Bringing the Dental School to the Community

Imagine if the pain from a decaying tooth is so bad that you have trouble sleeping or you’re having difficulty eating and your access to dental care is severely limited. You find yourself without a dental home or dental insurance, so you endure the pain for as long as you can, but the pain is now affecting your mental and overall physical health. For millions of Californians, this is their reality.

The numbers are dismal for the Golden State. Over 54 percent of children have tooth decay by the time they start kindergarten, increasing to over 70 percent by third grade. It is estimated that school-aged children miss 874,000 days of instruction each year due to dental problems, costing districts $29 million due to a reduction in attendance rates. Roughly 65 percent of pregnant women don’t receive dental care during their pregnancy. In 2012, the latest data available, there were over 113,000 visits to emergency rooms due to preventable dental conditions.

Unfortunately, oral health is not perceived as an important component of overall health until pain occurs and coupled with inadequate access to healthcare, many Californians are left with nowhere to turn.

Professor of public health and community dentistry, Dr. Jim Crall, has spent the majority of his career working to improve access to care, focusing largely on children and pregnant women. In 2013, with funding from the child advocacy and grant-making organization, First 5 LA, Dr. Crall, and his UCLA-First 5 LA team set out to increase access to dental and oral health services for children ages 0 to 5 to reduce the risk of tooth decay. The team focused on underserved communities, which traditionally have large numbers of low-income Latinos and African Americans. Through relationships with 22 community clinics, more than 75,000 preschool-age children in Los Angeles County received dental and oral health care – 30 percent over the initial target.

“By redesigning how our affiliated community clinics were operating, we were able to successfully double, and in some cases, triple their capacity to serve patients,” said Dr. Crall. “Our work, through the First 5 LA partnership, improved how the community clinics delivered oral healthcare to young children, increased parents’ and caregivers’ awareness of the importance of oral healthcare for young children, and developed a sustainable community-based ‘dental home’ model for improving the entire system.” 

Following the success and achievements of the UCLA-First 5 LA program, Dr. Crall’s team was selected as the lead entity for a Los Angeles-based dental pilot program under the Medi-Cal 2020 Dental Transformation Initiative. The program, which is administered by the California Department of Health Care Services, awarded funding to 14 programs throughout the state to expand preventive dental care and disease management for children enrolled in Medi-Cal, California’s Medicaid health care program. Through this initiative, UCLA and its consortium partners aim to improve oral health services for 500,000 L.A. County residents, ages 0 to 20.

The UCLA-led Dental Transformation Initiative entered the public phase this spring and focuses on three primary goals: using information technology to enhance the quality and continuity of care; developing new ways to expand preventive and disease management services within clinics, private practices, and community settings; and integrating oral healthcare services across dental, medical, and community providers.

“Our First 5 LA-funded work in Los Angeles revealed a much bigger problem that exists statewide,” said Dr. Crall. “Our UCLA-First 5 LA project and this new initiative with the Department of Health Care Services are important steps toward improving the systems that underserved Californians depend on to provide access to care, but much more remains to be done.”

According to the Centers for Medicare and Medicaid Services, only about one-third of California’s 6.1 million children and adolescents enrolled in Medi-Cal receive preventive dental care each year. Preventive services not only help maintain good oral health, but they also help reduce the need for costly treatment for tooth decay and cavities in hospitals and emergency departments. The California Healthcare Foundation found that the average cost of a preventive dental visit was only about one-third of the median cost of emergency treatment.

“Identifying the shortcomings in the operations at community clinics across Los Angeles County is just one piece of a much larger puzzle,” said Dr. Paul Krebsbach, dean of the UCLA School of Dentistry. “Several other barriers exist in California’s healthcare delivery system that need to be addressed before we can truly start to provide the care that everyone in this state should be receiving.”

One-third of California’s population is low-income and over half of the State’s children are covered by Medicaid. For those fortunate enough to have access to government-funded dental insurance, finding a dentist who accepts it can be difficult. Often times, the dentists who do accept their insurance do not have available appointments for weeks, if not months, ahead.

There aren’t enough providers practicing in federally qualified health centers, tribal clinics, dental service organizations, and private practices that treat underserved patients. Nationally, only 2 percent of the graduating dental workforce pursue a career in public health centers, roughly equating to 3,000 dentists serving 10 million people. By 2020, experts estimate that 40 million people will be in need of care, with a sizeable portion of those people living in California. Currently, it is estimated that 1.7 million California residents live in areas that have a shortage of dental care providers.

“To even come close to serving the oral health needs of the U.S. population, 20,000 dentists practicing in public health settings would be required – or almost seven times what we currently have,” said Dr. Bill Piskorowski, health sciences clinical professor of public health and community dentistry and associate dean for community-based clinical education.

Increasing Access to Care through Community-Based Clinical Education 

With a goal of improving access to care, and introducing predoctoral students to the idea of a career in public health, UCLA Dentistry has launched a new program called the Community-based Clinical Education program (CBCE). “The premise for this model is simple,” said Dr. Piskorowski, the program’s director. “Instead of bringing the patients to the dental school, we will be bringing the dental school to the community.”

Starting in March, the dental school began sending a group of fourth-year predoctoral students to five community clinics located throughout Southern California, including San Fernando, Palm Desert, Northridge, Venice, and El Centro. The first group began a 2-week rotation where they performed a wide array of services, including patient education, cleanings, fillings, dentures, and extractions.

The School estimates that in the program’s first year, the D4 students will be able to treat roughly 9,000 patients through partnerships with public health centers and affiliated community clinics. The patient population that the CBCE program is targeting includes those living at or below 200 percent of the federal poverty level, those struggling with access to care, and those who are covered by Denti-Cal. By 2022, the goal is to be able to treat over 20,000 vulnerable patients and eventually grow the rotation from two weeks to eight weeks.

“The CBCE program is developing an ethic of caring that many don’t get to experience and allows our students to explore a non-traditional and rewarding career path,” said Dr. Lisa Nguyen, CBCE program administrator. “Our students can help tackle the access to care problem and help thousands of underserved patients while gaining experience that will help them to be successful in their careers post-graduation.” 

This new model mimics a proven model from the University of Michigan (U of M) School of Dentistry’s Community-based Dental Education Program. In the past 10 years of the U of M program, the number of dental school graduates choosing to enter the public health field increased six times to roughly 12 percent of the last graduating class surveyed. The U of M model, which was launched and developed by Dr. Piskorowski, has been replicated several times over at dental schools across the country, all with successful results.

“An important feature of this model is that it is a self-supporting program,” said Dr. Krebsbach. “This is a win-win-win situation. Affiliated clinics gain the ability to see more patients. Our students gain valuable clinical experiences. Patients and the greater community experience improved overall healthcare.”

To ensure the quality of care at the satellite clinics is up to par with the dental school’s standards, an evaluation system has been put in place. Through a secure, cloud-based network, instructional preceptors and program administrators are in continual communication. The data generated will be used to improve patient care protocols and enhance the operations of affiliated satellite clinics.

“We hope to become a conduit of evidence-based information between experts and clinicians at remote locations,” said Dr. Piskorowski. “By enhancing education, we are improving systems and in-turn elevating the quality of dental care for vulnerable populations.”

Among the many benefits and anticipated positive outcomes of the CBCE program is the collaborative care approach. Current knowledge shows that oral health is linked to chronic disease, such as cardiovascular disease and other systemic health disparities. By having dentists work alongside primary care givers at centers with co-located services, providers can collaborate on cases. For example, sometimes symptoms appear in the mouth that only a dentist would spot, but the need for further assessment by a doctor is then required.

“Collaborative care is the future of healthcare delivery,” said Dr. Steve Lee, health sciences assistant clinical professor and CBCE program administrator. “This new program encourages both intraprofessional and interprofessional education and training, where our students are providing care within a health center and not just a dental clinic. They will be interfacing with dentists, dental hygienists, physicians, nurses, and social workers.” 

Dr. Lee also chairs the Systems-Based Healthcare course that is offered at the dental school in conjunction with the David Geffen School of Medicine at UCLA and the UCLA School of Nursing. The course is required curriculum for all third year dental students.

New additions to the UCLA model that didn’t exist at the U of M model include teledentistry and telementoring, two technological advancements that have changed the way dentists treat patients and the way dentists interact with each other. Teledentistry is one solution for a lack of providers in a remote area. It allows for patients to receive services by non-dentist providers, such as registered dental hygienists in alternative practice, under the supervision of a dentist, physically located elsewhere.  

“Telementoring can be helpful with specialized services, such as pediatric dentistry and hospital dentistry. Take a remote city like El Centro for example,” said Dr. Nguyen. “There may not be many pediatric dentists in the area, and the local general dentists may not feel comfortable providing the specialized care that toddlers and young children need. Telementoring allows a pediatric dentist from Los Angeles to guide a general dentist in delivering care to children in El Centro without physically being there.”

The CBCE rotation is meant to be the capstone of dental students’ careers and also a way to enhance the dental school’s current in-house training model. There is no better way to successfully transition dental students to real world scenarios than to provide hands-on experiences in the community. 

“We want to produce well-trained dentists who have a diverse portfolio of experiences,” said Dr. Krebsbach. “Our graduates will leave UCLA with the confidence and skills to take on any case that they are presented with, regardless of whether they go into public health or private practice.”

This model has proven that organizations that embrace the academic thread, through partnerships with institutions of higher learning, can attain outcomes that are more predictable and more productive. UCLA’s ultimate goal is to develop an anticipated, sustainable program with proven positive outcomes that can be disseminated and adopted by dental schools across the country. 

“We are finding solutions for people who can’t help themselves,” said Dr. Piskorowski. “The added benefit is that this program reminds our students why they got into healthcare in the first place.”