Lummi Tribal Health Clinic Uses Telehealth to Expand Dental Access

Innovative Teledentistry During COVID-19

During the COVID-19 pandemic, the Lummi Tribal Health Clinic is employing an innovative teledentistry model that can serve as a guide for other health advocates engaging in this work.

About the Lummi Tribal Health Clinic’s Model for Teledentistry

COVID-19 has exposed the many existing holes in our health care and other social safety net systems; it also has exacerbated existing barriers and inequities in access to dental care and oral health.

As advocates across the country continue to seek out best practices for maintaining access to care during the COVID19 pandemic, especially for underserved communities, teledentistry offers one opportunity for maintaining access while clinics and offices are closed and for expanding community-based dental care in the long-term.

During this pandemic, the Lummi Tribal Health Clinic is employing an innovative teledentistry model that can serve as a guide for other health advocates engaging in this work. More information about Lummi’s model is included below, along with resources to learn more.

Why teledentistry, both now and post-pandemic?

Teledentistry methods offer people the ability to be evaluated, to get expert advice from their provider and to receive some basic care without needing to leave their home or make it to a clinic or dental office for an appointment.

This offers protection from exposure to COVID-19 in the short-term and can expand the reach of the delivery system and help more people get access to timely care in the long-term.

In combination with universal, comprehensive coverage and the availability of community-based care by dental therapists, teledentistry can be part of a robust dental delivery system that meets people where they are.

How the Lummi Tribal Health Clinic uses teledentistry during COVID-19

The Lummi Clinic uses a combination of: (1) Video visits between a patient and a dentist based in the clinic and (2) Teams of “runners” who conduct no-contact visits to patients’ homes and/or their vehicles parked in the clinic lot.

Dentists remain on-site at the dental clinic and communicate with patients via video chat. Runners are equipped with iPads pre-connected to a mobile wifi unit with the video appointment already running, intraoral cameras pre-connected to iPhones, and various pre-made dental packs constructed for common oral health issues.

When a patient calls the dental clinic, a dental assistant or dental therapist assesses whether in-person emergency care or a teledentistry appointment is appropriate (dentists are nearby to help assess if needed). During this initial call, patients are also screened for symptoms and risk of COVID-19. If a patient is deemed high risk, the front desk staff coordinate with the medical team to triage the patient for testing and/or appropriate medical treatment.

If the patient is assessed as being a good fit for a teledental visit, a Zoom video chat appointment is created. At the time of the appointment, a runner either drives to the patient’s home or meets the patient in their vehicle in the clinic parking lot.

From their vehicle, the runner connects the iPad to the mobile wifi unit, starts the video meeting, connects the intraoral camera to the iPhone and tests that all of the technology is working. The runner then covers the devices (iPad, iPhone and wifi device) with plastic to keep them sanitary, places them into a bin and delivers the bin to the patient’s doorstep. The runner then goes back to their car, allowing the patient to retrieve the devices without contact.

As the runner has already started the video appointment, the patient simply needs to pick up the iPad and can immediately start talking to the dentist. The dentist begins the virtual appointment, where they can talk with the patient over video chat on the iPad and instruct the patient to use the iPhone with intraoral camera to take photos of the affected area.

The dentist can view those photos and provide a diagnosis via video chat. Depending on the diagnosis, the patient may be scheduled for an emergency in-clinic visit or be instructed on at-home care.

If prescribed by the dentist, the runner may drop off a pre-made dental pack (in the same no-contact fashion as noted above) with materials and instructions for at-home care.

Dental packs are created in the clinic prior to the teledentsitry appointment and runners have the most commonly-needed packs in their vehicle at the time of the visit. This enables the runner to supply needed materials to patients, based on the dentist’s diagnosis, without needing to return to the clinic.

The dentist and patient remain on video chat throughout the process so that patients can ask questions and receive real-time instructions. Dentists also remain in regular communication with runners via text message or phone call.

Types of teledentistry services offered

Patients can self-administer (with the help of real-time instruction from the dentist) a range of basic care using the pre-made dental packs that runners deliver.

Whether a patient is administered a pre-made dental pack and which pack to provide is determined by the dentist during their video consultation with the patient and communicated to the runner via text message.

All packs include limited quantities (i.e., enough to treat one tooth) of gloves, safety glasses, toothbrush and toothpaste, floss, iodine, fluoride varnish and dental napkins, as well as detailed written instructions with photos, and a trash bag for used and unused materials to be returned to runners for proper disposal. Additional items included in each specific pack depend on the diagnosis.

If the dentist determines during the teledental visit that the patient’s oral health needs are beyond the scope that can be covered via a teledental visit, the patient will be scheduled for an in-person visit at the dental clinic for further evaluation and/or treatment; this can be scheduled in real time during the video chat.

Pre-made dental packs

Specific packs include:

Dental decay/temporary filling pack: Silver diamine fluoride to temporarily treat decay and desensitize before placement of a temporary filling

Dry socket pack: Antiseptic medication and irrigation syringe;

Periodontitis pack: Antiseptic medication and irrigation syringe;

Dental hypersensitivity pack: Desensitizing medication and Sensodyne toothpaste

Denture pack: Fixodent, denture brush and cleaner.

Other: Antibiotics, chlorhexidine (an antiseptic medication) and oral analgesics can also be provided to patients by the runner. Prevention packs are also used, particularly for children, to offer advice for home care and provide essential supplies.

Does the Lummi Tribal Health Clinic employ dental assistants or similar professionals?

Yes, in addition to dentists and hygienists, the Lummi Health Clinic employs dental assistants, expanded function dental auxiliaries (EFDAs) and dental therapists. Many Lummi staff, including some dental assistants, EFDAs and dental therapists, have been reassigned to act as runners.

Dental therapists assist with urgent teledentistry appointments, teledentistry exams and conduct motivational interviewing with patients prior to in-office care. Dental hygienists and dental therapists also provide follow-up and oral hygiene appointments using teledental technology to further reduce the need for in-person emergency care.

Obtaining informed consent from patients

Upon initiating the teledental appointment via iPad, the first thing the provider does is obtain verbal consent. The dentist informs the patient that teledentistry is limited in scope and is not a substitute for longterm, in-clinic or definitive care. After the patient verbally consents, the appointment begins.

While patients are informed that teledentistry is being used in its current form as a temporary solution during COVID-19, the Lummi Clinic will continue using teledentistry to provide care, help prepare for in-person visits and to improve efficiencies even after the clinic re-opens broadly.

After scheduling a teledental appointment, patients also receive a flyer via email that contains information about what to expect during their appointment. Staff also review instructions with patients when a confirmation call is made the day before the scheduled appointment.

If silver diamine fluoride is to be used, a written consent is given to the patient and the patient is asked to sign and return the consent.

Technology used for teledentistry at the Lummi Tribal Health Clinic

Zoom software is used on iPads for video chats between providers and patients. Additionally, iPhones are outfitted with intraoral cameras that patients use to photograph symptomatic areas. Providers can then view photos in iCloud. Outlook calendars are also used to schedule and track appointments and providers access pre-obtained patient information through the Outlook calendar.

Resources

Lummi Teledental Workflow (PDF) — Provides an overview of the clinic’s process for scheduling and completing a teledental appointment

COVID-19 and Teledentistry (YouTube)— Indian Country ECHO webinar recording featuring representatives from the Lummi Tribal Health Clinic

Questions?

Reach out to Kasey Wilson, policy analyst, Dental Access Project.