Hawaii’s keiki have some of the worst oral health in the country.

To combat the state’s extremely high rate of tooth decay among children, a pilot teledentistry program on the Big Island and Maui is bringing dental treatment directly to preschools and other early education sites.

“The dental hygienist goes to the site, takes pictures, does a fast 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 a teeth cleaning and application of a fluoride varnish to prevent cavities.

Natasha Ala

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 Hawaii Department of Health’s Hospital & Community Dental Services Branch.

Since 2016, the West Hawaii Community Health Center has sent its teledentistry team to early education sites twice a year across the Big Island’s west coast, from Waimea to Kealakekua.

“A lot of the children are more cooperative, because at preschool they’re in their normal environment,” said John Gawlik, a pediatric dentist at West Hawaii Community Health Center.

More than a thousand images and X-rays of children’s developing teeth have been captured at Head Start preschools, Women Infant and Children centers, and Tutu and Me campuses. And follow-up appointments with pediatric dentists are made when necessary.

It’s been a huge weight off of 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 do not have cars or cannot take time away from work to take children to the clinic, especially because a trip to the dentist could take all day.

Natasha Ala

Because of the challenges, Pine and other dentists tend to see kids when the situation has become serious. Cavities and other dental diseases often do not cause pain until they reach an advanced state.

“If we wait until kids feel pain, we’re not being proactive enough,” Pine said. “By capturing these children when they’re young and educating the families on proper oral hygiene, hopefully we can correct these issues before they happen.”

It’s recommended children see a dentist by the time their first tooth comes in 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 Hawaii keiki have the highest prevalence of tooth decay in the nation.

Approximately 71% of Hawaii third graders are affected by tooth decay, compared to the national average of 52%.

The Hawaii Smiles report also discovered that nearly one in every four Hawaii children were found to have untreated tooth decay.

Kids living in Hawaii, Kauai and Maui counties were more likely to experience tooth decay than their counterparts in Honolulu, and oral health disparities become far greater when income and ethnicity are taken into account.

The same report showed Micronesian, Native Hawaiian, Guamanian, Chamorro, Samoan, Tongan and Filipino children to be significantly more likely to have untreated tooth decay compared to white, Japanese, Chinese and Korean children.

Most youngsters in Hawaii have health insurance. More than a quarter of Hawaii’s children rely on Medicaid or QUEST (CHIP) health coverage.

Still, oral health can easily be dismissed as unimportant, said Hawaii Children’s Action Network Executive Director Deborah Zysman.

“It’s not an insurance issue here, it’s other access-to-care problems we’re looking at,” she said. “That’s why we’ve been advocating for teledentistry. It’s cheaper and more effective.”

“There’s linkages to all kinds of other health problems down the line,” she added. “There’s also linkages to absenteeism. And then there’s monetary costs when you have to fly a child from a neighbor island (to Oahu), put them under anesthesia and do extractions, which is really traumatic for a child.”

State Budget Cuts, Lack Of Fluoridated Water

The photos and X-rays captured at school have enabled dentists to catch cavities nestled between teeth, which signal a lack of flossing. Dentists like Gawlik have also been able to identify cases of ankyloglossia, when the tongue is tethered too tightly to the floor of the mouth, which can inhibit the way children eat, speak or breastfeed.

Due to the economic downturn in 2009, the DOH’s Dental Health Division was terminated and consequently ended school-based screenings and fluoride application for the prevention of cavities. That same year, the state stopped paying for non-emergency dental care for low-income adults.

Another driver of poor oral health is the lack of fluoridation in Hawaii’s water, says Pine. The state of Hawaii does not mandate fluoridation, and just 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 who receive fluoridated drinking water through community water systems.

The Hawaii Department of Health is increasing telemedicine initiatives across all islands, since dental services 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 grant funding, and Pine says WHCHC is still working out a reimbursement structure with insurers. The pilot project’s grant funding stream is set to expire at the end of this year.

“There’s been a lot of questions as to how that pay structure will look,” Pine said. “We’re still working with our partners in making this a sustainable program.”

When the “Virtual Dental Home” found its way to Maui in 2017, thanks to a grant extension, the program partnered with organizations that serve seniors as well as children. A study that included research by the University of Hawaii found that once people turn 80 years old, they visit the dentist less frequently.

Partnering organizations include Hui No Ke Ola Pono, Maui Family Support Services, the Maui Economic Opportunity and the WIC program, or Special Supplemental Nutrition Program for Women, Infants and Children.

“Before this, it was really hard to get dentists to take 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, getting regular cleanings and actually, our staff is being trained to help take care of oral hygiene.”