The Rise of Digital Dentistry

October 19, 2016

The dentist’s office of the future will have little resemblance to the small private practices that many people visit today: offices staffed by one or two dentists and a handful of hygienists who may have treated the same families for generations. Within a decade, dentistry will become increasingly digitized, flexible and mobile—not just in industrialized countries, but around the world. Dentists who are part of the Millennial generation are already approaching their practice in a vastly different manner than their predecessors. Dentistry is going through a big transition, says Marko Vujicic, chief economist and vice president of the American Dental Association’s Health Policy Institute.

While dentists may continue to spend most of their time practicing in an office, they will increasingly rely on new technologies, cameras, an Internet connection, and greater collaboration. They will need to coordinate with professionals who perform cleanings and take x-rays at schools, in the homes of the sick or elderly, at pharmacies, and in community centers, assisted living facilities or mobile dental clinics.

It is a diverse set of patients with differing needs and motivations who are unwittingly driving these changes to the practice of dentistry, from the youngest to the oldest: children, Millennials, and the elderly. Early intervention has become a major focus, with a strong emphasis on preventing damage to children’s teeth. At the other end of the spectrum, while more elderly people are growing old with most of their teeth intact, many cannot afford dental care or have difficulty getting to a dentist’s office. For Millennials, there are a completely new set of issues: this generation is proving to be less loyal to a specific dentist than their parents have been, and will shop around for a practitioner who charges what they want to pay, is nearby, offers a broad slate of appointment times, and meets their expectations of care.

Together, these various patient populations are moving dentistry towards a more accommodating, on-demand model. Within this new paradigm, there is a greater emphasis on prevention and innovative modes of treatment, which experts say will ultimately reduce cost and bring care to hard-to-reach patient populations.

The Uberization of Dental Care

Consumers increasingly want instant everything, from takeout food and TV shows to taxis, and that list now includes oral health care. “It’s not a matter of if, but when dentistry becomes ‘Uberized,’” says Lynn O’Connor Vos, CEO at greyhealth group, a healthcare communications company.

Vos says that many, especially Millennials, are demanding more convenient dentistry, including evening and weekend appointments. She predicts that soon, some patients will want home visits, which could be possible via telemedicine.

The Millennial generation finds—or changes—a dentist almost as they would locate a restaurant: by reading reviews on Yelp or ZocDoc, says Vujicic. He notes that it’s a growing trend, and many patients do online research before making a choice. “Savvy patients today are looking at quality and cost information before they’re even picking up the phone to call providers,” he says.

It’s a global phenomenon. Filippo Graziani, a periodontist and a professor at the University of Pisa in Italy, says that the percentage of new patients who find him on the web has jumped from about four percent a decade ago to 15 percent today. Having an online presence and using social media to communicate with patients is becoming increasingly important, he says.

An unintentional benefit of “Uberized” dentistry is the impact on those who live far from a dentist—and the importance for older patients. People are living longer, and seniors, along with many people living in rural areas, are often physically unable to get to a dentist. However, Vos says, in many cases, “teledentistry” can help, with a patient or caregiver texting or emailing cell phone pictures of a problem tooth to a dentist, who then may be able to make a diagnosis from these images and recommend the next steps in treatment. Dentists can also use FaceTime or Skype to monitor a patient’s recovery following a serious procedure.

Already, there are examples of mobile dental care in the U.S. Mark Driscoll, a 59–year-old who lives in Montana, is wheelchair-bound due to multiple sclerosis. A dental hygienist visits him quarterly. She brings a “portable dentist” machine that resembles—and is about the size of—a carry-on roller suitcase. Driscoll says the hygienist worked with him to improve his daily oral care habits and helped him find a dentist who was able to handle more complex procedures—like removing his wisdom teeth. “We all deserve a nice smile,” he says.

Another potential way to reach elderly patients is through partnerships with pharmacists, says Ann Spolarich, director of research at the Arizona School of Dentistry and Oral Health. While older adults may not see a dentist consistently, many do go to a pharmacy on a regular basis, she says. Spolarich is currently training pharmacists to counsel older adults on oral health, and envisions drug stores one day becoming community centers for dental care. She pictures a situation where dental hygienists offer basic cleaning and preventative care, along with vaccines, screenings and other minor treatments currently offered at drug stores. “Pharmacists are optimally positioned to partner with dentists,” she says.

Google ‘Gum Disease’

A simple Internet search now gives patients a wealth of information on oral health. Joshua Austin, a 36-year-old family dentist in San Antonio, says it’s not uncommon for his patients to show up for an appointment with their own ideas about how to treat—or not to treat—their dental problems.

Sometimes a patient comes to him for a second opinion, armed with paperwork detailing another dentist’s recommendations. That’s great, he says, because they care about their health and want to weigh all possible treatment options. He welcomes the opportunity to discuss the alternatives. “Any time you empower someone to make a decision, it’s in everyone’s best interest because they have some buy-in and accountability,” he says.

The sheer number of websites and blogs devoted to oral health care has changed the conversation with patients, says Chris Salierno, another Millennial dentist who is based in New York. While he generally finds that background research is beneficial, he cautions that there is a lot of misinformation online. For example, he’s had a “small subset” of patients who cannot be convinced that a root canal doesn’t cause cancer—a myth that patients sometimes stumble across in web searches.

In general, practitioners are trying to encourage people to take a more active role in their oral health. One method uses “motivational interviewing” that asks patients lifestyle questions on diet, brushing habits, whether or not they smoke, and more. This method engages them directly, which is more effective than simply telling patients to brush or floss more, says Colin Reusch, senior policy analyst of the Children’s Dental Health Project. The reason: it empowers individuals to take positive steps to improve their own health, he says, and because of this, motivational interviewing has the potential to shift the paradigm. A study published last year in the Dental Research Journal found that plaque and gum disease were lower in children whose families were engaged in this kind of education. Another recent study, published in Frontiers in Psychology, found that adults who receive motivational interviewing floss more frequently.

Reaching Underserved Communities

The needs of patients have always influenced health care. For example, in the 1960s the Australian government realized that kids, particularly those living in remote parts of the country, did not get adequate dental care and only saw a dentist when they had problems. Building on a model developed in New Zealand in the 1920s, the government soon opened the first dental therapy schools in Tasmania and South Australia, training dental therapists to offer routine care to children. The program then stationed therapists within underserved populations, sometimes basing them in schools to do checkups, cleanings and fill cavities.

Julie Barker, who is the former president of the Australian Dental and Oral Health Therapists’ Association, says she was drawn to the profession because of the focus on prevention and patient education. “When I was a kid, I only went to the dentist when I had a toothache,” she says. “Not once did my dentist tell me that cavities were preventable.”

The success of that model brought the realization that dental therapists could provide services in many other settings, says Julie Satur, an associate professor of oral health at the University of Melbourne. In the 1990s and 2000s, Australia passed legislation expanding the role of dental therapists. Training, which up until then had been done by the government, moved to universities in an “oral health therapist” program that enabled graduates to work autonomously in private practices and to work on adults. Dentists still address patients with more complex needs.

But even those living far from the nearest city in the vast Outback or other remote areas can now get regular care for their teeth: more than 1,000 registered dental therapists and nearly 1,300 oral health therapists now work across Australia. Satur predicts that with increasing demand, that number will only continue to grow.

Both therapists and hygienists are trained to clean teeth, provide preventative care and assess oral health. Dental therapists can typically also perform some restorative work, and may have more autonomy, although their exact roles vary by country. Currently, dental therapists operate in 54 countries, from Canada to South Africa, and Thailand to Hong Kong and the Pacific Islands, predominantly treating children. Europe lacks dental therapy programs, with the exception of the U.K. and the Netherlands. However, some hygienist programs in Europe are now considering expanding their curriculums to include training in restorative care.

In the U.S., the need for affordable, accessible care is real. More than 100 million Americans don’t have dental insurance. Medicaid offers little care for low-income Americans and Medicare does not offer dental coverage for older adults. In 2009, Minnesota became the first state to allow licensing of dental therapists; by April 2016, 56 were practicing. Maine passed a law allowing dental therapists to practice in 2014, followed by Vermont in 2016, and a handful of other states are considering similar rules. Oregon and Washington both have pilot programs. In Alaska, dental therapists work within the Alaska Native Tribal Health Consortium under a federal program. Each of these states stipulates that dental therapists serve primarily underserved populations, working in schools, hospitals, public health clinics, or if in private practices, they must see a certain percentage of low-income patients. A study conducted by the Minnesota Department of Health found that clinics employing dental therapists are able to care for far more patients while providing the same quality of care people would receive in a traditional dentist’s office.

Therapists also serve an educational role. When they were first licensed in Minnesota, Sylvonna Jackson’s parents brought her to a dental therapist for basic care. Sylvonna, who’s now 18, still sees the same woman. She says that in addition to performing cleanings and fillings, she “gave me good advice on what I should do to stay healthy.”

A global review of dental therapy by the W. K. Kellogg Foundation in 2012 found that overall, it’s helped increase access to oral health care. In 2015, 228 dental therapists worked in schools and other public sector practices in Singapore, and in Hong Kong, more than 95 percent of children participated in dental therapist-run school programs. Countries without dental therapists are trying to reach those in need of care through free clinics, the use of teledentistry, and other methods, but in many nations, there is still a big gap.

Flormaria Batista, a doctor of oral medicine at Pontificia Universidad Católica Madre y Maestra in the Dominican Republic, has provided dental care to poor communities for the last five years. “I was surprised to see that the majority of my patients were largely unaware of basic dental hygiene techniques,” she says. Across the country most people do not receive preventative care and only see a dentist when they have a serious problem, which, she notes, “is very detrimental to patients.”

However, there has been a push to promote education, and both private and public institutions are reaching out to low income communities, says Batista. For example, universities have set up inexpensive clinics throughout Santiago, the second-largest city, to provide services at about a third of the cost of a private clinic. Although teledentistry is not yet widespread, Batista says they are exploring ways to utilize technology to reach patients. One possible model is in use in neighboring Puerto Rico, where dentists are using webcams to follow up with patients after they’ve had a tooth removed or had other surgical procedures to make sure they are healing properly, she says.

Many countries lack comprehensive oral hygiene education. In India, a 2012 survey conducted by the Indian Market Research Bureau found that only half of Indians brushed with a toothbrush and toothpaste. The survey also revealed a huge disparity in oral health between urban and rural populations because dentists in India are disproportionately concentrated in cities. There is one dentist for every 10,000 people in India’s cities, but that ratio drops to one in 150,000 in the countryside. The Indian Dental Association is now using traveling dental vans and free dental camps as part of a national campaign to improve oral health by 2020.

With growing global attention on prevention, and dentistry becoming more mobile and flexible in order to better serve the next generation, it is somewhat surprising that Betsy Woodson-Myles, a semi-retired 71-year-old in Washington State embodies the dental patient of the future.

Woodson-Myles prioritizes her health and still exercises five days per week. She does not have dental insurance, but gets regular cleanings for $92 from a hygienist who brings portable dental services to the Anacortes Senior Center, and she visits a traditional dentist when she needs more extensive work. She also takes an active role in her own care, asking her hygienist specific questions about the state of her mouth, like whether her chipped tooth has started to decay. She says her hygienist also informs her about various types of treatment. Woodson-Myles then brings that knowledge to her dentist, which facilitates communication about her options with better understanding of treatment recommendations and those procedures—such as a recent discussion on the pros and cons of getting a crown versus a composite filling. Empowered, indeed.

Credit: Science Photo Library