosis and treatment plan for each child),
prophylaxis/scaling, fluoride applications, dental
sealants, caries stabilization (using glass ionomer
fluoride-releasing materials as temporary fillings),
oral hygiene instructions, oral health education (including tobacco, nutrition and safety), and
sport safety mouthguards. A follow-up letter with treatment and referral recommendations is
mailed to the parent. When treatment is completed, the child returns to class and provides the
teacher with the name of the next student for dental care. Students are out of the classroom for
only the time needed for their individual preventive treatment needs.
Teledentistry is used to support the service delivery. The dental hygienist collects the oral
health assessment data including digital x-rays, intraoral photographs and charting. The data is
stored and forwarded (transmitted through a secured and encrypted channel) to the teledentist
for diagnose and treatment planning. When real-time consultation with the teledentist is needed,
a VPN line allows the dental hygienist in the field to connect to the HHCC patient management
system (RPMS) via an encrypted and secure avenue. Patient information is sent to a secure
location to be shared by identified users. The teledentist is able to review the information and
provide a consultation.
This school-based preventive dental program utilizes a multidisciplinary approach with school
nurses, school substance abuse counselors, and public health nursing (home visits for urgent
cases). The program involves teachers, parents, students and the community. Oral health
topics are also shared with teachers to help them develop lesson plans.

27

OUTPUTS AND OUTCOMES
For school year 2008-2009:
 5 of 6 elementary schools participated in the school-based program
 607 students were enrolled in the 5 schools
 533 of 607 (88%) students were seen by the school-based dental program
Dental needs data showed:
 371 (70%) had untreated decay
 444 (83%) needed sealants
 451 (85%) did not have a current dental exam (within the past 18 months)
Each of the 533 students seen by the school-based dental program received x-rays, an
examination supported by teledentistry, a prophylaxis, and a fluoride treatment. There were two
parents that requested no fluoride application. Caries stabilization was provided on 203 teeth
and 2,076 sealants were placed.
When this school-based model was presented to the school administrators and teachers, there
was no hesitation in wanting to move forward. Teachers commented that they are under a
tremendous amount of pressure to meet testing standards and appreciate the fact that HHCC
was looking for a way to decrease the amount of school time being taken to provide dental care.
The teachers absolutely value the dental service for their students (they realize the amount of
school time missed due to dental problems), so finding a good balance worked for all.
Schools are responding well to the dental program. For the new school year 2009-2010, all of
the six elementary schools will be participating in the school-based program. The increase from
five to six schools will add approximately 200 students to the program. The program will also
increase from two to three days a week in delivering preventive services at the schools.
The new school-based preventive dental program, that started full operation in September 2008,
has provided these benefits:
 Prior to 2008, 4 hours of school time per child was missed for limited services. In the
school year 2008-2009, the dental program took a child out of class for only one hour
and delivered more preventive services. At the early part of the school year 2009-2010,
the program already decreased the average “out of class” time to 45 minutes.
 Prior to 2008, 63% of the students were seen. In the first year of the dental program,
88% of the students were seen. In its second year (school year 2009-2010), the program
received parental consent for 100% of the children for the first scheduled school; the
program completed care for all the students in October 2009. The program provided
treatment for 97% (107) of the school’s children. Only 3% (7) parents opted out of the
program because their children were in current dental treatment or had just completed
their treatment.
 Prior to 2008, five dental providers dedicated four hours per week to seeing school-aged
children at the HHCC dental clinic. Currently, an additional 20 hours a week (one hour
per provider) is available for other dental services because the children are receiving
preventive care onsite at their schools.
A quality assurance (QA) assessment was conducted since the use of teledentistry is new to all
involved from the HHCC Dental Program. HHCC wanted to see how the teledentistry
examinations compared to a dentist’s traditional examination (an in-person assessment) for the
same children. During the first year of the school-based dental program, there were 26 children

28

that did not need any follow-up treatment based on their examination using teledentistry
technology. These children became the focus of the assessment since the other children will be
treated by the dentists at the HHCC dental clinic. A dentist, who was not part of the
teledentistry team, visited the schools and completed a traditional in-person examination. The
dental findings of the traditional examinations were compared to the teledentistry examinations.
The QA assessment showed that with the findings of the traditional examinations, there was no
change in any of the original treatment plans that were developed by the teledentist for the
same children. The HHCC Dental Program and the teledentistry team staffing the school-based
program will continue quality assurance efforts to establish and refine clinical protocols for
quality oral health data collection and manage issues related to teledental examinations.

LESSONS LEARNED
Lessons learned from the HHCC school-based preventive dental program include the following:
1. The pilot program was a great learning experience. The primary lessons learned were twofold: (a) the need for additional portable dental units to allow for better efficiency of services
and greater access, and (b) the need to redesign charting and data collection forms. A
proposal for a second unit was submitted to ITCA and the grant was awarded.
Spreadsheets and charting documentation forms were redesigned and streamlined. With
the addition of the second unit, it was determined that dental exams and caries stabilization
services need to be added to provide a more comprehensive program to address the needs
of the Hopi children.
2. The program staff noticed something unexpected. There appeared to be less behavior
problems with the children treated in the school-based dental program. Staff attributed this
to the children being in a more familiar environment that is less threatening to them.
3. After the first year of the school-based program, all of the schools preferred the dental
services to be delivered onsite at the school. Some schools have space issues so there
was some juggling in reserving rooms to provide space for the dental program. The noise of
the dental equipment created one situation in which the space assigned to the program had
to be changed. Also, a few of the schools forgot to include the dental program to receive
notices of school closures for the day, testing times, field trips, and cultural activities when
the children would not available to receive preventive services.
4. It took time for the mobile dental program to find the best solution in packing equipment and
supplies for transport. Many changes in containers and carts for equipment and supplies
were made. Now that the school-based dental program knows what is or is not available at
each school, the program is well organized. The dental program can now efficiently set up
the two dental treatment areas and the x-ray area.

29

Teledentistry in Arizona
S
Seeccttiioonn C
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Chhaapptteerr 22
IInnccrreeaasseedd S
Deelliivveerryy U
Ussiinngg TTeelleeddeennttiissttrryy
Seerrvviiccee D
Chapter contributed by:
Hopi Health Care Center Dental Program

BACKGROUND
In 2008, after completing a pilot school-based
dental program and acquiring additional
portable dental and teledentistry equipment, the
Hopi Health Care Center (HHCC) Dental
Program was ready to expand its school-based
preventive dental program to become fully
operational for the 2008-2009 school year. The
objective was to implement the program as a
teledentistry model in delivering preventive
dental care to children at five elementary
schools on the Hopi reservation. As part of this
preparation, a proposal was made to the HHCC
administration to hire and add a full-time dental hygienist to the HHCC staff and a justification
was presented. It was necessary to demonstrated to the HHCC administration that the schoolbased program had the potential to increase the capacity to deliver preventive services to all
elementary school children on the reservation, free more chair time at the dental clinic since the
children will receive care at the schools, increase patient visits per year, and increase revenue
from Medicaid reimbursements. This could translate to increased and sustainable revenue that
would be available to cover the salary of a new dental hygienist. The new dental hygienist and
the current dental hygienist (the HHCC teledentistry coordinator) would work as a team for the
HHCC Dental Program. Both dental hygienists would provide coverage to the HHCC dental
clinic and the school-based preventive dental program and deliver clinical services. The
increase in staff would allow the two dental hygienists more flexibility in meeting the scheduling
demands of the clinic for adult periodontal care and of the school-based program.

SETUP AND ACTIVITIES
The justification for a new full-time HHCC dental hygienist included the following analyses:
1. An Overview of the Problem and Solution
Table 1 provides a description of the status during the school year 2007-2008. The Hopi
children were transported in groups from their schools to the HHCC dental clinic for
preventive care. This resulted in each child missing a half day of school for a 30-minute
dental appointment. A school-based program offers a solution that delivers services onsite
30

at the schools and minimizes time away from class. A child would receive a teledental
examination, x-rays, oral health education, cleaning, and temporary filling/mouthguard as
needed. Additional benefits include children being comfortable in their school environment.
Table 1.

A Proposal for an Additional Dental Hygienist for the HHCC Staff
An Overview of the Problem and Solution

Status for the 2007-2008 School Year:
One half day a week, 20-30 school aged children are transported from school to the dental clinic.
The children arrive at the dental clinic between 8:30am and 9:00am.
The children receive a screening, sealants, fluoride and oral hygiene instructions (OHI).
The children leave the dental clinic between 11:30am and 12:00pm to return to school.
Problem

Solution

Additional Benefits

1. Children miss half a day of school for a
30 minute appointment.

1. Children will only miss class for
the length of time needed.

1. Children will be seen in their
own environment, less like an
actual dental office which can be
anxiety provoking.

2. Only those children that showed up for
school on the scheduled day can be
seen.

2. Children can be seen when they
return to school. Being on-site
allows this flexibility.

2. There is no school nurse on-site.
With dental on-site dental
emergencies can be assessed.

3. Only children whose parents returned
their permission slips in on-time can be
seen.

3. We would be at each school for
several weeks allowing parents
to have additional time to turn in
permission slips

3. Parents, teachers, and students
would have access to dental
information, education without
having to make an appointment.

4. When classrooms of children are bussed
to HHCC Dental, the clinic is overloaded
and not able to address needs of walk-in
and emergency patients efficiently.

4. The HHCC dental clinic will be
available for regularly scheduled
patients, resulting in increased
patient visits.
- Approximately 26 additional
patients could be seen a day.

4. Walk-in and emergencies would
be addressed efficiently.

5. Only limited preventive services can be
provided to the children in the 30 minute
allotted appointment time.

5. Expanded services will be
available and provided based on
the child’s needs.

5. Children would receive
additional services: exams, xrays, cleanings, Temporary
fillings, sport safety mouth
guards, tobacco and nutrition
education.

6. If the school bussing program cancels
last minute, the dental program will have
unfilled appointments for half a day.
- 3 clinic days were cancelled by
schools

6. The entire school will be a pool
of patients on site, no lost
treatment time.

6. No child will be left out of dental
services, except by
parent/guardian choice.

7. 4 out of 6 schools participated in the
bussing to the dental clinic.
- One school chose not to participate
due to the amount of time out of class.
- One school chose to be our pilot
school for the school based-program.
- All 4 schools capped the number of
bus visits to the dental clinic due to
budget issues.

7. Schools will not have to address
costly budget issues of bus
transportation, maintenance,
salaries, etc.
- School hours missed will be
greatly reduced from 4 hours
per student to 1 hour.

7. Long-term plan is to be able to
provide oral health preventive
services at the school.
- All 6 schools were interested
in this proposal.

8. Hygienist sees on average 7-10 adult
patients a day in the clinic. Adults
without private insurance do not have
billable services. On average, 1 out of
10 adult patients have private insurance.
ACHSS does not cover adult preventive
or periodontal procedures. Broken
appointment rate is 30-60%.

8. By increasing child visits, M&M
dollars can potentially increase.
Medicaid reimbursement is at a
fixed rate per visit for Medicaid
eligible children.

8. 85-90% of school aged children
are Medicaid eligible. 5-10%
have private insurance.

Note:

Goal: All school-aged children will
be seen for dental services.

292 children from Hopi schools
were not seen. (Children who were
not transported to the dental clinic.)

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2. A Comparison of Patients Seen by a HHCC Dental Hygienist in Two Clinical Settings
A HHCC dental hygienist delivers dental care at the HHCC dental clinic and at schools
through the preventive dental program.
HHCC Dental Clinic:
A dental hygienist typically sees 7-10 adult patients per day in the dental clinic.


Arizona Health Care Cost Containment System (AHCCCS), the state’s
Medicaid program, does not cover most dental procedures for adults.



Most adult patients do not have private dental insurance.



The clinic has a high broken appointment rate (30-60%).

School-Based Preventive Program:
A dental hygienist typically sees 12-20 children a day at the school.


80-90% of the children are AHCCCS (Medicaid) eligible; all preventive dental
services are covered by a fixed Medicaid reimbursement rate for each visit.



5-10% of the children have private dental insurance.



No broken appointments since there is a readily available pool of children at
the school to fill the clinical schedule.

A school-based program will increase the level of
preventive services HHCC can provide to Hopi
children and will free chair time at the dental clinic
for the general patient population (children are
provided preventive care at the schools instead of
the dental clinic). Since a large majority of the
children are Medicaid eligible, Medicaid
reimbursement for preventive care will establish a
sustainable source of revenue. The school-based
program will be able to maintain a full daily
schedule of child patients.

3. Analysis of Increase in Patient Visits
Based on HHCC dental clinic scheduling patterns, it is estimated that the HHCC Dental
Program will experience an increase in patient visits. The increased patient visits come from
two sources:


During a school year, 30 weeks have been reserved for children to be transported to
the dental clinic to received preventive care. With the school-based program, these
children will receive their preventive care at their schools. This will result in freeing
chair time at the dental clinic and allowing 26 dental visits to be filled by other
patients. For 30 weeks, there will be a total of 780 additional patient visits that can be
filled by the dental clinic patients.

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

In 2007-2008, 292 children were not transported from the six elementary schools to
the clinic for preventive care. One of the schools declined to transport all their
students due to school personnel’s concern about missing class time. With the
school-based program, it will be easier for these children to receive preventive care.
An additional 292 patient visits are expected to provide a preventive visit for each of
these children.



Therefore, a total increase of 1,072 additional patient visits per year (780 + 292
visits) is expected for the HHCC Dental Program (for both the dental clinic and the
school-based program).

The increased in patient visits shows
increased capacity to deliver services and
improved access to care.

4. Analysis of Increase in Revenue
Since the HHCC Dental Program is in a
hospital setting, AHCCCS (Medicaid)
reimbursement rate is based on a daily
rate, rather than based on fee-for-service
which is more common for private
practices.
Estimates of revenue generated by the HHCC Dental Program include both dental clinic and
school-based program:


For the HHCC dental clinic, 7-10 adult patients will generate approximately $0 - $300
per day.



For the school-based program, 12-20 AHCCCS eligible child patients will generate
approximately $4,000 per day



Using a conservative estimate that 75% of the 783 students enrolled in all six
elementary schools on the Hopi reservation are AHCCCS eligible and the remaining
students do not have private dental insurance, the school-based program provide will
generate approximately $150,000 in revenue per school year.



A dental hygienist salary would range from $40,000 to $60,000 a year.

This analysis shows that the new school-based prevention program will increase revenue
($150,000 per year) which will cover the salary for an additional full-time dental hygienist
($40,000 - $60,000 per year). The school-based preventive dental program, using a
teledentistry model to deliver preventive care and to coordinate care with the HHCC dental
clinic for other unmet treatment, is cost-effective.

OUTPUTS AND OUTCOMES
Data were tracked and compiled to show that the new school-based preventive dental program
would cover the salary for an additional full-time dental hygienist and increase access to
preventive dental care for the Hopi children. The administration approved hiring a new dental

33

hygienist for the HHCC Dental Program. A second dental hygienist was hired in October 2008
to provide services for both the HHCC dental clinic and the school-based preventive dental
program.
The school-based program had its first year of full operation during 2008-2009 school year,
providing two clinical service days a week. The program, staffed by both HHCC dental
hygienists, delivered services to 533 children at five Hopi elementary schools. Prior to 2008,
63% of the elementary students were seen; in the first year of the program, 88% of the students
were seen. This is a 25% increase in the proportion of all elementary school children on the
Hopi reservation receiving dental services.
For the 2009-2010 school year, the school-based program will serve all six elementary schools
on the Hopi reservation and will operate three days a week.

LESSONS LEARNED
Lessons learned included the following:
1. The first year (2008-2009) of the new school-based dental program has been successful.
The justification provided to hire a new dental hygienist had projected increased preventive
services to children, increased patient visits for service delivery, and increased revenue from
Medicaid reimbursement. These benefits have been realized during the first year.
2. The second year (2009-2010) of the school-based program has started and the program
has completed preventive care to all students in the first scheduled school in October 2009.
The program staff has become more efficient; the same preventive services are now
delivered in less time (e.g., a 45-minute visit instead of a 60-minute visit in the previous
year). School and family support for the program is strong, indicated by a 100% of the
students in the first school having parental consent to participate in the program.
3. The success of the first-year operation of the school-based preventive dental program has
resulted in interest to replicate the program and the teledentistry model by the Phoenix Area
Indian Health Service.
4. The HHCC dental clinic and the school-based program continue to adjust, complement and
coordinate services delivered at both clinical settings.

34

Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 33
C
Suuppppoorrtteedd bbyy TTeelleeddeennttiissttrryy
Caarree C
Coooorrddiinnaattiioonn S
Chapter contributed by:
Scottsdale HealthCare & Community Health Services
Neighborhood Outreach Action for Health Program

BACKGROUND
Scottsdale, Arizona is known as an affluent,
resort community and rarely evokes images of
poverty, hunger and need. However, like many
urban Arizona communities, Scottsdale is home
to a large immigrant population drawn to job
opportunities in the construction and support
service industries. Conservative estimates
predict that more than 3,000 immigrant families
live and work in greater Scottsdale.
To meet the health care needs of the large,
primarily uninsured immigrant population,
Scottsdale Healthcare (a non-profit hospital
system) established two health centers to
provide primary care medical services in 1997.
Scottsdale Healthcare & Community Health
Services’ Neighborhood Outreach Action for Health (NOAH) Program began with one clinic as a
community-based/neighborhood clinic and a second as a school-based clinic. These two
centers were staffed by family medicine physicians and pediatric nurse practitioners, who
provided primary medical services to more than 3,200 uninsured patients each year.
The NOAH Program began delivering oral health services with oral health screenings and
referrals for restorative care services. Today it has evolved to include interdisciplinary,
integrated care planning and the provision of preventive and restorative dental health services
at both clinic sites. In spring 2006, NOAH built two dental clinics, each adjacent to the medical
clinic to enhance the integration of medical and dental services. Each health center houses a
medical clinic with two examination rooms and a dental clinic with two dental treatment chairs
with x-ray units. Each NOAH clinic is now staffed with family medicine physicians, family
practice nurse practitioners, affiliated practice dental hygienists and general dentists. The NOAH
Program serves the uninsured and underinsured children and their immediate family members
(their parents and older/younger siblings) in the Scottsdale and Paradise Valley School districts;
however, dental care services provided to only children.

35

SETUP AND ACTIVITIES
NOAH’s School-based and School-linked Dental Clinics
The dental clinic at the Palomino school-based health center operates five days a week. Four
days are devoted to delivering preventive dental services by the dental hygienist; one day a
week is scheduled for the dentist to deliver restorative dental care. The Paiute neighborhood
dental clinic (a school-linked dental clinic) provides dental hygiene services 2-3 days per week
and restorative dental care by the dentist two days per month.

Affiliated Practice Dental Hygienist Model
Typically, practice laws require a dentist to provide direct or general supervision of a dental
hygienist, as well as require an examination before any treatment services can be delivered by
a dental hygienist. However, the Arizona Dental Hygiene Affiliated Practice Act provided a new
opportunity for the NOAH Program to develop a cost-effective dental care model.
Legislation HB-2214 that passed in late 2004, allowed for a
registered dental hygienist to provide dental hygiene services
under an affiliated practice relationship, as prescribed in
Arizona Revised Statutes section (A.R.S.) §32-1289 and §321281. The legislation allows a public health agency or
institution, or a public or private school authority, to employ a
dental hygienist to perform dental hygiene procedures under
either general or direct supervision, or to enter into a contract
for dental hygiene services with licensees who have entered
into an affiliated practice relationship with a licensed dentist.
Statute (A.R.S.) §32-1289 and §32-1281 for affiliated practice
also limited the scope of practice to children aged 18 and
under. This change in Arizona’s practice laws enabled dental
hygienists to initiate treatment based on their assessment of
patient’s needs without specific authorization of a dentist, to
treat the patient without the direct supervision of a dentist, and
to maintain a provider-patient relationship.
In October 2009, new changes to the AZ dental statutes (Legislation SB 1400) lifted the age
restriction for dental hygiene affiliated practice. While plans for the near future do not include
adults, the NOAH program will provide oral health care for children below the age of 21.
NOAH currently employs two affiliated practice dental hygienists. One dental hygienist (the lead
dental hygienist) is full time working four clinical days per week; the other dental hygienist (the
on-call dental hygienist) is part-time working 2-3 clinical days per week. The lead dental
hygienist typically covers both dental clinics, while the on-call hygienist is available for days
when both clinics have appointments. In addition to clinical duties, the lead dental hygienist
also performs managerial duties, such as ordering supplies, posting work schedules, grant
management, case management, and equipment repair/maintenance oversight.
Clinically, the dental hygienist sees all new patients, gathering and recording diagnostic data
that needed by the dentist, such as digital radiographs, intraoral photographs, and pertinent
discussion with the parent and/or the child. The dental hygienist is responsible for scheduling
the patient with the dentist for the examination and restorative treatment. At this time, the
36

hygienist triages the clinical needs of the child, getting those with urgent needs appointed as
soon as possible. Preventive dental care includes: extensive oral hygiene instructions provided
in a one-on-one interactive format with the child and the parent; scaling and polishing; dental
sealants; and fluoride varnish. The affiliated practice legislation allows the dental hygienist to
assess the need for sealants without a dental examination.

Clinical Staff
The clinical staffing at each of NOAH’s two dental clinic is as follows:
1. At the Paiute school-linked dental clinic:
1 dental hygienist – affiliated practice 2-3 days per week
1 part-time contracted dentist provides 2 days of restorative services per month.
1 FTE dental assistant
2. At the Palomino school-based dental clinic:
1 dental hygienist – affiliated practice 4 days per week
1 part-time contracted dentist provides 1 day of restorative services per week.
1 FTE dental assistant
In 2009, the NOAH Program also became a
Medicaid (Arizona Health Care Cost
Containment System or AHCCCS) provider and
planned to broaden program services to
address community-wide oral health needs.

Patient Population
NOAH serves families with incomes less than
200% of the Federal Poverty Level. Annually,
NOAH Health Care Centers serve
approximately 3,200 uninsured children and
their family members.
Prior to 2009, the NOAH dental clinics accepted children 0-18 of age, treating children from
preschool through high school. After October 2009, due to new legislation allowing affiliated
practice dental hygienists to see adults, the dental clinics have now increased the age level to
children below age 21. Future plans to increase the adult population in a controlled manner are
being developed.
The NOAH Program has also implemented a change in geographic eligibility for patients. Prior
to August 2009, eligibility to receive care in the NOAH Program required a family to live within
the borders of Scottsdale Unified School District, Paradise Valley Unified School District, or
Cave Creek Unified School District. Now there is no geographic requirement for eligibility.
The NOAH school-based clinic is located in the Palomino Elementary School. As a result, the
majority of dental patients are the school children from the Palomino Primary School (PreKindergarten through 3rd Grade) and the adjacent Palomino Intermediate School (4th Grade
through 6th Grade).

37

Dental Services
Both dental clinics provide the following services: oral health assessments by affiliated practice
dental hygienists, dental examinations by dentists, x-rays, treatment planning, prophylaxis (teeth
cleaning), dental sealants, fluoride varnish, restorative care, and referrals to specialists.
Affiliated practice dental hygienists provide preventive services. Every child is assessed
according to clinical need for the frequency of fluoride varnish treatments (up to 4 applications)
per year and is seen on a minimum of a 6-month recare schedule.

Care Coordination Between the Two NOAH Dental Clinics
Since the dentist and the dental hygienist provide care on different days, communication
between them is crucial. The utilization of teledentistry can support critical communication for
the dental team with digital radiography, electronic patient records, and intra-oral photography.
Case management is a key component of the affiliated
practice model. With this model, the affiliated practice
dental hygienist can see the patient first, providing a
screening examination, oral hygiene instruction,
prophylaxis and fluoride varnish. The affiliated practice
hygienist can then triage the need for dental care,
getting those children with the greatest need scheduled
with the dentist as soon as possible. The use of
teledentistry allows the dental hygienist to compile data
for the patient record and send that data to the dentist
for review and consultation.
By compiling an electronic record of the patient at the hygiene appointment, the dentist is able
to see improvement or deterioration of the child’s oral condition at the time of the dental
examination appointment. Teledental consultation also serves to eliminate travel time and
transportation issues for the patient. Consultation can also take place between the dental
hygienist and the dentist to determine the need for further referral to outside specialists.
Consultation can occur with specialists, so they have a more
accurate and complete record to determine their course of
treatment.
Children are at times referred and scheduled to receive care
from one NOAH dental clinic to the other clinic when patient care
needs to be scheduled at an earlier date or for specialized
procedures provided by the dentist at the Palomino clinic, who
performs endodontic treatment and 3rd molar extraction.
Children from the school-based Paiute clinic are often referred to
the school-linked Palomino clinic. Computerized clinical records
from both clinics can be viewed at either clinic at any time, thus
allowing the dentists to view any and all records that have been
recorded. At this time, only the Palomino clinic has digital
radiography and intra-oral photography capability, so the
teledental exchange of oral health data is not yet at full capacity.

38

NOAH provides taxi services for families with hardship in reaching either of the dental clinics.
The city of Scottsdale provides free shuttle services throughout the city with a scheduled stop at
the Paiute Neighborhood Center. This support service provides a viable option for families and
children to have care coordinated at both dental clinics.

Referrals to Specialists
Both NOAH dental clinics refer children to dental specialists in the community. Only endodontic
treatment (e.g., root canals) is provided at the Palomino clinic with most specialist referrals
made to oral surgeons, pedodontists and orthodontists.
The oral surgeon referrals are usually for 3rd molar extraction and mesiodens (a supernumerary
tooth between the upper central incisors), although as more children are obtaining orthodontic
treatment (e.g., braces to correct the alignment of teeth), referrals have been made for
orthodontic extractions. The NOAH Program currently has one oral surgeon who donates eight
cases per month and two others who donate to a lesser degree.
Very young children and those who are difficult to manage are referred to the pedodontist. As
the focus for treating 0 to 5 year-olds is expanded, the need for this type of referral will also
increase. Currently, one pedodontist has committed to donating at least one case per month.
Referrals for orthodontics are the most numerous. It is interesting to observe that the desire for
“straight teeth” crosses socio-economic status. When provided an opportunity, parents are
making the investment for orthodontic services for their children. The NOAH clinics have three
orthodontic offices, each providing care at reduced fees.
Dental referrals to specialists are routinely made by the NOAH clinics to achieve optimal care
for the children. The lead dental hygienist serves as a case manager for the dental referrals to
specialists. Teledentistry will support for referrals to specialists and will improve care
coordination that will maximize the quality and efficiency of the referrals.

Calibration
Another needed step in integrating teledentistry into the NOAH Program is to assure that the
dentist and affiliated practice dental hygienist are calibrated in their teledentistry communication
and data sharing. With calibration, the dental hygienist will assure that all the necessary and
appropriate oral health assessment data is collected for the dentists to complete the dental
examination. It is critical to assure that diagnoses and treatment planning provided for the
patient after the dentist reviews the teledentistry oral health data is comparable to diagnoses
and treatment planning the dentist would provide after a traditional “face-to-face” dental
examination.
The calibrating efforts for both the dentist and dental hygienist will diminish inconsistencies,
allow both professionals to function as a coordinated dental team, and increase chair time for
the dentist to deliver treatment. Also, once the dentist and dental hygienist are calibrated, the
dental team can increase its productivity in delivering care and improve patient scheduling.

39

OUTPUTS AND OUTCOMES
The NOAH Program is in the early stage of integrating teledentistry for care coordination.
Teledentistry technology went live in 2009. The first stage of integrating teledentistry into
NOAH’s dental care delivery system is to use the technology to support care coordination
between the two dental clinics, make referrals to specialists, and calibrate how the dental team
(dentists and affiliated practice dental hygienists) will use teledentistry to provide efficient and
quality patient care.

Care Coordination Between the NOAH Dental Clinics
The NOAH Program has utilized teledentistry multiple times for
consultations and care coordination (e.g., consulting with the
clinic dentist and scheduling patients). For example:
One such instance involved a 6 year-old boy who presented
at his dental hygiene recare appointment in pain with a
dental abscess. The dentist would not be in the clinic for two
weeks. Digital radiographs and intraoral photographs were
taken and sent via secured email to the dentist for a
consultation. Rather than place the child on a course of
antibiotics and reschedule in two weeks, the dentist found
time to come into the clinic and extracted the tooth.

Referrals to Specialists
Referrals to specialists often present challenges to parents and their children due to
transportation issues and lost time from work and school. The NOAH Program, in its first efforts
to use teledentistry to support referrals to specialists, has found better efficiency in making
referrals and reducing lost time for families. The following story illustrates the advantages that
teledentistry has provided:
A 4 year-old child arrived in the NOAH clinic for his first
intake well-child appointment. The physician noted that he
was in a great deal of pain, listless, and running a fever.
The parents and child were walked down the hall to the
adjacent dental clinic for consultation with the affiliated
practice dental hygienist. The dental hygienist observed
signs and symptoms consistent with early childhood tooth
decay and a dental abscess but cannot make the diagnosis due to the state practice act.
The dental hygienist discussed and showed the physician the decayed teeth and the area
with swelling. The physician prescribed antibiotics for the fever and signs of infection. The
dental hygienist initiated a referral to the pedodontist. With teledentistry technology,
intraoral photographs were taken and transmitted to the pedodontist’s office. The specialist
agreed to accept the child in his practice. With further care coordination, after several
phone calls between the pre-school community liaison, the parents, the NOAH dental
hygienist and the pedodontist’s office, the child was seen by the specialist for emergency
care.

40

With teledentistry support, the NOAH Program has also noted that referrals to an oral surgeon
have been simpler with transmitting digital radiographies. For example:
NOAH referred a child for extraction of a molar tooth
(#14) due to severe tooth decay. The ability to quickly
send the radiograph via secured email to the oral
surgeon enabled him to assess needed treatment and
appropriately plan for the children’s first appointment to
his office. This also let the NOAH providers prepare the
parent and child for their appointment with the specialist.

Calibration
For the NOAH Program, calibration efforts are in the early stages and in progress. However,
the dental team has noted that the intraoral photographs together with the digital radiographs
prove to be very beneficial to improving communication between the dentist and the dental
hygienist. Since the NOAH Program’s dental care model rarely schedules the affiliated practice
dental hygienist with the dentist on the same day together at the same clinic, the teledentistry
technology provides higher efficiency in the exchange of a patient’s oral health information for
care management by the dental team. The ability to view the same chart (with digital images)
from either of the two NOAH dental clinics is most helpful when the dentist is scheduled at one
clinic and the affiliated practice dental hygienist is scheduled at the other. The dentists and
dental hygienist can both pull up the chart and discuss the patient management and clinical
issues over the phone. The NOAH Program anticipates that more opportunities will present to
the dental team and calibration will be refined.

LESSONS LEARNED
1. All NOAH clinics and the mobile unit have strong Information Technology (IT) support for the
electronic medical/dental record system. This IT support was very helpful to address
teledentistry interfacing issues with the medical record system.
2. There is a need to train all staff personnel on the teledentistry hardware and software. This
has been a challenge for the NOAH Program since some of NOAH’s clinical staff work part
time and have different schedules of work days.
3. There are questions regarding putting teledentistry into practice related to (a) legal issues
related to practice laws for teledentistry, (b) supervision via teledentistry such as the role of
the distant teledentist and affiliated practice dental hygienist in supervising dental assistants.
4. More time is needed for the NOAH Program to consider how best to expand the
teledentistry model. The program will aim to include more services that have been are part
of telehealth (e.g., real time patient consultations and consumer education).

41

Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 44
TTeelleeddeennttiissttrryy ffoorr C
Neeeeddss
Caarree ooff P
Paattiieennttss w
wiitthh S
Sppeecciiaall N
Chapter contributed by:
North Country HealthCare and Arizona School of Dentistry and Oral Health

BACKGROUND
The utilization of teledentistry has been a welcomed challenge for North Country HealthCare
(NCHC). While NCHC has been a pacesetter in the field of telemedicine, challenges with the
teledentistry model have reflected the
difference in the delivery of medical care
versus dental care. Dentistry, with its
nearly exclusive “hands-on” model of
care delivery, differs from the traditional
model of medicine with its emphasis on
diagnosis and pharmaceutical
management. NCHC’s use of the
teledentistry model is skewed towards
patient management and information
dissemination.
NCHC patients are from all walks of life
with varying income levels. NCHC
accepts most insurance plans and
Medicaid. There is also a sliding fee-scale option for eligible patients. Patients range from the
very young to seniors. Individuals with special health care needs, including mentally and
physically challenged, are also a part of NCHC’s patient population.
The NCHC Dental Services and the Arizona School of Dentistry and Oral Health (ASDOH) at
A.T. Still University has established a collaboration to integrate teledentistry for the care of
patients with special needs and for professional development. ASDOH maintains a Special Care
Dental Clinic to offer comprehensive special care dentistry for patients with intellectual, physical,
and emotional disabilities, and other special healthcare needs. Teledentistry will be used to
support the care of patients with special needs, allowing NCHC providers, residents and
students to consult with specialists at ASDOH.

SETUP AND ACTIVITIES
North Country HealthCare’s Dental Clinic and Clinical Staff
NCHC presently employs seven oral health providers comprised of two dental hygienists, four
general dentists, and one locum tenens general dentist (temporary substitute). All dentists work
42

full-time with the exception of the locum dentist. The Dental Director is a full-time clinician. Of
the ten NCHC facilities, three clinics offer dental services. The Flagstaff clinic provides dental
care five days per week. The Winslow clinic provides care four days per week. Dental providers
rotate to the Ashfork clinic one day per week alternating between dental hygienists and dentists.
Each clinic maintains its own schedule of dental patients and medical services are provided at
each clinic.
The NCHC clinical staff provide preventive dental services including dental cleanings,
comprehensive examinations, x-rays, fluoride treatments and oral cancer screenings. The
clinical dental staff also provide restorative care such as fillings, crowns, bridges and dentures.

Students and Residents
Dental hygiene students from Northern Arizona University (NAU) in Flagstaff have rotated to
NCHC for eleven years. At the present time, two senior dental hygiene students rotate one day
per week to the Flagstaff clinic. The health center also serves as a summer extern site for rising
senior dental hygiene students. The typical summer externship is six to eight weeks in length.
Both of NCHC’s dental hygienists serve as faculty for the NAU dental hygiene program.
NCHC has served as a residency site
for the Lutheran Medical Advanced
Education in General Dentistry Program
(AEGD) since 2002. The dental
department at NCHC and the dental
department of Winslow Indian Health
Center have partnered together to
provide Lutheran dental residents an
opportunity to work in two unique public
health organizations. The dental
resident stationed at NCHC rotates
three to four times per month to the
Winslow Indian Health Center. At the
center, they work with specialists in the
areas of Oral Surgery, Orthodontics,
Periodontics and Endodontics. All residents in the Northern Arizona area convene at NCHC,
one day per week, for video educational conferencing. This meeting provides residents with
“classroom” instruction by Lutheran staff and includes various topics of dental interest.
NCHC also serves as a rotation site for students from the Arizona School of Dental and Oral
Health (ASDOH). Students from ASDOH can choose from a number of clinical sites, where they
are “graded”, by adjunct faculty, on specific clinical competencies. Students rotate between two
to eight weeks in a chosen site. Students that come to NCHC rotate between the Flagstaff and
Winslow clinic sites.
Dental hygiene students, dental students and dental residents are mentored by all NCHC dental
providers. Patients are not pre-selected for students or residents. It is hoped that this results in
students and residents receiving a more “realistic” patient care experience.

43

Patients with Special Health Care Needs
The NCHC tries to increase the number of patients seen and treated in the three dental clinics
on an on-going basis; particularly for the largest dental clinic in Flagstaff. Many patients at
NCHC are medically complex. They have advanced disease processes that are “managed” by
medication. This may be largely due to the lack of access to routine care and thus, early
identification and treatment of disease does not occur.
Patients with special needs, e.g. cerebral palsy, those with severe brain injury; have historically
been seen by a limited number of local dentists and by providers in the Phoenix area. Travel to
Phoenix is costly and time consuming for many families. NCHC’s goal is to serve as the
northern most medical and dental service “hub” for the patients with special needs and their
families. The goal of this model is to prevent further oral disease rather than manage advanced
oral disease.

Training for the Management of Dental Patients with Special Health Care Needs
The management of oral disease may vary slightly in the special needs population, but more
importantly, the appropriate physical and emotional management of the individuals will assure
their continued relationship in seeking care with competent medical and oral health care
providers. General dentists have very low exposure to patients with special health care needs
during their formal training. The Arizona Dental Association, Arizona Department of Health
Services Office of Oral Health, and ASDOH have responded to this through sponsoring 30+
hours of continuing education in the treatment of the special needs patient. Two of the dentists
currently employed by NCHC have completed this course.
NCHC’s linkage to specialists at ASDOH will fill in “experiential gaps” (e.g., understanding by
experience) when serving the special needs population. Relevant oral health topics will be
presented by specialists from ASDOH to both physicians and dentists. Rotating dental and
medical students as well as dental residents will have access to the wealth of knowledge
present at ASDOH.
The success of this training effort will accomplish two major goals: (1) the provision of dental
care to an overlooked population, and (2) the education of oral health and medical professionals
who will be competent in treating all members of the community.
ASDOH Special Care Faculty is experienced in training students/residents, practicing general
dentists and support staff in patient management of children and adults with special health care
needs. In 2007, ASDOH provided an intensive training program targeting general dentists and
their support staff at three geographically diverse sites. The course provided hands-on training
on the dental treatment of developmentally disabled patients. NCHC’s collaborative partnership
with ASDOH will provide added benefits to their students/residents, staff dentists and patients
with special needs.

Integrating Teledentistry into the Care for Patients with Special Health Care Needs
The NCHC Dental Services and ASDOH are partners in developing a teledentistry program that
will provide training, consultation and technical support for the care of patients with special
health care needs. Since an objective of the ASDOH Special Care Dental Clinic is to increase
access to care for persons with special health care needs throughout the state of Arizona,

44

teledentistry will further develop ASDOH’s role as a hub providing consultation to distant dental
clinics.
NCHC would use this technology to record and transmit a patient’s vital information to
specialists at ASDOH. This information would include routine medical histories. Subtle
information, traditionally gleaned from personal contact, could be transmitted. This information
would include a physical and emotional assessment. For example, is the patient easily
agitated? Does the patient exhibit spastic or sudden movements? Is the patient communicative
or combative? How might the caregiver be able to help in the treatment process?
Recommendations could be made by ASDOH specialty staff concerning issues such as
sedation suggestions, appropriate use of acceptable restraining techniques and sequencing of
needed treatment, specifically for a patient. Dental provider staff would then oversee the
treatment of these patients by ASDOH students and Lutheran dental residents.
There will undoubtedly be some patients that will require care beyond the scope of a health
center. Specialists at ASDOH and the patient’s physician will be instrumental in the treatment
delivery decision(s) for those patients that require more specialized care.
The initial patient visit would be recorded and then reviewed by ASDOH faculty, a NCHC
provider and the student/resident, at a pre-scheduled time. The student/resident would prepare
a case presentation for ASDOH faculty. At this time a recommendation for care would be made.
This model would be an extension of the educational mission of ASDOH and NCHC and would
incur little, if any, cost to the patient or their family. “Real time” care consultation will be limited
and will likely incur a clinical consultation charge since an appointment will be required to secure
provider time.

Linking Teledentistry and Telehealth
NCHC presents a special environment to
integrate teledentistry with the
telemedicine/telehealth network in
Arizona. Since NCHC has an extensive
telemedicine/telehealth network of
providers through their ten satellite clinics
in the state, linking teledentistry program
with physicians, nurses and allied health
professional will present opportunities to
improve the care of their medical and
dental patients, including patients with
special needs.
Building linkages has already begun. The
NCHC teledentistry program has initiated
oral health continuing education (CE) through their NCHC telehealth CE program. In
partnership with ASDOH, the ASDOH Director of Special Care Dentistry (who is also the CoDirector of Advanced Education in General Dentistry Program) has provided two presentations
in October/November 2009. These presentations were the first oral health topics provided by
the NCHC telehealth CE program. NCHC connected their distant learning center and telehealth
provider network to the oral health CE presentations.

45

OUTPUTS AND OUTCOMES
Efforts to Address Security Issues Related to Teledentistry
NCHC, with the support of its Health Information Technology Director, has identified two primary
issues to address in order to establish full telecommunication with ASDOH as teledentistry
partners:
1. It is likely that there will be outsiders or non-clinical persons present in teleconsultations
(may include non-clinical technicians, camera people, schedulers who may be located
on either side of a telemedicine consultation or at the site of a service provider, either
physically or via the technology they support). Also, clinical personnel who may not be
visible or observable by the patient in a teleconsultation may be present. NCHC and
ASDOH each must be fully covered through the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) compliant sign-offs.
2. Encryption of patient data during transmission. All data shared between NCHC and
ASDOH must be encrypted and decrypted during the transmission process to assure
continued protection of sensitive information. A protocol that is amenable to each party
must be established.
The NCHC Dental Director is working with the Health Information Technology Director to set up
the necessary procedures, measures and documents to manage HIPAA and security issues.

Oral Health Continuing Education for the Telehealth Providers
In addition, two oral health continuing education events have been held in October and
November 2009. The presentations were titled:
1. Review of Evidence-based Oral Health Guidelines for the Medical Providers
2. Fluoride Varnish – What’s New? What’s True?
Participants for the two events totaled 34 (individuals who attended in person at the HCHC
Learning Center in Flagstaff and who used a website connection). Participants included
medical/dental providers and support staff in the telehealth network. Evaluation showed that the
presentations were well received. This is the first effort in building linkages with NCHC
telemedicine network and initial Arizona teledentistry network. In addition, the NCHC distant
learning center has a website that that archive the CE presentations to provide open access to
providers to view the videos any time.
There is potential to continue an “oral health integration” series of CE presentations for
telehealth providers if the NCHC and ASDOH teledentistry partnership. Furthermore, ideas are
developing in connecting with the full Arizona Telemedicine Network by starting with oral health
integration presentations for medical providers.

46

LESSONS LEARNED
Fiscal Challenges in Dental Care for Patients with Special Needs
Due to the current economic climate, state Medicaid programs have reduced budgets for
health care. The State of Arizona piloted a program to provide individuals with long-term
disabilities fifteen hundred dollars ($1,500) for dental services. It was hoped that the pilot’s
innovation in oral health care delivery may reduce a portion of the healthcare costs for
citizens with long-term disabilities. During this time, the dental clinic at NCHC began to see
an increase in the individuals targeted by this pilot program. Unfortunately, many of the
treatment plans for these individuals were not completed due to additional administrative
time required by the pilot that took away needed treatment time during dental visits. The
pilot had specific registration prerequisites that required the front operations personnel to
acquire "prior authorization" from the program before the patient's first examination visit.
This process proved time-consuming, cumbersome and confusing. Patient care time was
lost and families and patients became frustrated with the administrative procedures. The
pilot program ended in 2008, resulting in patients and their families now having to pay a
larger portion of oral healthcare costs.

Teledentistry Security Challenges
As mandated by HIPAA, health care providers who engage in HIPAA standard electronic
transactions must comply with the protection of patients' individually identifiable health
information. These electronic transactions include the use of telehealth technologies.
In order for NCHC to participate fully in any electronic sharing of patient data or telehealth
programs including patient diagnosis, all participants must be trained about security and
designate a grant privacy officer. A Trading Partner Agreement (a formal legal document
validating the legality of the business transactions which will be electronically processed.)
must also be developed that extends privacy protections to third party business associates.
Finally, a protocol will need to be developed to obtain patient consent for most disclosures of
protected health information which assures NCHC transmits and provides the minimum
amount of information necessary.
Before NCHC can share information using telehealth modalities, NCHC must assure that
Arizona State laws work to preempt Federal laws. Federal laws preempt state laws that are
in conflict with regulatory requirements or those that provide less stringent privacy
protections, but those states that have more stringent privacy laws would preempt Federal
law. Under these circumstances, telehealth practitioners will be faced with complicated
privacy standards. It is important to have a heightened level of concern for patient privacy in
the telemedicine environment, especially where patient visits are occurring in real-time. The
potential for more complicated informed consent requirements under HIPAA that could
inhibit obtaining the necessary patient consent signatures which are necessary prior to
initiating telehealth activities.

47

Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 55
TTrraaiinniinngg ooff D
Deennttaall H
Hyyggiieennee S
Sttuuddeennttss iinn TTeelleeddeennttiissttrryy
Chapter contributed by:
Northern Arizona University Department of Dental Hygiene

BACKGROUND
The teledentistry program at the Northern Arizona
University (NAU) Dental Hygiene Department is
developing an educational framework (for both
distance and face-to-face environments) to train
students to acquire and digitally transmit all
necessary diagnostic data to a dentist at a remote
site. The distant dentist will diagnose and prescribe
dental hygiene treatment to new or existing
patients of record and make referrals for additional
dental treatment as necessary. The NAU Dental
Hygiene Department is in a unique position to
develop face-to-face and distance educational
frameworks, facilitate training, and promote the use of teledentistry to provide remote diagnosis,
appropriate referrals, and dental hygiene services for underserved populations.

SETUP AND ACTIVITIES
Teledentistry Hardware and Software
NAU received delivery of all of the teledentistry equipment (hardware) and computer programs
(software) in March 2009. The teledentistry hardware and software included:


Two Dell laptop computers



Two Nomad X-ray units included training software (for dental radiographs)



Two Scan-X Duo digital film processors and installation software



Scan-X Duo digital film processor cleaning strips



Two Acclaim intraoral cameras included installation software (for intraoral photographs)



Phosphor films (#2, #1 and #0), film barriers, and film transfer boxes



One Velscope (oral cancer screening system)



One Spectra (fluorescence based caries detection system)



Open Dental software (open source dental management software)



TigerView software (digital imaging software)

48

A technical representative from TigerView came to NAU and installed the appropriate software
on the laptop computers and made sure all of the appropriate hardware worked correctly.

First Group of Students Trained
Ten senior students, two months from their graduation, began working with the NAU
Teledentistry Coordinator/Principal Investigator to learn how to use the teledentistry equipment.
The first step was to view all the technical data and training materials for the Nomad X-ray unit.
In addition to the training materials, Nomad provided a certification examination, which the ten
students successfully completed.
The next step was to teach the students to use
the TigerView software and import digital
images from both the Scan-X Duo digital x-ray
film processors and the Acclaim Intraoral
Camera. This was very easy to accomplish
because the students are already comfortable
with digital technologies.
Once the students learned how to use the
Scan-X Duo and the TigerView software basics,
the students began taking digital x-rays on a
DXTRR mannequin.
Individually, the students took several digital x-rays and intraoral photographs and imported
them into appropriate patient files. Each student then exported all of the patient's digital data
using various store-and-forward techniques such as e-mail, burning discs, and thumb drives.
Every student participated in eight hours of training and all were able to demonstrate complete
competency in all aspects of teledentistry techniques including the ability to assemble and
disassemble all of the equipment.

OUTPUTS AND OUTCOMES
Ten senior NAU dental hygiene students have been trained in the use of teledentistry
equipment. They have become proficient in using teledentistry technology in collecting oral
health assessment data (using a digital x-ray unit and an intra-oral camera) and transmitting
images.
Two alumni have been hired by a private practice pediatric dentist who will use teledentistry to
provide community outreach services.
The conclusions of the Teledentistry Program Coordinator/Principal Investigator on the initial
training is that the students were receptive to learning new technology, easily learned the use of
the equipment, and were enthusiastic in incorporating the technology into practice.
Based on the ease of training, the successful outcomes of the initial teledentistry endeavors,
and the treatment advantages teledentistry offers patients, NAU plans to move forward
49

incorporating teledentistry into the dental hygiene curricula. Several senior students will be
trained in teledentistry during the fall semester; the entire senior class will be trained during the
2010 spring semester.
The Teledentistry Program Coordinator/Principal Investigator will be the lead instructor of a
spring semester course, DH-470 Professional Seminar, and will teach all aspects of
teledentistry to the senior students. Additionally, senior students will accompany the
Teledentistry Program Coordinator/Principal Investigator into the community to provide
teledentistry-assisted dental hygiene treatment for children and adults from the dental hygiene
affiliated practice demographic.
Several senior students and NAU dental hygiene graduates will be assisting the Teledentistry
Program Coordinator/Principal Investigator with teledentistry-assisted dental hygiene services
provided to Coconino County First Things First children beginning in October, 2009 and will be
continued through May, 2010. In May 2010, members of the Class of 2011 will accompany the
PI to several remote areas in Arizona to provide teledentistry-assisted dental hygiene services
to First Things First children. In all cases, data will be acquired as to number of children treated,
diagnostic outcomes, etc.

LESSONS LEARNED
The initial student training in teledentistry has provided these lessons:
1. Unlike many older people, today's students
have grown up in the digital era. Coupled with
the fact that the NAU senior students are well
educated in dental hygiene and ready to enter
the professional world, their familiarity with
digital technologies makes for a nonintimidating learning environment, teledentistry
simply makes sense to these students.
2. The TigerView software has an easy-to-use,
intuitive user interface. Although TigerView
provides a complete user's manual, the
students were able to teach themselves how to
utilize the software by simply exploring the various interface options and experimenting.
3. The learning process for using the Scan-X Duo was equally as easy. By reading through the
Scan-X Duo user manual, the students quickly learned how to set the unit to process digital
films. Additionally, the students learned the importance of running a cleaning strip through
the Scan-X Duo on a regular basis as dust can accumulate within the Scan-X Duo and
compromise the quality of the scanned image.
4. In taking digital x-rays on a DXTRR mannequin, an important lesson learned is that standard
XCP x-ray film placement devices are not appropriate for use with the Nomad X-ray unit.
The arm on the XCP that allows the positioning ring to slide to and from the patient's face is
too long and prevents the operator from being able to have the lead-lined glass shield
placed at the most distal position on the Nomad's collimator. With the lead-lined glass shield
placed somewhat proximal on the collimator, the operator is less protected from scatter
50

radiation. If the film is exposed with the lead-lined glass shield in its most correct position,
and an XCP is used, the distal end of the collimator is a few inches farther from the patient's
facial area than it should be, thus exposing more of the patient's face and neck to radiation
than is necessary. Upon investigation, there are a number of x-ray film positioning devices
available with a shorter arm, which allow the Nomad's lead-lined glass shield to be properly
positioned for maximum safety.
5. Placement of films utilizing bitewing tabs and Stabe Styrofoam positioning devices for
periapical and occlusal views work well. Utilizing bitewing tabs and Stabes in the field
prevents the need for on-site sterilization of XCP type devices. Although NAU have since
obtained several XCP-type devices appropriate for use with the Nomad, the NAU students
use bitewing tabs and Stabes as their first choice of film positioning devices — specifically
because there is no sterilization required, which facilitates extending services to remote
areas.
6. Because the Nomad X-ray unit has factory settings for traditional x-ray film, x-ray sensors,
phosphor plates, patient size, and bitewing or periapical film placement, it was not
necessary to calibrate exposure times. The students were able to take diagnostically
appropriate x-rays on DXTRR at their first endeavor. The students easily created a patient
file for DXTRR within TigerView, processed their films with the Scan-X Duo, and easily
imported the films to DXTRR's file. Once the film images were stored within DXTRR's
TigerView file, the students easily created a variety of x-ray film mounts for the diagnosing
dentist.
7. Learning to use the Acclaim Intraoral Camera was also easy. The Acclaim intraoral images
are viewed on the laptop screen while in the TigerView environment. Capturing an image
requires only the push of a button and the image is stored within the patient's file. These
images can then be exported separately or included within a typical x-ray mount view.
Images collected via the Acclaim Intraoral Camera are extremely high quality. While viewing
through the camera, it is possible to have the intraoral image visible full-screen on the laptop
computer screen. A projector can also be attached to the laptop computer to project the
images to a screen or on a wall for easier viewing by the operator. The use of a projector will
be further discussed in this document.

51

Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 66
TTeelleeddeennttiissttrryy aatt aa FFrreeee A
Annnnuuaall K
Kiiddddiiee C
Clliinniicc
Chapter contributed by:
Northern Arizona University Dental Hygiene Department

BACKGROUND
Northern Arizona University (NAU) hosts an annual Kiddie Clinic to provide dental hygiene
services and complete dental examinations for local children. The annual Kiddie Clinic, which
has been in existence for twenty-five years, is supported through community donations and the
services of local volunteer dentists. The
Kiddie Clinic provides head-and-neck
examinations, dental examinations,
radiographs, prophylactic dental hygiene
services, dental sealants, fluoride varnish,
and appropriate dental referrals to all
participants.
In years past, a Kiddie Clinic provided
services for up to 140 children during the all
day event. Typically, processing the x-ray
films for so many children caused significant
delay. In 2009, the Kiddie Clinic integrated
teledentistry technology to improve efficiency.

SETUP AND ACTIVITIES
The 2009 Kiddie Clinic was held in the middle of April. Ten senior students, with several weeks
of training in using teledentistry equipment, were ready to provide digital radiographs and
appropriate intraoral photographs to facilitate the event.
NAU uses Dentrix in the dental hygiene clinic but has not yet linked the teledentistry software to
Dentrix. However, the NAU Teledentistry Program Coordinator/Principal Investigator decided it
would be appropriate to store and forward the digital images to Dentrix using small, portable
thumb drives.
The Kiddie Clinic would be an excellent opportunity to use teledentistry technology and to share
the digital images with several volunteer dentists that provide their services in Kiddie Clinic,
which would allow for evaluation of diagnostic quality. Although NAU has two complete sets of
teledentistry equipment, the Teledentistry Program Coordinator/Principal Investigator decided to
use only one set for the Kiddie Clinic in order to closely supervise each patient's data
acquisition.
52

At the Kiddie Clinic, the Teledentistry Program Coordinator/Principal Investigator managed all
data input. Students took the radiographs and intraoral photographs. The patients' data were
exported to a thumb drive and the students opened the images for the dentists on the computer
at their individual operatory.

OUTPUTS AND OUTCOMES
There were 117 children (patients) served at the 2009 Kiddie Clinic, 46 sets of digital x-rays,
bitewings and occlusal views were collected, and a few intraoral photographs were taken.
Several positive outcomes occurred. The clinic dentists found the digital diagnostic data very
acceptable for diagnosis. Students who had no training with the teledentistry equipment were
able to use the Nomad X-ray unit and easily acquired the appropriate x-rays under the guidance
of the teledentistry-trained students. Throughout the day, all of the clinic dentists visited the
digital diagnostic data acquisition area and had no negative comments about the procedures
they viewed. In fact, two dentists inquired about adding teledentistry to their practice.
This first experience of using teledentistry
technology in the 2009 Kiddie Clinic has helped
the planning for the next Kiddie Clinic in 2010.
For the next event, students will use both sets
of teledentistry equipment and will acquire
digital diagnostic data from all of the
participating children. Two separate areas will
be used. By the time of the next Kiddie Clinic,
students may be able to import the images
directly into the clinic's Dentrix program. Data
will be gathered on the number of patients
seen, the dentists' opinions of the diagnostic
quality of the images, students' opinions of ease
of use, and suggestions from the dentists on ways to improve the outcomes.
Beginning in 2010, NAU's Kiddie Clinic will be able to routinely provide teledentistry-assisted
digital radiographs and appropriate intraoral photographs – all will be acquired by students. The
Spectra caries detection device will be utilized as much as possible; the use may be limited
since NAU only has one Spectra at this time. Additionally, parents can be screened with the
Velscope for intraoral cancer if they choose to participate.

LESSONS LEARNED
Several lessons were learned with integrating teledentistry technology at the 2009 Kiddie Clinic:
1. It became apparent that the small screen on the laptop computer was not conducive for
easy viewing when trying to take intraoral photographs and the thought of utilizing a
projector to project a large view of the computer screen seemed appropriate.

53

2. Too many people present at the event hindered the data acquisition process.
3. Young children tended to bite the occlusally-placed phosphor plates and damaged them.
4. The success of this limited first endeavor to use teledentistry in a “free dental clinic event”
proved that teledentistry-assisted data acquisition is very successful in providing diagnostic
data to the clinic at a much improved and efficient pace. In the future, NAU’s Kiddie Clinic
may be able to serve more children during the one day event with a fixed amount of time for
dental treatment.

54

Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 77
TTeelleeddeennttiissttrryy ffoorr H
Heeaadd S
Sttaarrtt &
&C
Coom
mm
muunniittyy O
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Chapter contributed by:
Northern Arizona University Dental Hygiene Department and
Northern Arizona Council of Governments Head Start

BACKGROUND
Annually, Northern Arizona Council of
Governments (NACOG) Head Start provides
services to more than 1,500 preschool age
children (including 100+ prenatal moms, infants
and toddlers) at twenty-six local centers in four
counties covering 27,000 square miles of rural
northern Arizona. Only eight centers are located
within a thirty minute drive from Flagstaff; the
other centers are located one to more than three
hours drive one way from Flagstaff. Currently,
children living in Navajo or Apache counties who
require specialized services from a pediatric
dentist must be referred to a pediatric provider in either Flagstaff or Phoenix with Flagstaff being
the closest. NACOG Head Start has contracted a pediatric dentist, who has a private practice
located in Flagstaff, as a specialist provider.
Discussions between the Northern Arizona University (NAU) Teledentistry Program
Coordinator/Principal Investigator, the NACOG Health Start Health Services Manager, and the
NACOG contracted pediatric dentist led to piloting a Head Start community outreach model for
teledentistry. A partnership of NAU and NACOG was established to conduct the pilot project in
June 2009. The community outreach model was set up to bring teledentistry equipment to local
United Way of Northern Arizona KinderCamps in Flagstaff. (KinderCamp children include both
Head Start children and preschool children from the Flagstaff unified school district who are
ready to transition into Kindergarten.) A teledentistry team collected oral health assessment
data, delivered preventive care (applied fluoride varnish), stored and forwarded oral data to the
pediatric dentist, and facilitated entry to a dental care delivery system (NACOG Head Start and
the contracted pediatric dentist).

SETUP AND ACTIVITES
As part of the NACOG Head Start and NAU partnership, NACOG’s contracted pediatric dentist
and the NAU Teledentistry Coordinator/Principal Investigator (an Affiliated Practice Dental
Hygienist) established an affiliated practice. This allowed the NAU Teledentistry
Coordinator/Principal Investigator the option of delivering preventive services typically provided
by dental hygienists at the Head Start Kindercamps.
55

Joining the teledentistry team was one of pediatric dentist's newly employed dental hygienists, a
2009 NAU dental hygienist graduate who was trained in teledentistry. She traveled with the
NAU Teledentistry Coordinator/Principal Investigator to the Kindercamps to support service
delivery and brought the store and forward oral health data back to the pediatric dental office.
The pediatric dentist provided medical history and permission-to-treat forms to the NACOG
Head Start Health Services Manager. The Health Services Manager had all of the documents
completed prior to the arrival of the teledentistry team.
The equipment was setup in an empty classroom and
KinderCamp children were brought in for an oral health
assessment. Each child also received fluoride varnish
application. Small chairs and small tables from the
kindergarten classroom were used to accommodate the
children. Parents were not present during the procedures. The
dental hygienist from the pediatric practice had high skills in
pediatric patient-management, which were of significant value
to the teledentistry process of collecting oral health data. Data
acquired included a review of the medical history, questions
regarding the young patients' chief complaints and current home care, a head-and-neck
assessment, charting existing conditions, intraoral photographs, occlusal and bitewing digital xrays. Digital information was transmitted via a store and forward mechanism (along with paper
forms used to record other oral health information) to the pediatric dentist.

OUTPUTS AND OUTCOMES
During two five-hour periods at the Kindercamps, 28 five-year-old patients were seen and all
onsite services originally planned were provided by the teledentistry team.
After the store and forward oral health data (e.g., digital
radiographs and intraoral photographs) and other dental forms
(e.g., medical/dental histories and dental chartings) were
provided to the pediatric dentist, he completed the dental
examinations, made diagnoses, and developed treatment
plans for all 28 children. The parents/primary caregivers of the
children needing further dental treatment were contacted by
the pediatric dental office and the children were scheduled
with the pediatric dentist in his Flagstaff office. The pediatric
dentist believes that the Head Start community outreach
model using teledentistry is efficient and plans to further integrate and expand the use of the
technology in his practice.
The children, with a few exceptions, were very cooperative with the teledentistry team. Those
who were uncooperative were afraid because they had previous and extensive dental
procedures. One child, who was very anxious, asked if we were going to, "give [him] a shot."
The teledentistry team obtained digital diagnostic data from almost all of the children and did not
push procedures for those who were overly anxious.

56

When the teledentistry team began bringing the children in small groups, rather than
individually, the children all behaved more cooperatively. They liked the Nomad X-ray unit,
which we referred to as our camera. Size-one digital x-ray films were appropriate for the
bitewing x-rays, size-two films were appropriate for the occlusal films. All of the children liked
seeing their own and their peers' digital x-rays and intraoral images. The teledentistry team
quickly learned it was appropriate to seat the children in a position so they could easily see their
digital images, which helped keep the children seated in an appropriate position to gather the
data.

LESSONS LEARNED
Several lessons were learned from the Head Start community outreach pilot project:
1. To avoid phosphor plate damage while taking occlusal films, film-holding devices were used
to prevent the children from biting the phosphor plates. This presented a problem in that the
film-holding devices required sterilization for repeated use. A sufficient number of filmholding devices were available so that the process was not hindered. The NAU Teledentistry
Coordinator/Principal Investigator has since purchased Stabe styrofoam film-holding blocks,
which are inexpensive and disposable.
2. During the first screening session, children were brought to the examination area one at a
time; this was time consuming and perhaps a bit frightening for the children. An adjustment
was made in the following session and the children were brought in groups of three, which
was less intimidating for the children and more time efficient for the teledentistry team.
3. A projector was used to display the intraoral images on the wall, which allowed much easier
image acquisition for the operator. This also entertained and engaged the children in the
process of gathering their intraoral photographs.
4. The NACOG contracted pediatric dentist was able to efficiently triaged and diagnosed from
the acquired oral health data (digital data and dental forms) and has began seeing the
children in his dental office to provide needed dental care.

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Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 88
IInnttrroodduucciinngg TTeelleeddeennttiissttrryy TThhrroouugghh aa B
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Mooddeell
Chapter contributed by:
Northern Arizona Council of Governments Head Start

BACKGROUND
Northern Arizona Council of Governments
(NACOG) Head Start, a non-profit organization,
provides comprehensive programming to children
and families throughout Apache, Navajo, Coconino
and Yavapai counties in Northern Arizona.
Program services include dental care for Head
Start children and are coordinated in 26 local Head
Start centers in the four rural counties. One
challenge to providing dental care for preschool
children is access to pediatric dental specialists.
For example, in Navajo and Apache counties, there
are no pediatric dentists.
Children living in Navajo or Apache counties who require specialized pediatric services must be
referred to a pediatric provider in either Flagstaff or Phoenix. Although Flagstaff is the closest,
for some families, a one-way drive can take three hours. Typically, pediatric referrals require a
minimum of two trips: the first trip for a dental examination and the second trip for treatment.
These travel distances present barriers for families in obtaining dental care for their preschool
children:


low income families typically have less reliable transportation to travel these distances
and the travel expense may be a hardship.



parents cannot afford to miss two full days of work in order to travel to Flagstaff.

SETUP AND ACTIVITIES
NACOG’s Vision of Using Teledentistry
Through the use of teledentistry equipment provided by the State of Arizona’s Office of Oral
Health, NACOG Head Start’s proposal was to solicit a Flagstaff, Arizona based pediatric dentist
to provide specialized services in the underserved areas of Northern Arizona. The teledentistry
equipment would enable the pediatric dentist to send out trained dental staff to the local
underserved area on a routine basis.

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The dental staff would provide an oral assessment of the preschool child by collecting data
using teledentistry equipment (including digital radiographs and intraoral photographs) as well
as record other dental data such as a medical/dental history and tooth charting (including
suspected tooth decay, existing fillings, tooth mobility and adjacent soft tissue observations).
Oral data would then be either transmitted real time or via a store and forward mechanism to the
primary office for the pediatric dentist to establish an appropriate treatment plan for the child.
The use of teledentistry technology would eliminate the need for travel to Flagstaff for the first
dental visit and would provide a mechanism for triage and scheduling of the second visit for
treatment.
The pediatric dentist would have the option to schedule the child for treatment at either of two
locations:
1. The primary office – The pediatric dentist can treat the child in his Flagstaff dental office.
2. The remote office – The pediatric dentist can established a partnership with a dentist to
utilize a local dental office (e.g., in Navajo or Apache counties) to deliver treatment. This
local office would mean shorter travel distances for the parent and child. To maximize
efficiency, the pediatric dentist could schedule several children during his treatment day
at the remote office.

NACOG Head Start Service Area
27,000 Square Miles

No pediatric
providers
in Navajo
or Apache
Counties
3-hour drive
(one-way) to
pediatric dentist
in Flagstaff

The figure below illustrates the NACOG Head Start’s current system to obtain pediatric dental
care. A local dentist refers a child to the pediatric dentist in Flagstaff. The parent and child
must travel to the pediatric dental office for an examination and return for a treatment visit. The
figure below also compares this current system to the vision of integrating teledentistry for
pediatric dental care.

59

A Comparison of NACOG Head Start’s
Current System and Utilization of Teledentistry for Pediatric Dental Care

CURRENT SYSTEM

Child referred
by local general dentist
to the pediatric dentist
in Flagstaff, AZ

UTILIZING TELEDENTISTRY

Pediatric dentist
receives referral

Pediatric dentist
receives referral

Oral examination
scheduled in
Flagstaff at the
primary office

Oral assessment
scheduled at the
remote (local)
location

Parent and child travel
3 hours one-way to
pediatric dentist’s primary
office located in Flagstaff.
Examination is completed
and treatment scheduled.

Trained dental staff travel
to remote (local) location
and complete oral
assessment utilizing
teledentistry equipment

Pediatric dentist reviews
data, makes diagnoses,
plans treatment, and
schedules treatment.

Parent and child travel 3
hours one way to
pediatric dentist primary
office located in Flagstaff.
Treatment is completed.

Pediatric dentist travels to remote
site (local provider’s office) to
provide follow-up treatment.
Pediatric dentist provides treatment
to multiple children during the visit.

Parent lost 12+ hours in travel
time for 2 visits. Parent
missed 2 days of work and
incurred transportation cost.

Parent lost minimal time
related to travel and missed
work. Transportation cost is
also reduced.

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Current Relationship with a Pediatric Provider Group for Teledentistry
NACOG Head Start currently has dental service
contracts with twelve (12) dental providers
throughout Northern Arizona including three (3)
pediatric dentists. In 2006, a local pediatric dentist
joined NACOG Head Start’s Health Services
Advisory Committee and his dental group was
contracted as a dental provider – Flagstaff Pediatric
Dentistry (a private practice with three pediatric
dentists). The provider group agreed to support the
NACOG teledentistry project. Several delays
occurred since the initial agreement including a
change in ownership of the practice. In January
2009, the transfer of ownership was completed and
the practice, now called the Around the Mountain
Pediatric Dentistry (ATMPD), continued its support
of the NACOG teledentistry project.

A Need for a Tool to Introduce Teledentistry and to Structure Discussion
In contracting a pediatric dentist for the NACOG teledentistry initiative, the NACOG Health
Services Manager had negotiated with three pediatric dentists over a span of two years. For
each provider, the Health Service Manager needed to have a series of discussions to convey
information about the purpose of the teledentistry project, the vision of how teledentistry can be
integrated into a private practice, and how the pediatric dentist and support staff would use the
technology to improve access to care for Head Start children. As a result, it became evident
that a tool was needed to help private dental practitioners learn and understand how
teledentistry can fit into their practices. The Health Services Manager decided that a business
model should be developed for this purpose.

Developing a Business Model
During this period, discussions and conversations continued on how to best utilize the
teledentistry equipment to create a win/win situation for both the dental provider and NACOG
Head Start. One of the most important questions considered when approaching teledentistry in
a private practice setting is the “WHY?”. The business aspect of private practices will require
the dental practitioners to give full consideration to WHY should teledentistry be integrated into
the practice. Reasons include the following:
1. Business Expansion – In some instances, a provider may be considering expanding their
client base but wants to build up the client base before investing significant startup
capital. The utilization of teledentistry is a way of performing basic clinical services in a
desired market area to establish the dental practice. It is also a way to determine if the
local market will sustain the expansion and provide for the recoupment of the capital
investment over the desired period, such as establishing another “bricks and mortar”
dental office.
2. Enhancement of Operational Efficiency – Another consideration for utilizing teledentistry
is the improvement of overall operational efficiency. This is particularly useful when

61

serving remote clients or when the number of failed appointments is high. By taking the
services to the client instead of expecting
the client to drive significant distances for
basic services can generate higher
appointment compliance. Further, when
serving low income families, reliable and
affordable transportation is often a barrier
to services.
3. Charitable Benefits – A provider may wish
to provide free services at health fairs and
health promotion events. By utilizing
teledentistry equipment, the provider is
able to provide a more thorough
examination and utilize the immediate
results to converse with clients and the
parents of children on dental needs.
While the original concept was to reduce the number of trips the parent and child had to travel to
a pediatric dental practice in Flagstaff for care, the project evolved over time to incorporate more
business considerations including the expansion of the current ATMPD practice into NACOG’s
eastern service region. The plan has continued to evolve into a broader concept with future
plans of having a “bricks and mortar” facility with eventually opening a remote or satellite office
in the eastern service region and someday recruiting and permanently placing a pediatric dentist
in the region.
Having no practical experience utilizing the teledentistry equipment, ATMPD was able to utilize
the Northern Arizona University Teledentistry Coordinator to provide onsite training to staff
during the summer of 2009. The collaboration and partnering between NACOG Head Start
(with ATMPD) and NAU have not only initiated the development of the business model but have
also developed a training protocol for private practices who will implement teledentistry.

OUTPUTS AND OUTCOMES
NACOG Head Start is developing a business model for introducing teledentistry to private
practice. In order for NACOG to make the teledentistry project sustainable for the long term, a
business model is needed in order to substantiate that teledentistry is a financially viable means
to conduct business for the private provider.
One of the primary considerations for the business model is “can you build a plane while in flight
without crashing”. In other words, is it financially feasible to integrate teledentistry into an
existing dental practice without causing negative financial and operational outcomes? Will
existing and future referral sources be threatened by the possibility of services being provided in
their “back yard”?
1. A Business Model Template in Development:
As part of the ongoing process, NACOG Head Start and ATMPD have developed core
questions to be answered during the implementation of teledentistry in a private practice.
The questions are not all inclusive and are only the beginning of a full business analysis
model that is in development. These questions, listed in Attachment 1, are only the
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beginning of what will be used to create spreadsheet data models for future private
providers to use when considering the integration of teledentistry in their practices.
2. Future Plans for the Business Model Template
NACOG Head Start will continue the development of the business model with these next
steps:
 Work with ATMPD and additional providers to answer the questions in Attachment 1
with actual practice financial data. This will lead to the development and
vetting/selection of an Excel spreadsheet data analysis model. It is anticipated that
the model will allow prospective teledentistry providers to load their existing data and
also make certain assumptions. The model can then help dental practitioners make
informed decisions about integrating teledentistry into their practices.
 Develop a marketing video “Introduction to Teledentistry” to inform and educate
dental practitioners.
 Explore and enlist partners to support and develop a “loaner” program for providers
to initiate teledentistry with lower startup capital equipment costs.
 Address policy development to allow teledentistry to advance in Arizona (e.g.,
Medicaid reimbursement policies and practice laws).
By developing and field testing this business model, NACOG plans to have a full model
completed in 2010. Having an operational model in place will allow for the introduction of
teledentistry to other private dentists throughout Arizona. NACOG Head Start will seek out
additional partnerships and collaboration with other teledentistry pilot programs to promote
the exchange of ideas and information to better promote teledentistry.
When the business model is completed along with supplemental spreadsheet for data
analysis, NACOG Head Start anticipates using it to introduce teledentistry to other general
dentists and specialists contracted by NACOG; these practitioners may become additional
partners who will utilize teledentistry in their practices to improve dental access for not only
Head Start children but other underserved populations. In addition, NACOG will share this
business model statewide as a tool to help practitioners in the private and public sectors
learn about teledentistry by considering the business aspects of integrating the technology
into dental practices.
While the current teledentistry project has been focused on the provision of services to
children, the business model will be developed with an “open end” structure that will allow it
to be utilized by dental providers outside the pediatric specialty. Dental professional serving
the geriatric population could utilize the teledentistry business model to explore the provision
of services to resident in long term nursing facilities and assisted living facilities where
access to dental services has historically been limited.

LESSONS LEARNED
Several lessons were learned:
1. The utilization of teledentistry to bridge long distance between providers and patients
opens up possibilities and considerations in how a remote (spoke) dental site should
operate and connect with the primary (hub) site for maximum efficiency. For example,

63

NACOG Head Start and its teledentistry providers will need to consider the “best” setup
of a remote/spoke site in terms staffing, facility, equipment and administrative tasks:
 What will be the ideal dental team at a remote/satellite site and how will they
connect with the primary office or hub site? Will a core 3-staff team be the most
efficient and which combination of dentist, dental hygienist, dental assistant, and
administrative staff will work best with the primary office?
 A preview of each remote/spoke site will provide an advantage in assuring
adequate space for the dental examination/treatment area, access to electrical
outlets, and appropriate furniture for setting up the teledentistry equipment.
 In addition to teledentistry equipment, portable dental chairs and dental lights
may be needed for easier and efficient delivery of dental care services. For
example, taking digital radiographs with the child sitting in a portable dental chair
instead of a regular office chair will improve positioning.
 Having Internet access will allow completing same-day insurance verifications.
Head Start centers can provide online access via their computers but other
community settings may not provide such access.
2. The teledentistry dental team (dentist, dental hygienist, dental assistant and other
support staff) will have a learning curve in becoming competent in the use of the
teledentistry equipment, efficient in the setup of equipment and the dental treatment
area, and proficient in the scheduling and time management of patients in a remote site.
For example, initially the teledentistry team took about 30-45 minutes to complete their
setup to receive the first patient but the process became easier and more efficient with
each child.
3. Implementing teledentistry in a private practice setting took longer because of the
pediatric dentist had time constraints and could only allot limited time for the project
during clinical days. A longer timeline than expected may be needed for planning and
setting up teledentistry due to other clinical demands on the dental providers and
support staff.
4. Teledentistry provides additional options to introduce dental care and manage young
children. For example, Head Start children are at ease in the Head Start centers, which
are more familiar space and surroundings. Further, more points of entry to the NACOG
dental care delivery system can be created by bringing teledentistry equipment and
technology into other remote settings as efforts in community outreach.

64

Attachment 1

A Business Model Introducing Teledentistry in a Private Practice
Data Analysis Questions
The following questions will guide an analysis to compare the benefits and costs related to
integrating teledentistry into a private dental practice. The questions are representative of
general dental practices and do not include additional cost/revenue assumptions that may be
relevant to specialized services.
Question

Pre-Teledentistry

1. Staffing patterns:
a. Dentist
b. Dental Hygienist
c. Dental Assistants
d. Support/Administrative Staff
2. Number of new patients per 30 days being
added to the practice
3. Number of procedures delivered per hour:
a. Dentist
b. Dental Hygienist
c. Dental Assistant
4. Average number of procedures per patient
5.

Total number of work hours available by
category:
a. Dentist
b. Dental Hygienist
c. Dental Assistant
6. Non-Clinical Operating Costs
7.

Clinical Operating Costs

8.

What is the overhead cost per patient?

9.

What is the cost per patient ratio to handle X
number of new patients?
Can you increase number of procedures
provided at remote location without a direct
increase in overhead costs? Does the
increase in procedures delivered provide a
higher rate of return?
How much capital equipment costs is needed
to start up teledentistry in my practice and
what indirect costs are associated – such as
software and computer upgrades?
What is the rate of return for the capital
investment? How long will it take to recover
the investment in the teledentistry
equipment?
Other indirect costs such as training?

10.

11.

12.

13.

65

Post-Teledentistry

Teledentistry in Arizona
S
Seeccttiioonn C
C // C
Chhaapptteerr 99
TTeelleeddeennttiissttrryy C
Coom
mm
muunniiccaattiioonn
Chapter contributed by:
Northern Arizona University Dental Hygiene Department

BACKGROUND
In Arizona, teledentistry was initiated in 2006 with the support of a three-year oral health
workforce grant from the Health Resources and Services Administration (HRSA) Bureau of
Health Professions. During the course of the
grant, five provider sites developed their
teledentistry program. For this early stage of
teledentistry, it is important to communicate
the progress made, lessons learned and
plans for future efforts to a wide range of
audiences who may become supporters in
expanding teledentistry in the state.
Northern Arizona University (NAU) Dental
Hygiene Department, one of the first five
teledentistry providers in Arizona, has
provided communication on their teledentistry
model and experience. NAU’s
communication is educating stakeholders on
teledentistry and building linkages with potential partners.

SETUP AND ACTIVITIES
The NAU communication on teledentistry included presentations at the following events:
1. NAU College of Health and Human Services' Leadership Council Meeting – June 2009
2. The State of Arizona Head Start’s 2009 Oral Health Forum
3. The Arizona Public Health Association’s 2009 Annual Conference
4. Arizona Telemedicine Council Meeting – October 2009
An example of how NAU’s communication can help advance teledentistry in Arizona is the
linkage established with the Arizona Telemedicine Council. The Arizona Telemedicine Council

66

has been created by the Joint Legislative Budget Committee of the Arizona State Legislature
and chaired by the Chairs of the House and Senate Appropriations Committees. The Council
provides oversight for the Arizona Telemedicine Program and the development of its
telecommunications network. When the Arizona Telemedicine Council invited NAU to present
teledentistry at one of their meetings during the fall of 2009, an opportunity presented to NAU to
network with this leadership group and to connect teledentistry and telemedicine in the state.
The NAU teledentistry presentation was well received by the Arizona Telemedicine Council and
its various allied members including the Arizona Senate President Bob Burn. Following the
presentation, NAU's Dental Hygiene Program Chair had the opportunity to discuss teledentistryassisted affiliated practice dental hygiene with Senator Burn.

OUTPUTS AND OUTCOMES
NAU’s communication on teledentistry has resulted in these added linkages:
1. The NAU Dental Hygiene Department has been asked to provide teledentistry-facilitated
oral cancer screenings for the NAU athletes on an ongoing basis beginning in the fall
semester of 2009.
2. NAU has been asked to facilitate teledentistry screenings and services for Coconino
County Health Department. This will engage NAU dental hygiene students in public
health projects for their training.

To further teledentistry, NAU will be gathering data to analyze outcomes and track opportunities
to provide teledentistry services resulting from various communications. A coordinated effort in
communications and building linkages will be explored with the other Arizona teledentistry
providers.

67

LESSONS LEARNED
Several lessons were learned:
1. More communication on teledentistry is needed for providers, program administrators,
policymakers and funders to establish linkages, form partnerships, and build infrastructure
for teledentistry in Arizona. Further coordination with all teledentistry providers in Arizona on
developing key messages will be beneficial in helping a wide range of audiences understand
the teledentistry efforts in Arizona.
2. The current teledentistry providers in Arizona can help allay any hesitation on the part of the
dental community to provide teledentistry services based on their experiences. The
teledentistry providers can share their successes to help acknowledged the advantage of
having multiple dental professionals form a teledentistry team and using available
technology to connect providers and patients over distance to improve access to dental
care.

68

Teledentistry in Arizona
Section D
Future Efforts

69

Teledentistry in Arizona
S
Seeccttiioonn D
D // C
Chhaapptteerr 11
FFuuttuurree E
Addvvaannccee TTeelleeddeennttiissttrryy iinn A
Effffoorrttss ttoo A
Arriizzoonnaa

Future Efforts to Advance Teledentistry in Arizona
Future efforts in the advancement of teledentistry in
Arizona will address these needs as reported by
the initial five teledentistry providers:


Infrastructure Needs: Establish advisory
committee/council; develop linkages with
state leadership, existing oral health
coalitions and other influential
stakeholders; develop provider retention
and recruitment strategies.



Policy Needs: Develop a policy agenda;
clarify practice laws; assess the need of
legislation changes.



Communication Needs: Raise awareness
of teledentistry practice; develop, gather
and provide access to resource materials
for enhancing their practices; disseminate
information to replicate improved access
to care strategies.

Arizona Population Density

New HRSA Grant Supporting Teledentistry in Arizona
In 2009, the Arizona Department of Health Services, Bureau of Women’s and Children’s Health,
Office of Oral Health responded to the HRSA Oral Health Workforce grant announcement and
submitted a program proposal to improve accessibility of oral health services for underserved
populations and areas in Arizona by improving the oral health workforce. A grant was awarded
to Arizona and will begin in FY 2009-2010.
The grant funding will support a 3-year program, Improving Arizona’s Oral Health Workforce
through the Promotion of Enhanced Dental Teams Utilizing Teledentistry Practice and/or
Affiliated Practice. The proposed program goal is to promote and develop enhanced dental
teams, utilizing teledentistry practice and/or affiliated practice, to improve workforce capacity,
diversity and flexibility for providing oral health services to underserved populations and
underserved areas. The program objectives are:

70

1. Build and expand regional/local program development infrastructure;
2. Train providers for enhanced dental teams and increase provider understanding and
competencies for teledentistry practice and affiliated practice;
3. Educate and increase awareness of program administrators, policymakers and funders
about enhanced dental teams and how teledentistry practice and affiliated practice can
increase workforce capacity and flexibility in community settings;
4. Increase the number of enhanced dental teams at the state, regional and local levels;
5. Develop and gather resource materials, tools and lessons to support development of
practice models, making this information accessible to providers, programs and
communities.
Activities will include developing advisory committees to address barriers/challenges for
teledentistry practice and affiliated practice; building linkage with the state’s oral health coalition;
training providers on teledentistry technology; and gaining the support of regional partnership
councils for enhanced dental teams. Activities will also include implementing three
demonstration practice models striving for best practices to serve preschool/school-aged
children and educate their parents/primary caregivers. The program will use communications to
develop support networks, provide resource information on a Website, and share
lessons/successes at the national, state and local levels.
All of the initial five teledentistry providers have committed to being an integral partner of this
new grant program. They will build and support the leadership needed to advance teledentistry
and will work together to address the infrastructure, policy and communication needs of
teledentistry in Arizona.

71

Teledentistry in Arizona
Section E
Appendices

72

Teledentistry in Arizona
S
Seeccttiioonn E
E
A
Appppeennddiixx A
A:: R
Reegguullaattiioonnss

Regulations
The goal of this grant is to provide underserved populations with examination, consultation, and
referral services for both basic and specialized oral healthcare. In addition to the main goal the
grant’s intent is to deliver these services under the state statutes, rules and regulations.
The Arizona Statute 32-1281 for dental hygienists reads as follows:
Article 4 Licensing and Regulation of Dental Hygienists
32-1281 Practicing as dental hygienist; supervision requirements; definitions
Sec E.a dental hygienist shall practice under the general supervision of a dentist licensed
pursuant to this chapter.
Sec I.
#2. “General Supervision” means that the dentist is available for consultation, whether or not the
dentist is in his office, over procedures which the dentist has authorized and for which the
dentist remains responsible.
3) Arizona Revised Statutes 32-1281,
Sec B.
Only a licensed dental hygienist or dentist may perform the following:
1. Prophylaxis
2. Scaling
3. Closed subgingival curettage
4. Root planning
5. Administering local anesthetics and nitrous oxide
6. Placing of periodontal sutures as prescribed in subsection F
7. Examining the oral cavity and surrounding structures
8. Periodontal examination
9. Recording of clinical findings
10. Compiling case histories.
Sec C.
A licensed dental hygienist may:
1. Expose and process dental radiographs
2. Perform all functions authorized and deemed appropriate for dental assistants.
Sec D.
The Board by rule shall prescribe the circumstances under which a licensed dental hygienist
may:

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1. Apply preventative and therapeutic agents, used in relation to dental hygiene procedures, to
the hard and soft tissues.
2. Use emerging scientific technology and prescribe the necessary training, experience and
supervision to operate newly developed scientific technology.
3. Perform other procedures not specifically authorized by this section.
Arizona Statutes and Arizona Administrative code do not directly address teledentistry.
However, both the statutes and rules read together may support the need for teledentistry in a
limited fashion.
Whether a dentist may utilize teledentistry to examine a patient, diagnose a condition to be
treated, and authorize procedures that a dental hygienist may perform and satisfy the general
supervision requirement is not addressed in either the State statutes or administrative code.

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Teledentistry in Arizona
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Reimbursement
The ability of providers to bill and collect fees for dental services provided through teledentistry
is a primary issue for sustaining such models. If reimbursement systems are not in place these
models are not likely to continue.
Reimbursement for telehealth services is limited and reimbursement for teledental services is
almost non-existent. The U.S. Department of Health and Human Services, Centers for Medicare
and Medicaid Services (CMS) administers Medicare and Medicaid programs in the United
States. CMS recognizes telemedicine not as a discrete medical procedure, but rather as a
method for delivering care.
The Medicare program, permits reimbursement for telehealth in rural health professional
shortage areas (HPSAs) in three areas: remote real time patient-to-provider services seen via
live video conferencing; non face-to-face services that can be conducted either through live
video conferencing or via store and forward telecommunication services; and for home
telehealth services. Dental services for Medicare patients are not required of states and
therefore teledental services are not reimbursable under Medicare.
In the Medicaid program, which covers dental services for eligible children, pregnant mothers
and some adults, allows each state to elect whether they will reimburse for telehealth and
teledental services. As such, Medicaid reimbursement for telehealth services varies from state
to state. In 2003, 34 states had some reimbursement for telehealth services. Arizona’s Medicaid
program the Arizona Health Care Cost Containment System (AHCCCS) does reimburse for
telehealth services. Currently there is no policy at AHCCCS that addresses teledental services.

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