Bassett Successfully Improves Oral Health Through Teledental Education Visits During Dental Closures
In 2020, the COVID-19 pandemic forced School-Based Health Centers (SBHCs) to quickly pivot to telehealth in order to continue delivering care among the chaos of school closures and ever changing COVID-19 guidelines and regulations. The NY School-Based Health Foundation (the Foundation), with the support of the Mother Cabrini Health Foundation, developed a telehealth technical assistance program to support SBHCs in making the transition. Emerging from the program were many creative uses of telehealth to meet children’s health care needs. Our first ever Telehealth Story Contest identifies some of the most innovative which we are sharing in the hope of inspiring others.
This is the story of how the school-health team at Bassett Healthcare Network creatively utilized telehealth during a year of closure in order to deliver virtual dental care and education for students to improve their dental hygiene. Special thanks to the Dental Hygienist, Catherine Rogers, for her story submission.
Introduction
Bassett Healthcare Network operates 21 school-based health clinics (SBHCs) across three rural counties in New York state: Otsego, Chenango, and Delaware. Their SBHCs offer physical examinations, comprehensive health care, mental health care, and preventative dental services to all students, ages Pre-K through 12th grade, enrolled in the school districts they serve.
Due to the rural nature of Bassett’s SBHCs, delivering dental services to their clients is of particular importance. According to the Rural Health Information Hub, rural communities often lack adequate oral healthcare and subsequently miss out on the benefits of good oral health (1). Several factors have been well documented as contributing to the dental health challenges of rural America including geographic barriers to oral care, low oral health literacy, and lack of fluoridation of water supplies (1).
Knowing these disparities already existed, at the start of the COVID-19 pandemic, Dental Hygienist Catherine Rogers took it upon herself to brainstorm solutions to the growing lack of access to dental care as the state paused non-emergency dental services.
Dental Programs Closed During Pandemic
The COVID-19 pandemic resulted in severe limitation and closure of dental practices across the world (1). This delay in services can be detrimental to individuals’ oral health, particularly for children whose teeth are developing.
“For kids, one of the risks of delayed dental care is abscesses,” said Chad Meyerhoefer, a professor of economics at Lehigh University in Pennsylvania who has researched the economics of health and nutrition, “There have been kids who died of dental abscesses” (2).
According to Professor Meyerhoefer, it is not clear exactly how many children have experienced deteriorating oral health because of school closures. He states in a New York Times article, however, that in rural areas, fluoride, which works preventatively against decay, is often not added to the water (2). As a result, rural students are particularly vulnerable to this lack of access to dental care (2).
While dental programs were closed across New York State, Ms. Rogers was pursuing her certificate in Community Dental Health Coordination. During their last semester, students were tasked with a pilot project. Bassett Healthcare Network’s school-based dentist and Chief, Dr. Leah Carpenter, suggested that Ms. Rogers create a pilot program utilizing teledental.
From there, Ms. Rogers developed the Teledental Visit Program. Since dental clinics had been closed at that point for a few months, it was an ideal time to reach out to Bassett’s school-based health patients who had no access to dental care.
It’s estimated that 1 million Medicaid-enrolled children nationwide rely on schools to access basic preventive dental care (3). “Historically, school-based dental clinics provide dental care for families in underserved neighborhoods who otherwise have difficulty finding access to dentists,” says Larry K. McReynolds, executive director of the Family Health Centers at NYU Langone and a board member of the Foundation.
Echoing Professor Meyerhoefer, Dr. Carpenter discusses how patients in rural areas are especially at risk for dental health problems due in part to the lack of fluoride in well water supplies, and the financial and geographic inaccessibility of regular dental services (4).
When discussing Bassett’s school-based dental program, Dr. Carpenter comments on their commitment to accessibility, “We’re a safety-net program. We see all kids, regardless of their family’s insurance or their parents’ ability to pay,” she said. “Some of these kids have never seen a dentist. The problem was around long before COVID, and COVID obviously didn’t make it any better” (4).
It was over a year before school-based dental was allowed to reopen in New York state (5). According to Ms. Rogers, when Bassett’s services returned, they were primarily using teledental calls to assess patients. If any patient was experiencing dental pain, staff could receive special permission to see the patient in-person in order to take images and properly assess.
However, the reopening dental services was accompanied by extensive guidelines required to start services up again (5). For the patients at Bassett, students were gravely behind on cleaning, resulting in tartar build-up and increased cavities.
Even though services have been reopened for nearly 2 years now, Ms. Rogers finds that her small dental team of three is still playing catch-up, as some students have not been examined in over 2-3 years. With these disparities in mind, the Teledental Visit Program and education that was provided is all the more important to avoid dental problems down the line.
Bassett’s Solution: Virtual Dental Education
Ms. Rogers’ vision for the program was to encourage children to retain a healthy smile during the prolonged quarantine period. With a mission of improving oral health and access to care for underserved students during a pandemic and beyond, Ms. Rogers created the Teledental Visit Program which planned and documented students’ virtual visits to reach these goals.
Ms. Rogers and her team planned to achieve their mission by creating two separate Teledental video hygiene visits one month apart for 10 students in their target group. These students were mostly in 2nd grade and ranged in age from 7 to 9 years old.
The Teledental Visit Program had three main objectives: 1.) To reduce plaque index score by 20% in the target group, 2.) To increase flossing frequency by 20% in the target group, and lastly 3.) To increase nutritional knowledge by 20% in the target group.
To reach these objectives and show measurable results with data, each video visit covered plaque index scores, brushing and flossing instructions, self-reporting flossing charts, and a nutritional fun interactive game.
For their first teledental video visit, students were given various envelopes to address plaque index scores, proper flossing, and dental nutritional information. The first envelope contained a toothbrush, toothpaste, a small cup, and dental disclosing tablets. Disclosing tablets are chewable tablets that stain plaque and show one where they have not adequately brushed.
After opening the envelope, students were asked to brush their teeth as normal and take the first disclosing tablet. Of course, students found they were missing spots while they brushed.
Students were then introduced to Ollie the puppet, who gave them brushing instructions and tips. They then repeated the brushing process using these tips until all of the disclosing tablet was gone.
Next, students opened their second envelope which contained a flosser, flossing chart, and a tooth stamp. Students were asked how often they currently floss, and were given flossing instructions and a demonstration. For the remainder of the month, participants were asked to keep a flossing chart by stamping each day they floss.
Lastly, the third envelope contained a tooth magnet and writing board. Students were asked six nutritional questions with examples and the number of correct and wrong answers were recorded.
A month following their first visit, students completed their second teledental video visit with the same three envelopes, plus an additional fourth envelope that contained a surprise for the participants.
In order to determine improvements to their plaque index scores, students were asked to perform toothbrushing again, hopefully using the tips they learned in their first visit. After brushing, disclosing tablets were used and with the help of parents, plaque index scores were measured once again.
To measure plaque index, the team took the number of plaque surfaces visible on the tooth and divided that by the total number of surfaces. For this program, plaque index scores were calculated using 24 buccal only surfaces as this is the most that can be seen by video and is the easiest for parents to help count. If students were still struggling with brushing, staff offered reinstruction.
For flossing, each participant was asked to share their flossing log during the second visit and flossing reinstruction was provided if needed. Finally, the third envelope contained the same six nutritional questions as the first visit, and students were asked to answer again having learned from the first game.
Ms. Rogers found that the envelopes helped keep students focused on each activity without being distracted by all of the materials they received, “The most engaging process we used and that worked very well was before each Teledental video hygiene visit, each child was given a bag with envelopes containing supplies needed for the visit. These bags were either delivered, sent home or picked up by a parent. These envelopes were labeled by numbers 1 through 3 according to each objective. The fourth mystery envelope was their prize envelope. By opening each envelope of goodies with each objective instruction topic, we were able to keep them focused on that specific topic and they loved seeing what was in each one.”
To recruit their ten students to the program, Ms. Rogers consulted her team to find the patients that would benefit the most from the program. After deciding, she reached out to their parents and, if they agreed to participate, they were sent paperwork along with the necessary envelopes for the activities. While successful, the program did not come without its challenges and lessons, as it was the first of its kind to be introduced at Bassett.
Adjusting the Program to Suit Virtual Care and Overcoming Obstacles
Once the Teledental Visit Program was launched, certain elements of the project were adapted to work better with the students. For instance, Ms. Rogers initially designed the nutritional portion to have ten questions but soon found that number was too many for the age group, so she shortened the list to six questions.
Additionally as mentioned, the plaque index score needed to be adjusted to accommodate the virtual nature of the exercise. Ms. Rogers notes how she had to modify the plaque index measurement almost immediately after starting sessions, as she could not see every tooth even with the help of parents.
Beside this technical limitation of telehealth, the team found that connecting by video had its challenges as well. While staff did their best to troubleshoot with parents if the virtual program was not working, there were times where they had to be flexible and work with what they had available, “We sometimes had to try different emails or connect by video and call by phone for audio. Some parents had to use their phones [for video] which made it a bit more difficult to see.”
Lastly, they faced the ongoing difficulty of scheduling with students and their families. Some parents in the program had to reschedule their second appointment repeatedly, and one family withdrew from the program prior to their second visit. While challenging, Ms. Rogers was able to find another family to participate and completed both visits for the student.
Ms. Rogers and her team were pleased by how attentive students were to their educational materials, however, and attributes this success to how interactive the program was. It helped to have parents monitoring the sessions, but overall, the students were engaged with the program and their oral health reflected that “I was surprised that the kids were very engaged during the sessions. I was concerned about keeping their attention through the computer screen. However, they seemed very into it. It was very encouraging to see the results as well.”
Successes of Virtual Dental Education
After measuring students’ progress between the first and second visit, the dental health team at Bassett Healthcare met all three of their objectives of the Teledental Visit Program. Their virtual brushing demonstrations and tips led to a 50.3% decrease in plaque index scores.
Additionally, the virtual flossing education and flossing chart resulted in a 43% increase in flossing frequency, as students went from less than once per week to three times per week on average of days they flossed. Lastly, students experienced a 30% increase in dental nutritional knowledge following the nutrition question game.
Beyond these tangible results, Ms. Rogers reported that students felt that they really were flossing more and parents enjoyed the disclosing tablet demonstration. Some even tried them themselves.
Furthermore, parents were excited that their children were receiving any kind of dental care during this period and were engaged by their child receiving dental health education when it was needed most. For many parents and students, remote education and virtual health support was a new and interesting concept. Ms. Rogers found that just by explaining to parents what a Teledental hygiene visit meant was enough to gain their support.
While visits are now primarily back in-person, Ms. Rogers and the team at Bassett Healthcare plan on expanding the program, “Currently we are trying to "catch up" with direct patient care; however, we hope to reach out with Teledental visits to more students and schools” in the future.
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