To combat the extremely high rate of tooth decay among children in the state, a pilot teledentistry program on the Big Island and Maui is bringing dental treatments directly to kindergartens and other early childhood education locations.
“The dental hygienist goes to the location, takes pictures, does a quick assessment, shoots the pictures back to the dentist, and the dentist looks at it and comes up with a treatment plan,” said Joey Gonsalves, executive director at Hui No Ke Ola Pono, the Maui Native Hawaiian Health Care System that implemented the program on Maui.
The visit may also include brushing your teeth and applying a fluoride varnish to prevent cavities.
The pilot program is supported by the Hawaii Dental Service Foundation, HMSA Foundation, and funding for three-year grants on each island totaled nearly $900,000, according to the Hospital & Community Dental Services Branch of the Hawaii Department of Health.
Since 2016, the West Hawaii Community Health Center sends its teledentistry team twice a year to early education locations along the West Coast of the Big Island, from Waimea to Kealakekua.
“A lot of the kids are more cooperative, being in their normal environment in kindergarten,” says John Gawlik, a pediatric dentist at the West Hawaii Community Health Center.
More than 1,000 photographs and X-rays have been taken of children’s developing teeth at Head Start Kindergartens, Women’s Infant and Children’s Centers, and the Tutu and Me campuses. And if necessary, follow-up appointments with pediatric dentists are made.
A huge weight has been lifted from parents’ shoulders, says Steven Pine, who oversees the program on the Big Island as dental director of the West Hawaii Community Health Center. Many families he sees on the Big Island don’t have a car or can’t take time off from work to take kids to the clinic, especially since a visit to the dentist can take all day.
Because of the challenges, Pine and other dentists tend to see children when the situation has become serious. Cavities and other dental conditions often do not cause pain until they are in an advanced stage.
“If we wait for kids to feel pain, we’re not being proactive enough,” Pine said. “By capturing these children when they are young and educating the families about good oral hygiene, we can hopefully correct these problems before they arise.”
It is recommended that children see a dentist by the time their first tooth comes through or by the time they turn 1 year old.
A screening study conducted by DOH and the Hawaii Primary Care Association in 2015 among third graders showed that Hawaiian keiki has the highest prevalence of tooth decay in the country.
About 71% of Hawaii’s third graders suffer from tooth decay, compared to the national average of 52%.
The Hawaii Smiles report also found that nearly one in four Hawaiian children were found to have untreated tooth decay.
Children living in Hawaii, Kauai and Maui counties were more likely to have tooth decay than their Honolulu counterparts, and the disparities in oral health widen when income and ethnicity are taken into account.
The same report found that Micronesian, Native Hawaiian, Guamanian, Chamorro, Samoan, Tongan and Filipino children are significantly more likely to have untreated tooth decay compared to white, Japanese, Chinese and Korean children.
Most youth in Hawaii have health insurance. More than a quarter of children in Hawaii rely on Medicaid or QUEST (CHIP) health coverage.
Still, oral health can easily be dismissed as unimportant, said Deborah Zysman, executive director of Hawaii Children’s Action Network.
“It’s not an insurance issue here, it’s other access to health care issues that we’re looking at,” she said. “That is why we advocated teledentistry. That is cheaper and more effective.”
“There are links to all sorts of other health issues down the line,” she added. “There are also links with absenteeism due to illness. And then there’s the financial cost of having to fly a kid from a neighboring island (to Oahu), put them under anesthesia, and do extractions, which is really traumatic for a kid.
State budget cuts, lack of fluoridated water
The X-rays and X-rays taken at school have enabled dentists to catch cavities between teeth, which indicate a lack of flossing. Dentists like Gawlik have also been able to identify cases of ankyloglossia, when the tongue attaches too tightly to the floor of the mouth, which can hinder the way children eat, speak or breastfeed.
Due to the economic downturn in 2009, the DOH’s Dental Health Department was disbanded, ending school screening and the use of fluoride to prevent cavities. That same year, the state stopped paying for non-emergency dental care for low-income adults.
Another cause of poor oral health is the lack of fluoridation in Hawaii’s water, says Pine. The state of Hawaii does not mandate fluoridation, and only 11.7% of the population is served by a public water system that is fluoridated, compared to three-quarters of the total U.S. population that receives fluoridated drinking water through community water systems.
The Hawaii Department of Health is expanding telemedicine initiatives across all islands as dental and other medical services are concentrated on Oahu. In 2017, Hawaii law changed to require Medicaid to cover telehealth services.
But the teledentistry program is still entirely dependent on grants, and Pine says WHCHC is still working out a fee structure with insurers. The subsidy stream for the pilot project will expire at the end of this year.
“There have been a lot of questions about what that compensation structure will look like,” Pine said. “We are still working with our partners to make this a sustainable program.”
When the “Virtual Dental Home” made its way to Maui in 2017 thanks to a grant extension, the program partnered with organizations that serve both seniors and children. A study from the University of Hawaii found that once people reach the age of 80, they go to the dentist less often.
Partner organizations include Hui No Ke Ola Pono, Maui Family Support Services, the Maui Economic Opportunity, and the WIC Program, or the Special Supplemental Nutrition Program for Women, Infants, and Children.
“Before that, it was very difficult to get dentists to admit our residents,” said Wesley Lo, CEO of Hale Makua Health Services, which provides senior care at two nursing home locations on Maui. “It’s really great because they’re comfortable, they get regular cleanings, and actually our staff is trained to help with oral hygiene.”