Chapter 6. Dental Care Models:
A Range of Options
This chapter will describe a variety of
models for providing clinical care in the community to young
children, including examples of programs. Models include community
clinics (both with and without a medical component), hospital-based
programs, private practice-linked systems, mobile vans and
trailers, portable dental equipment, and teledentistry. Indications
for their use, benefits and limitations, cost issues, and
logistics will be covered.
of any dental care delivery model
is to get an appropriate mix of
quality services to those who
need them in a timely manner.
A secondary goal is to reduce
care-seeking for dental problems
at inappropriate places such as
hospital emergency rooms.
Many places in the US, particularly rural
communities, lack coordinated systems of care that are linked
to other community services. Yet today there are more options
for financing, new preventive services and dental materials,
and different modes for delivering care than in any other
The models of dental care delivery described
in this chapter should not be considered as "all or none"
options. Each has its advantages and disadvantages for different
communities and populations, and they can be used in combination.
For example, a private practice office might use portable
equipment to provide a certain level of care in the local
nursing home or to place sealants in a school setting. A community
clinic might use a mobile van to outreach to isolated areas
or to migrant farmworker camps.
The key to creating
a successful and coordinated dental care system is to carefully
assess the needs of the different population groups in your
area; consider the geography and climate; decide which needs
are not being met; assess your financial and personnel resources;
determine what system(s) can best meet those needs; and identify
what realistically can be done with existing and new resources.
Demographic variables are important but
sometimes difficult to predict, e.g., influx of retirees,
young people leaving to work in urban areas, business closures
that cause an out-migration or increased numbers of families
on welfare, immigration of non-English speaking populations
because of job opportunities.
Self-Assessment: Inventory of Existing
Populations and Dental Care Models
Any needs assessment of a community should
include an inventory of the existing populations and the dental
care models. Plotting these by location will help in analyzing
any gaps in coverage. Location of services, alone, however,
does not indicate availability of services to all populations.
The type of practice and financing mechanisms also need to
be assessed (see chapter 10 for financing options). List the
resources in your area using the self-assessment Plotting
Existing Clinical Resources. Then analyze these resources
for apparent gaps using the Worksheet:
Identifying Gaps in Dental Services.
Types of Programs
Private Practice Office
Ninety percent of dental professionals
in the US practice in private practices because of the desire
to be an independent practitioner. Of the approximate 23,000
active dentists in California, about 81% are in general practice
(do not formally limit their practice to a specialty). Most
practices are dentist-owned, and they operate as any other
private business. Overhead costs for equipment, supplies and
staff are high, usually 60-75% of total income, much higher
than physicians' offices. Some private dentists have formed
group practices where there is a mix of general dentists and
one or more specialists such as endodontists or orthodontists.
See the California Dental Association website (http://www.cda.org/public/dentalcare/patguide.htm)
for descriptions of these specialties and the basic functions
of staff. Staffing usually includes one or more dentists,
dental assistants (DA, RDA and/or RDAEF), dental hygienists
(RDH, RDHAP), and office managers or receptionists.
Care is provided in separate rooms called
dental "operatories" or sometimes in an "open
bay" layout without intervening walls. Because of the
high overhead costs, scheduling services to maximize productivity
is important. Some practitioners may block certain times for
children so they can plan for that mix and level of services
and the number of people sitting in the waiting room. This
is an efficient way to schedule Head Start populations as
a group and to allow substitutions if a child is absent from
school. Some laboratory services (e.g., dentures, crowns)
may be performed onsite while others are sent out to a dental
laboratory and returned to the office for insertion. Financing
is typically mostly private pay or insurance, supplemented
with other local or state sources such as Medicaid (Denti-Cal
in California) or the Children's Health Insurance Program
(Healthy Families in California). In California in 2003, less
than 50% of private practice dentists were active Medicaid
providers (saw 1 or more patients per year).
Examples of Programs
- Some providers "adopt" a local
Head Start program to provide needed care to those children.
- Some dental offices take a family approach
and will only see children if their parents are patients;
this provides a focus for education and continuity of care.
- A number of programs provide a referral
and case management approach (see Chapter 5), asking local
dentists to see a limited number of children and matching
their criteria to specific children's needs. Share the Care
Program in San Diego conducts a very successful program
where volunteer dentists are matched with children needing
urgent dental care. See their website at http://www.sharethecaredental.org/website/getting_involved/index.html
Another example is the Donated Dental Services Program.
In this program, volunteer dentists agree to accept a certain
number of needy patients each year who are disabled, medically
compromised or elderly to treat in their offices where they
can work more efficiently with their own equipment, supplies,
and staff. Although the focus generally is on older patients,
this could be a resource for young children with special
health care needs (see Chapter 5 for more details.)
- In some states, dental schools or dental
hygiene programs place students in private practices as
an extramural rotation, with the dental care providers acting
as mentors and adjunct faculty. Often these students will
see young children, especially those who are eligible for
Medicaid or other public assistance. The University of Colorado
is one state where this has been used extensively in the
past with both dental students and dental hygiene students.
- Many dental societies ask their members
to provide free or reduced care on a certain day or during
one week each year. Give Kids a Smile is a national program
held annually, sponsored by the American Dental Association
and others, that works primarily through private dental
practices to examine and treat children who "fall between
the cracks" in healthcare. "The overarching concept
of the initiative is to create a national umbrella for the
numerous charitable education, screening, prevention and
comprehensive treatment programs already in existence by
having as many of them as possible occur on the same day.
At the same time, the campaign will provide a framework
for identifying, cataloging and recognizing the many access
programs that take place throughout the year." View
a description of the program at http://www.ada.org/prof/events/adaevent/kidssmile/kidssmile2.html.
Thousands of California dentists signed up to participate
in this program in 2003 and 2004.
Community clinics serve as the primary "safety net"
for uninsured and underinsured individuals. They can be
established and funded in a number of ways. Start-up costs
for constructing and equipping a 3-operatory clinic are
about $437,000. A fixed facility-a stationary building--generally
is a preferable place to provide care
because it is an integral part of the community
and often can be co-located with other health and support
services. It also provides space for records and storage of
supplies. Continuity of care is easier to achieve since services
are provided in one place. A fixed facility, however, may
not be accessible to isolated populations, especially if transportation
is a problem or if families can't take time off work to access
care. Clinics generally are built similar to private practices,
with dental operatories or an open-bay design. They may, however,
share a waiting room, record room or receptionist with other
health or social services.
The Community Health Center (CHC) Program is a Federal grant
program funded under the Public Health Service Act to provide
for primary and preventive health care services in medically-and
dentally underserved areas throughout the US and its territories/jurisdictions.
CHCs can have special designations and funding for migrant,
homeless, and rural care. The Migrant Health Program (MHP)
of the HRSA Bureau of Primary Health Care provides grants
to community non-profit organizations for a broad array of
culturally and linguistically competent medical and support
services to migrant and seasonal farmworkers (MSFW) and their
families. The MHP currently provides grants to 125 public
and private non-profit organizations that support the development
and operation of 400 migrant clinic sites throughout 40 states
and Puerto Rico. In 2001, Migrant Health Centers served over
650,000 migrant and seasonal farmworkers. To learn more about
this program, go to http://www.bphc.hrsa.gov/programs/MHCProgramInfo.htm.
CHCs can be a "catalyst
for economic development, generating jobs, assuring the presence
of health professionals and facilities in underserved areas,
and utilizing local services. In FY 2000, the CHC investment
generated over $3 billion in revenues for impoverished underserved
communities across the country." In 2000 only 25% of
CHCs in California had a dental component, but that is increasing
with the Bureau of Primary Health Care's new initiative on
The Indian Health Service
funds clinics to care for American Indians and Alaska Natives
in rural areas or on reservations. They usually are staffed
by federal and tribal employees. Tribally run clinics also
use similar clinic models. Payment for many of these services
is subsidized by the Indian Health Service or the tribe, and
supplemented with fees or third party payments.
Federally funded clinics are reimbursed on an "encounter
system" vs. a fee-for-service system and are sometimes
limited to how many types of procedures can be done in one
visit. They generally are required to collect and track information
on their patient services and thus have a good idea of the
demographics of their entire patient population. Their mission
and operation are based on a population approach, with varying
levels of service and, it seems, an ever-expanding pool of
Other types of community clinics may be funded by city, county
or local government; operate as satellites of dental schools;
or may be run by non-profit organizations and funded from
multiple sources. These programs usually start off as small
clinics (2-3 chairs) and expand as demand increases and additional
funding is sought. Some of these organizations establish full
or part-time satellite clinics that function under one umbrella
organization, and may rotate staff among the sites.
When planning for
a community clinic, try to envision if expansion will be needed
when you are constructing or renovating a facility.
Examples of Programs
- San Ysidro Health Center (SYHC) has
been providing quality, low-cost, primary health care services
to South Bay residents for over 32 years. In addition to
the main health center in San Ysidro, SYHC maintains satellite
clinics in Chula Vista and National City that are conveniently
located and easily accessible using the public transit system
- bus or trolley. SYHC offers an extensive array of family-oriented
primary health care services, including dental services.
Since 1999 the Health Center has partnered with the UCSF
Department of Pediatric Dentistry to conduct research on
oral health needs and the best preventive services for children
and their families.
- Dientes! Clinc, Santa Cruz, CA is a
private non-profit community dental clinic that was established
in 1994 to provide dental care for low-income residents
of Santa Cruz County. Their full service clinic and mobile
programs bring services directly to the patients who need
them most: those who live in poverty, who lack insurance,
the homeless, patients with HIV, migrant farm workers, children
and others who lack access to care. View an article on the
clinic at http://www.cda.org/member/pubs/journal/jour598/dientes.html.
- The Open Door Community Health Center's
Burre Dental Center opened in October 2002 and quickly had
to establish a waiting list due to the demand for services.
The Dental Center provides dental care for Humboldt and
Del Norte county families who have limited or no dental
insurance or who are eligible for Healthy Families or Medi-Cal.
Free clinics for Head Start children take place once a month
and are funded by grants from the Union Labor Health Foundation
and the Humboldt Area Foundation.
Communities that are contemplating establishing
a dental clinic have a number of resources to inform them.
- The Ohio Department of Health, in cooperation
with the Association of State and Territorial Dental Directors
and the Indian Health Service, has developed an online Safety
Net Dental Clinic Manual (http://www.dentalclinicmanual.com)
that highlights all aspects of dental clinic development
as well as ongoing operations. Five chapters cover 1) Partnerships
and Planning, 2) Facility Design and Staffing, 3) Financing,
4) Clinic Operations, and 5) Quality Improvement. There
are links to websites and interactive worksheets, as well
as tips, photos, floor plans, sample policies, and much
- Volunteers in Healthcare (http://www.volunteersinhealthcare.org/)
is a non-profit organization that assists communities that
are organizing or expanding volunteer-led medical and dental
services for the uninsured. The organization offers technical
assistance, seed grants, educational opportunities, and
other services. The website is a resource for news, notes
from the field and case studies, tips, publications, and
grant opportunities. Many of these resources relate to dental
clinics and issues in rural areas. The California Primary
Care Association serves as a catalyst and representative
for more than 500 member clinics and health centers. CPCA
provides training and technical assistance, information
systems support, educational and networking opportunities
for clinicians, and a CFO network. View more information
The website includes a membership directory, job bank and
need to have special permits in California as well as have
hospital privileges to provide advanced behavioral management
or surgical services in hospital clinics. Each hospital establishes
their own privileging requirements, first to affiliate and
then to practice within their jurisdiction.
See the information for special permits
required in California on the Dental Board of California website
A separate application form is used for each permit and can
be accessed on the website or by calling the appropriate permit
program unit. This includes use of conscious sedation or general
anesthesia services. Children with chronic medical conditions
such as HIV, kidney disease, heart disease, organ transplants,
blood disorders/dyscrasias, or congenital anomalies such as
cleft palate often benefit from a multidisciplinary team approach
and family support that a hospital can provide. Children's
hospitals or medical centers connected with a dental school
or residency program are excellent resources for such treatment,
but usually are located in urban areas. Currently there are
10 children's hospitals in California (see http://www.aapca1.org/aapca1/kidhosp.html
for links to their websites.) Not all of them have a dental
component that is obvious via their website. In addition to
these advanced services, some hospitals provide outpatient
dental services and outreach programs in the community.
Examples of Programs
- The Anderson Center at Children's Hospital
and Health Center, San Diego is a good example of a hospital
that provides a variety of care within the hospital and
in the community to young children and children with disabilities
- In 1998, Redwood Coast Regional Center
purchased and installed dental equipment in local hospitals
to enhance access to dental care for consumers who require
anesthesia. The St Joseph Hospital Based Dental Service
treats 65 children per year and has a coordinator funded
by the Circle of Smile Partnership.
- Poisson Dental Facility at Catholic
Medical Center in Manchester, NH is expanding from a 2-chair
to a 4-chair clinic; they have good support from a number
of community groups. http://www.catholicmedicalcenter.org/services/dentalfacility.php
- The American Association of Hospital
Dentists, consisting of about 1,000 members, will 1)"Assist
you in gaining and maintaining clinical skills and knowledge
to treat special patients in your office and in increasingly
new areas, such as ambulatory care and surgical centers,
urgent care centers, dialysis centers, extended care facilities,
and hospice care settings; 2) Provide education to help
you assess and treat the needs of patients who have complex
medical conditions, are elderly, are victims of child abuse,
are severely diabetic, suffer from hemophilia, or are developmentally
or otherwise disabled; 3) Give you practical assistance
to improve the organization and management of your dental
practice; 4) Work to develop new sources of payment and
greater levels of reimbursement for dental care to special
patients; 5) Work to expand the opportunities for postgraduate
training in the care of special patients." This group,
in conjunction with the Academy of Dentistry for Persons
with Disabilities, and the American Society of Geriatric
Dentistry conduct an Annual National Conference on Special
Care Issues and publish a journal Special Care Dentistry.
More information is available on the Special Care Dentistry
website at http://www.scdonline.org.This
group also is developing Clinical Guidelines for Providing
Dental Treatment under General Anesthesia for People with
Special Needs that includes care for young children with
- UCLA sponsors courses such as Certification
in Pediatric Oral Sedation (3-day course) and a one-day
re-certification course. Other universities also sponsor
Mobile clinics are usually either:
- a self-propelled, self-contained
motorized van driven by clinic staff or a hired driver
to different locations
- a trailer that is hauled or towed by
a truck to set-up at a location for a specific time period
- equipment that is transported by a
truck and set up in a facility as a dental operatory.
Indications for mobile vans include areas where populations
can be served at a community site such as a school or Head
Start Center where services are not available locally to needy
populations. Limitations include difficulties in mountain
terrains, inclement or extremely hot or cold weather, large
enough space to park it and access utilities, secure storage
facility, availability of a driver who may need a commercial
license, different set of regulations and different insurance,
increased coordination and a system to assure continuity of
care. A system is also needed for identifying, gaining consent
for, and scheduling patients, including for follow-up care
or specialty referrals.
This option can have expensive initial start-up costs, averaging
around $336,000 to order a new van and the equipment and supplies
needed. Most vans require electric and water hook-ups (shorepower).
Annual operating costs then include maintenance costs for
the equipment and the vehicle itself. It would probably not
be cost efficient to use the van only for very young children,
unless the population numbers warranted it. In California
a special permit is needed to practice dentistry in a mobile
clinic (call 916-263-2300, ext 2332)
Those considering this option should talk extensively with
people who use this delivery mode, and work closely with the
van manufacturer on design elements. Most people strongly
recommend against converting an existing RV to a dental van.
The Association of State and Territorial Dental Directors
has been funded to develop an online resource manual on mobile
and portable dental care systems (www.mobile-portabledentalmanual.com);
it will probably be available in late fall 2004. The manual
will cover important questions and decisions; provide tips,
worksheets, and samples; and include links to websites and
other resources. In the meantime, you can view some comparisons
of fixed clinics vs. mobile vs. portable systems in the Safety
Net Dental Clinic Manual, Chapter 1, Section II (i) and Chapter
2, Section I(a) at http://www.dentalclinicmanual.com.
Examples of Programs
- Ventura County's Maternal & Infant
Oral Health Program, Mobile Dental Office in Oxnard, provides
dental care and education services for mothers and children
from birth to 3 years. Funded with First 5 monies, the 35-foot
van travels to WIC sites in the county (800-698-9799). A
team of dentists and a dental assistant staff the clinic.
- The Mobile Dental Center in Gonzales,
uses a non-motorized van to primarily serve children who reside
in remote areas of South Monterey County and whose families
are federally designated as residing in a medically underserved
area (MUA). The initial target service area includes the communities
of Soledad, Gonzales, Greenfield, King City, San Lucas, San
Ardo, and Bradley, an area of 800 square miles. The Mobile
Dental Center annually sees almost 1,000 individual patients
through almost 4,000 patient encounters. The overwhelming
majority (more than 85%) of these children are from farm worker
and/or migrant farm worker families The Mobile Dental Center
is 2 mobile homes (12 x 60 & 12 x 44, not including towing
hitches) requiring water service, sewer hook-up and power.
Their sister program, Children's Oral Health Program of Monterey
uses a motorized van to provide community outreach and dental
- The Miles for Smiles Mobile Van (http://www.kindsmiles.org/mile4smile.htm)
is a state-of-the-art dental clinic that provides comprehensive,
quality dental care, including emergency care when necessary,
to children in rural communities on Colorado's Western Slope.
The custom-built 36-foot Airstream Coach features two operatories,
a digital x-ray system, and an integrated sterilization
center. It also includes a computer network and software
package for charting patient records and scheduling, mobile
nitrous oxide cart for conscious sedation of patients, laboratory/support
equipment center, reception/desk station, and a wheel chair
- Saint Mary's-Reno has developed a mobile
dental outreach program to schools and supermarket locations
in Nevada for preventive and restorative dentistry. See
- USC sponsors a number of mobile programs
using both vans and portable equipment. http://www.usc.edu/hsc/dental/community/mobile_clinic.htm
- PRASAD Children's Dental Health Program
of California provides oral health education and free dental
care for Alum Rock School District children ages 4-14 using
a mobile van. See description at http://www.prasad.org/program_21_dental_care_cdhp_ca.html.
- Ronald McDonald Corporation funds pediatric
healthcare mobile units for bringing medical and dental
services and health education to children in underserved
communities. They have programs in about 16 or more cities
so far, including San Jose and Contra Costa County CA (http://www.rmhc.com/mission/access_healthcare/access_care_mobile/index.html)
- Apple Tree Dental has developed a dental
delivery system that is designed specifically for special
care populations, including providing onsite care at nursing
homes, Head Start centers, and other group sites. Apple
Tree combines a complex system of mobile dental equipment
and digital x-ray machines that are loaded and shipped to
sites via trucks with some portable equipment options. The
equipment provides almost the same clinical environment
and technology that is available in most dental offices.
The also mobilize groups in the community to support and
expand access to dental care. Approximately 75% of the patients
are enrolled in Medicaid. Apple Tree has sites in 6 states,
including one in San Francisco. Apple Tree offers clinical
experiences to dental and dental hygiene students and educates
practitioners through a mini-residency program and presentations
at national meetings. They recently added a teledentistry
- Brooks C, Miller L, Dane J et al. Program
evaluation of mobile dental services for children with special
health care needs. Spec Care Dentist 22(4):156-60, 2002.
- At least two field reports on mobile
vans are posted on the Volunteers in Health Care website
|Portable equipment can generally be
defined as equipment weighing less than 50 pounds that
can be transported and carried into a site. Some equipment
is more "portable" than others--some is cumbersome,
does not come with a carrying case, or is difficult to
fit into small automobiles or carry upstairs. Components
chairs, x-ray machines, generators, suctions,
with containers also needed to carry supplies and instruments.
The number of portable
dental equipment manufacturers and the variety, quality
and affordability of portable dental equipment have increased
greatly in the past few years. Such systems provide greater
flexibility to reach certain populations, but generally are
not needed for screening or providing preventive services
to children under age two. Dental screening and school-based
sealant programs have greatly benefited from the use of portable
equipment. Isolated areas in Alaska routinely transport portable
equipment in airplanes, automobiles or snowmobiles to meet
the needs of isolated villages. Limitations include the set-up
and break-down time, reduced efficiency in some cases due
to equipment capacity, separate storage needed for records
and supplies, space needed within a building where there is
access to appropriate utilities.
is best used for clinical preventive procedures or simple
restorative procedures where air, water and suction are needed.
Providing care with this equipment can
be ergonomically uncomfortable if done full-time, and most
providers will only do it for limited periods of time. Start-up
costs for two chairs with supplies averages about $20,000.
Examples of Programs
- Christian Dental Society makes available
its portable equipment on a first come, first serve basis
to CDS members who complete an application and want to use
the equipment on a mission. They provide operative units;
compressors; portable chairs, lights and x-ray units; restorative
kits, surgical kits and pressure pots for sterilization.
Units such as this are taken in to remote, isolated or undeveloped
areas to provide care to children and adults. http://www.christiandental.org/equipment.
- With California Department of Developmental
Services funding, Alta Regional Center purchased portable
and stationary dental equipment surgical instruments and
dental supplies for Colusa Community Hospital and Barton
Memorial Hospital to enhance access to dental care for consumers
who require anesthesia.
- The Virginia Dental Health Foundation
launched Mission of Mercy projects in underserved areas
of the state. Volunteers provide the care in cooperation
with the VCU School of Dentistry and Dental Hygiene, using
portable equipment for most care and performing difficult
extractions in the VCU School of Dentistry mobile van. http://220.127.116.11/public/VDHF/VDHF_MOM.html.
- Murphy JE, Jr. Mobile Dentistry.
Tulsa, OK: PennWell Books. 1996. This reference book includes
information on both mobile vans and portable equipment.
- Mobile-Portable Dental Manual.
is an attempt to connect primary care clinicians to specialists
to increase access to timely diagnosis and care for selected
individuals in areas where access to dental care and specialists
is a problem. This process can include new electronic
advances and broadband capability to perform videoconferencing,
and transfer of digital radiographs, patient history and
exam information, and other clinical information.
be "real time" or "stored and forwarded"
for review at another time, with possible visits to the area
by the specialists. It has been used extensively by the US
Department of Defense. Some groups are using this model to
enable dental hygienists to practice in underserved areas
in states where general supervision or independent practice
are allowed so they can benefit from dentist consultation.
To make this a viable
option requires purchase of the necessary hardware and software,
high-speed access to the Internet, and relationships with
specialists who are willing to participate. Issues such as
licensure, accountability, liability, privacy, consent etc.
are still fairly untested in law.
Examples of Programs
- Northern Sierra Rural Health Network
links rural residents to specialists to help diagnose problems
and conduct follow-up visits. This creates stronger links
between local providers and specialists and more coordinated
- Childrens Hospital Los Angeles/USC Teledentistry
project started around orthodontic consultation but has
been expanding into other specialty areas. The 3-year project
has received funding from the California Wellness Foundation
and the Harold McAlister Charitable Foundation. This project
interfaces with the USC Mobile Dental Clinic. http://teledentistry.usc.edu
- Redwood Coast Regional Center
uses teledentistry and a number of other oral health strategies.
Chang S et al. Teledentistry in rural California:
A USC initiative. CDA Journal. 31(8):601-8, 2003. Includes
a useful glossary of technological terms in teledentistry.
Sierra Telecommunications Coalition (http://www.sierra-telecom-coalition.com)
works to get broadband telecommunications in the Sierra for
health care and other purposes.
The self-assessment allowed you to develop
an inventory of existing populations and dental care models
in your community or geographic area. The chapter reviewed
the various settings for providing dental care, noting benefits
and limitations, and providing examples of programs. The goal
of this chapter is to help you design a comprehensive system
of oral health care for your community so that access problems
are minimized and resources are used in a cost-effective and
Mertz EA, Manuel-Barkin CE, Isman BA and
O'Neil EH. Improving Oral Health Care Systems in California:
A Report of the California Dental Access Project. San
Francisco, CA: The Center for the Health Professions, UCSF.
Belt D. California's colorful quilt of
care is stitched with compassion. CDA Journal. Aug 2002. View
What did you learn or accomplish as a result
of reading this chapter? Did it help you to organize your
thoughts about dental care delivery options in your community?
Were the resources and examples helpful? Complete the feedback form for Chapter 6 and tell us what was useful and not useful for you.