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(/.$0()$ Telehealth refers to the use of technology to provide health care at a distance. The important and increasing role of telehealth in the delivery of health care has been recognized for several decades. Although there are fewer reports on the use of telehealth to deliver oral health services, evidence is emerging that these technologies can enhance the ability of the oral health delivery system to reach vulnerable and underserved populations.
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Paul Glassman, 11., 2(, Michael Helgeson, 11., everal terms have been used to Opportunities,” reviewed the history and 2/(, is a professor of is chief executive officer, describe the use of technologies use of telemedicine nationally and in Dental Practice, director Apple Tree Dental, in that facilitate interaction among California. !e report described the use of Community Oral Health, Minneapolis, Minn. and director of the Pacific Conflict of Interest patients and health care provid- of telemedicine technologies to deliver Center for Special Care, Disclosure: None reported. ers in geographically separated health services in state prisons through Arthur A. Dugoni School of Slocations. Much of the literature uses the regional service delivery mechanisms Dentistry in San Francisco. Jenny Ka3love, is terms “telemedicine” to describe these centered at the University of California, Conflict of Interest director, Strategic Health interactions. In the last decade, the use of Davis, in outreach systems managed by Disclosure: None reported. Initiatives, The Childrens Partnership, in Los these technologies in dentistry has been the Veterans Administration, in out- Angeles. referred to as “teledentistry.” More recent- reach managed by rural health centers, Conflict of Interest ly, these terms have been combined and and for use in diagnosis and treatment Disclosure: None reported. referred to collectively as “telehealth.” of a wide variety of health conditions. !e important and increasing role of Delivery of health care using tele- telehealth in the delivery of health care medicine technologies is recognized by has been recognized for several decades. the federal government as a “cost-effective !e California HealthCare Founda- alternative to the more traditional face- tion in a report, “Telemedicine in to-face way of providing medical care” due California: Progress, Challenges, and to the ability to provide earlier diagnos-
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tic and preventive services and savings as a legitimate means of providing health videoconferencing equipment; digital in transportation and other associated care. !e stated intent of the law was to cameras; electronic clinical devices, such costs. !e Center for Medicare and Med- support the idea that “!e use of telecom- as digital stethoscopes; and disease man- icaid Services (CMS) has indicated that munications to deliver health services agement and health education software. “for purposes of Medicaid, telemedicine has the potential to reduce costs, improve Telehealth has been used in many ap- seeks to improve a patient’s health by quality, change the conditions of practice, plications including emergency and criti- permitting two-way, real-time interac- and improve access to health care in rural cal care, vision screening, mental health tive communication between the patient and other medically underserved areas.” evaluation and treatment, telepharmacy, and the physician or practitioner at the Common applications of telehealth child abuse evaluations, and diagnosis and distant site. !is electronic communica- include videoconferencing between a treatment of a variety of other health con- tion means the use of interactive telecom- patient and health care provider for a ditions.- A recent study demonstrated a munications equipment that includes, at consultation or among groups of patients percent lower rate of rehospitalization a minimum, audio and video equipment.” or providers for education, support, and for patients on home health care regi- CMS further stated that “states may reim- mens who were followed using telehealth burse the physician or other licensed prac- technologies versus those in a nontele- titioner at the distant site and reimburse %&'()*+,(& -&. *,/ health group. !e savings from this a facility fee to the originating site. States of the leading states intervention were substantial given an can also reimburse any additional costs average cost of readmission of , per such as technical support, transmission in adopting legislation person for the group of patients studied. charges, and equipment. !ese add-on to define and support the It has been argued that telehealth is costs can be incorporated into the fee- a critical modality to address the severe for-service rates or separately reimbursed role of telemedicine in shortages of health care available for as an administrative cost by the state.” health care delivery. large numbers of people in our society. In A report, “Meeting the Health California, Medi-Cal has recognized the Care Needs of California’s Children: value of telehealth and reimburses provid- !e Role of Telemedicine,” by !e Chil- ers who use videoconferencing to provide dren’s Partnership, stated that “Quality care coordination; transmission of data, care. Medi-Cal also provides a facility and health care no longer requires a health such as X-rays, photographs, video, and transmission fee to the originating site to care provider and patient to be in the audio files; remote monitoring of vital compensate for the telecommunications same room at the same time. With the signs and other health indicators; and and other costs associated with originating advancement of information and com- Internet applications for patient educa- a telehealth visit. Medi-Cal also reimburses munications technology (ICT), children tion and disease management. Telehealth for store-and-forward applications related and adults can receive high-quality can occur in “real time,” where the patient to teledermatology, teleophthamology, and health care from a distance through and his or her provider are at one site specific types of teleoptometry services.- telemedicine. In fact, telemedicine is communicating with another provider at rapidly becoming a viable solution to another site simultaneously. Videocon- Teledentistry meeting the health care needs of patients ferencing is the most common real-time Application and use of telehealth in in rural and other underserved areas.” telehealth interaction. Telehealth also oc- dentistry are not as well-developed as the California was one of the leading curs using “store-and-forward” methods. use of telehealth technologies in other states in adopting legislation to define and A store-and-forward interaction involves aspects of the health care delivery system. support the role of telemedicine in health the transfer of data, such as an X-ray or a However, telehealth technologies have care delivery. In , California adopted digital image, from an originating site to been available and used in the delivery of the Telemedicine Development Act of a distant site for review and consultation oral health services for quite some time. . !is law put California in the posi- at a later time. Telehealth also involves the An early report on the use of technology tion of national leadership on telemedi- use of an ever-growing menu of software to allow collaboration between distant cine policy and supported telemedicine and technological devices, including dental providers described a system in use
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by the U.S. Army to transmit still color with dental specialists for temporoman- Access to Oral Health Care for Vulner- images over a modem to allow periodon- dibular disorders, orofacial pain, and oral able and Underserved Populations.”, tists to view healing after periodontal sur- medicine issues. A report described !ese reports emphasize the significant gery without the patient having to travel the use of teledentistry technologies to oral health disparities among a num- long distances. A series of articles in the triage the need for a referral to a re- ber of underserved population groups February issue of the Journal of the mote oral medicine hospital clinic. and call for new methods and systems California Dental Association recognized In , a report described the ability to address these disparities. !ere is the potential for telehealth but expressed of endodontic specialists to remotely specific mention of the role of tele- significant caution about how these tech- locate the canal orifice to assist general health as a component of future oral nologies would develop and be used., In dentists in performing endodontic treat- health delivery systems that can better spite of the widespread use of telehealth ments. A publication described reach and serve these populations. in medicine, there are far fewer reports an initiative developed by the North- in the literature on the application of ern Arizona University (NAU) Dental Teledentistry in the California Virtual telehealth concepts to the delivery of oral Dental Home Project health services. !e emphasis of those !e virtual dental home project, reports that are available on teledentistry $%& '($( directed by the Pacific Center for Spe- has been on the use of these technologies is stored on a secure cial Care at the University of the Pacific as a means to share records between den- Arthur A. Dugoni School of Dentistry and tists and dental specialists or as screen- web server and described in more detail in other articles ing tools to determine the feasibility or accessed using in this issue, uses telehealth technolo- urgency of need for dental treatment.- gies to facilitate acquisition of records by !ere are some more recent reports a web browser from allied dental personnel, including dental in the literature that describe the use of any location. hygienists and dental assistants, in com- teledentistry to facilitate geographically munity sites and review of these records distributed, collaborative dental care. An by dentists who are not on site. !ese initiative based out of the University of dentists make decisions about the best Southern California demonstrated in Hygiene Department where affiliated course of treatment, and provide remote that dentists were able to work with a practice dental hygienists can digitally general supervision of the allied personnel dental hygienist at a remote location, to acquire and transmit diagnostic data to a performing preventive and early interven- decide on preventive services that could be distant dentist for triage, diagnosis, and tion treatment. !e virtual dental home delivered by the hygienist at that location, patient referral. Remote general supervi- model is being demonstrated in schools, and to facilitate referrals to the USC mobile sion allowed these hygienists to provide Head Start centers, residential facilities dental clinic that delivered on-site dental preventive services permitted within the for people with disabilities, and long-term services at a later date. A report scope of their licenses. Although the care facilities for dependent and elderly reviewed the available telehealth technolo- potential for enhancing oral health care individuals. !e techniques and illustra- gies and outlined the potential for using through the use of telehealth technologies tions of the equipment used for capturing these technologies to foster collaboration is just beginning, these technologies hold telehealth records in a laptop computer in between dentists and dental hygienists in great promise in improving the oral health the virtual dental home system are also order to reach and improve oral health of of underserved populations through described in other articles in this issue. underserved populations. A review fostering and facilitating geographically !e virtual dental home model uses a of the uses of teledentistry described both distributed collaborative systems of care. cloud-based software system called Denti- real-time consultations and store-and-for- In , the Institute of Medicine con. !e software has all the features of ward applications in use at that time. In and the National Research Council of the a locally installed dental patient manage- particular, a system was described in Min- National Academies of Science issued ment system. However, the data is stored nesota where real-time videoconferencing two reports on oral health, “Advancing on a secure web server and accessed was used to facilitate remote consultations Oral Health in America” and “Improving using a web browser from any location.
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%&'()* 1. Periodontal chart from the Denticon Electronic Dental Record. %&'()* ,. Restorative chart from the Denticon Electronic Dental Record.
!is cloud-based arrangement facilitates email communication and phone calls Application of Teledentistry by Apple acquisition of records in one location that supplement the record review. Tree Dental and review in another. !e entire system Once a dentist has reviewed the Another example of the use of tele- is fully HIPAA compliant and patient records and talked, if needed, with the health technology to facilitate oral health privacy is fully protected. Only users with allied personnel who are on-site, the care is the delivery system from Apple authenticated credentials can access the dentist decides the best course of treat- Tree Dental (Apple Tree) in Minnesota. system and upload or review records. ment for that patient. In the majority of Apple Tree is a unique, nonprofit staff- %&'()*+ , -.)/('. 0 illustrate screen cases, these individuals are kept healthy model dental practice that currently captures from some of the information in the community location by preven- operates five regional dental access available in the Denticon web-based tive and early intervention activities programs in urban and rural areas of software system. As illustrated in these of the allied dental personnel. In cases Minnesota. Telehealth technologies link figures, dentists who are reviewing these where the dentist determines that the special care dental clinics with on-site records have access to electronic restor- individual has treatment needs that can dental clinics at schools, Head Start ative and periodontal charts, a system only be addressed by a dentist, they are Centers, group homes, assisted-living that records caries risk factors and referred to and assisted with receiving centers, nursing facilities, and other com- assigns a caries risk score, a system for treatment in a dental office or clinic. munity sites for people facing physical, tracking patient status to facilitate case If the treatment is performed by the financial, and geographic access barriers. management, and high-quality radio- dentist who reviewed the virtual dental !e Apple Tree model links dental graphs and photographs. Also included home records then that dentist already hygienists working under “collaborative in the records, but not illustrated here has access to records and is familiar agreements” with dentists. Apple Tree has are treatment plans, patient ledgers, with the treatment needs of the indi- demonstrated the ability for a dentist at a progress notes and other electronic vidual. If treatment is performed by distant dental clinic to safely and accurate- health record (EHR) components. Com- another dentist, records can be exported ly assess the permanent teeth of high risk munication between the allied person- from the system and made available. children for sealant placement without the nel on-site at the community location, In either case, valuable time is saved need for a face-to-face examination. Den- and the dentist off-site in a dental office at the dental office because diagnostic tists made decisions using live videocon- or clinic, is facilitated by the electronic and preventive procedures have been ferencing, digital radiographs, Diagnodent records described here, and enhanced by performed and records are available. readings, and high-resolution intraoral
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$%&'() +. Status tracker screen from the Denticon Electronic Dental Record. video and still images. !e decisions they mendations.” !e report documents !e most significant of these is the made using the store-and-forward records the use of and barriers to the spread of uncertainty about payment for telehealth closely matched the decisions made using telehealth across the nation and proposes services. If providers believe they can- live videoconferencing and those made a model statute to optimize the use not be paid for delivering services using after a second face-to-face examination. of telehealth in California. !e intent telehealth technologies, they have little Apple tree is now using oral health of the report was to propose a way to motivation to join telehealth-enabled assessments and store-and-forward create parity between health services provider networks or receive training records collected in Head Start Centers and delivered using in-person methods with in the use of telehealth technologies. nursing homes and reviewed by off-site health services delivered using telehealth In , based on the Center for dentists to determine what treatment is methods. !e important determinant Connected Health Policy’s report, Cali- needed and the best location for treatment is whether the service was delivered ef- fornia Assemblyman Dan Logue (R-Lake of children and vulnerable adults in these fectively and not the technologies chosen Wildwood) introduced Assembly Bill locations. Approximately percent of by the provider to deliver the service. , the Telehealth Advancement Act of children in the Head Start Centers being !e report identified multiple barriers ., Effective Jan. , , this new served need only preventive services per- to wider deployment of telehealth includ- law modernizes California’s landmark formed by the dental hygienist. For the ing confusing or contradictory definitions Telemedicine Development Act of percent who need treatment by a dentist, of telehealth, the uncertainty of payment to reflect advances in the field since the this is provided by a dentist who comes on for services, difficulties in developing and original law’s passage. It updates the site with portable equipment. !e same sustaining provider networks, the chal- definition of telehealth to reflect the pattern is followed in the nursing home lenge of integrating technology among broader range of services in use today, and using Apple Tree’s mobile dental office. providers, and lack of training resources. allows all licensed health professionals in
Barriers and Solutions to Adoption and Spread of Telehealth Even as the use of telehealth tech- nologies is spreading in general health services and delivery of oral health services, barriers remain that are slow- ing down or blocking the wider-spread adoption of this method of delivering health care. !e Center for Connected Health Policy, a nonprofit organization devoted to influencing policy to improve health care delivery in California through telehealth, issued a comprehensive report in , “Advancing California’s Leader- ship in Telehealth Policy A Telehealth Model Statute and Other Policy Recom- $%&'() ,. Radiographs from the Denticon Electronic Dental Record.
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payers reimburse providers for services delivered using telehealth technologies. It was primarily fiscal considerations that kept full parity in delivery and payment from being included in the law. However, there is increasing evidence that the use of telehealth in the delivery of health servic- es will actually save scarce state resources as well as deliver better health care. For example, the Center for Connected Health %&'()* +. Photographs from the Denticon Electronic Dental Record. Policy in a report, “Fiscal Impact of AB : Potential Cost Savings from Expansion of Telehealth,” has predicted California to engage in telehealth. Specific regardless of where it takes place. !is that telehealth has the potential to reduce components of the legislation include: can include patient care management health care costs in the California Medi- Q Replacing the outdated legal ter- programs that employ home monitoring Cal program by several hundred million minology of “telemedicine” with “tele- devices, in-home patient medical appoint- dollars per year annually if telehealth is health” throughout California law. !is ments, and physician or dentist reviews utilized to its fullest potential in treat- change makes it clear that applications of health data in any location in real time ment of cardiac disease and diabetes. of telehealth technology to the delivery and using store-and-forward methods. !ere is also reason to believe that the of oral health services are included in all Q Expanding the list of health profes- use of telehealth technologies can save aspects of the law. !e law broadens the sionals who can provide telehealth ser- scarce resources in providing oral health to modalities that are included in telehealth vices to include all professionals licensed underserved populations. !e virtual dental to include multiple forms of electronic or under the state’s healing arts statute. home delivery model is demonstrating the distance communications and explicitly Q Removing a previous Medi-Cal ability to deliver more health per dollar includes store-and-forward technologies regulation requiring providers to docu- spent than other methods when applied to in the definition. Telehealth, the new legal ment a barrier to an in-person visit before the state’s most vulnerable populations. !e terminology, refers to the technology- a beneficiary could receive telehealth emphasis on prevention and early interven- enabled delivery of services, rather than services, which was widely viewed by tion will have a significant impact on down- a specific medical practice. !is allows for providers as a disincentive to its use. stream “costs of neglect” for untreated den- a far broader range of telehealth services Q Removing a previous requirement tal disease such as increased costs for more than the old law, and does not limit future that patients sign a separate, written, complex dental treatment needed later on, telehealth technologies, because of its en- telehealth-specific consent form before cost of emergency-room visits, cost of care compassing, forward-looking definition. any type of telehealth service could provided in hospital emergency departments Q Removing limits on the physical be delivered. Providers found that the and operating rooms, and lost days of work locations where telehealth services may be written consent form stigmatized the and school from dental pain and infection. delivered. Under the old law, telemedicine use of telehealth, and created an un- appointments had to take place only in necessary barrier to care. !e new law Future Advancement of Telehealth in licensed health care facilities, such as hos- replaces the written consent with a verbal Delivery of Oral Health Services pitals or physician offices and Medi-Cal consent that must be recorded in the !e history and recent advancements restricted telemedicine delivery to four patient’s record. !is establishes parity in the use of telehealth technologies to types of licensed facilities only: hospi- between services provided in person, improve general health care and oral tals, clinics, physician offices, and skilled and those provided via telehealth. health care delivery, along with the recent nursing facilities. !e new law removes While AB clarified and improved legislation in California, point to an limits on the locations for telehealth. !is many important areas of telehealth, it did increasing awareness of the importance will allow for telehealth to be covered, not mandate that Medi-Cal or any other of these technologies. Given the large
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general health and oral health disparities Development Act of 2006 h)p://www.leginfo.ca.gov/pub/95- 24. Cruz-Correia AR, Frias-Bulhosa J, Remote diagnosis of faced by many members of society and 96/bill/sen/sb_1651-1700/sb_1665_bill_960925_chaptered.pdf. children dental problems based on noninvasive photographs Accessed May 9, 2012. — a valid proceeding? Studies Health Technol Informatics the difficulty many populations have ac- 6. California Telemedicine and eHealth Center, A glossary 150:458-62, 2009. cessing the traditional health care system, of telemedicine and ehealth. Sacramento, Calif., California 25. Kopycka-Kedzierawski DT, Billings RJ, Prevalence of dental it is clear that telehealth will have an Telemedicine and eHealth Center, 2006. caries and dental care utilization in preschool urban children 7. Kon AA, Marcin JP, Using telemedicine to improve commu- enrolled in a comparative-effectiveness study. Eur Arch important and growing place in health nications during pediatric resuscitations. J Telemed Telecare Paediatr Dent 12(3):133-8, June 2011. care delivery. Demonstration projects, 11(5):261-4, 2005. 26. Chang SW, Plotkin DR, et al, Teledentistry in rural Califor- such as the virtual dental home project 8. Marcin JP, et al, Use of telemedicine to provide pediatric nia: a USC initiative. J Calif Dent Assoc 31(8):601-8, August critical care inpatient consultations to underserved rural 2003. in California, are already illustrating the Northern California. J Pediatr 144(3):375-80, 2004. 27. Sanchez Dils E, Lefebvre C, Abeyta K, Int J Dent Hygiene 2, value of telehealth systems in address- 9. Krumholtz I, Results from a pediatric vision screening in its page 161-4, 2004. ing the chronic and severe oral health ability to predict academic performance. Optometry 71(7):426- 28. Fricton J, Chen H, Using teledentistry to improve access to 30, 2000. dental care for the underserved. Dent Clin North Am 53(3):537- disparities faced by large number of 10. Chen Y-l, et al, Computer real-time analysis in mobile ocular 48, July 2009. people and the ability to do so in a way screening. Telemed e-Health J 12(1):66-72, 2006. 29. Bradley M, Black P, et al, Application of teledentistry in oral that can improve health and lower costs. 11. Waters RJ, The role of technology in pediatric home care, medicine in a community dental service, Northern Ireland. Br Carinf 2005. drinkerbiddle.com/files/Publication/0e1b589a- Dent J 209(8):399-404, October 2010. To fully realize the potential for 323e-40ba-ba59-a88c63b8417e/Presentation/ 30. Brullmann D, Schmidtmann I, et al, Recognition of root telehealth to improve the oral health PublicationA)achment/5ea07431-ca14-4cb0-bedd-abe- canal orifices at a distance — a preliminary study of teleden- of vulnerable populations, policy and 4f5a398e8/HCGR2005-0905-CARINGWATERS.pdf. Accessed tistry. J Telemed Telecare 17(3):154-7, 2011. February 4, 2012 31. Summerfelt FF, Teledentistry-assisted, affiliated practice delivery system reforms are needed 12. TeleKidcare, Center for telemedicine and telehealth, Kansas for dental hygienists: an innovative oral health workforce to ensure that telehealth delivered or University Medical Center. July 2007. www2.kumc.edu/tele- model. J Dent Ed 75(6):733-42, June 2011. enabled activities are reimbursed in parity medicine/Programs/TKC.htm. Accessed May 9, 2012. 32. The Institute of Medicine, Advancing oral health in America. 13. Chen HF, Kalish C, Pagan J, Telehealth and hospitalizations The National Academies Press. Washington, DC, 2011. with in-person activities that provide the for Medicare home health care patients. Am J Managed Care 33. The Institute of Medicine and the National Research same health service. What is also needed 17(6):e224-e230, 2011. Council, Improving access to oral health care for vulnerable is the expansion of delivery systems that 14. Youngblade L, Telemedicine for CSHCN: a state-by-state and underserved populations. The National Academies Press, comparison of Medicaid reimbursement policies and title v Washington, DC, 2011. link geographically distributed provider activities. Florida: institute for child health policy, University 34. Planet DDS, Denticon Web-based so,ware. planetdds. teams and training of current and future of Florida, 2005. ichp.ufl.edu/files/2011/11/Telemedicine-in- com/. Accessed May 9, 2012. providers to use telehealth technologies Medicaid-and-Title-V-Report.pdf. Accessed May 9, 2012. 35. AB 415, Chaptered Oct. 7, 2011. leginfo.ca.gov/pub/11-12/ 15. California statutes, chapter 449, 2005. leginfo.ca.gov/ bill/asm/ab_0401-0450/ab_415_bill_20111007_chaptered.pdf. and work in these teams. New telehealth- pub/05-06/bill/asm/ab_0351-0400/ab_354_bill_20050930_ Accessed May 9, 2012. enabled delivery systems will help ensure chaptered.pdf. Accessed May 9, 2012. 36. The Center for Connected Health Policy, The Telehealth that vulnerable populations can gain 16. California AB 1224 (Hernandez), chaptered 11 October 2007, Advancement Act of 2011. connectedhealthca.org/policy-proj- Jan. 2, 2008. leginfo.legislature.ca.gov/faces/billNavClient. ects/telehealth-advancement-act. Accessed May 9, 2012. access to the oral health care they need xhtml?bill_id=200720080AB1224&search_keywords=. Ac- 37. The Center for Connected Health Policy, Fiscal Impact of by extending the reach of dentists and cessed May 9, 2012. AB 415: potential cost savings from expansion of telehealth. other oral health providers to locations 17. Rocca MA, Kudryk VL, et al, The evolution of a teledentistry connectedhealthca.org/sites/default/files/Fiscal%20 system within the Department of Defense. Proc AMIA Symp Impact%20of%20AB%20415%20Potential%20Cost%20 where they are needed most. 921-4, 1999. Savings%20from%20Expansion%20of%20Telehealth_0.pdf. 18. Clark GT, Teledentistry: what is it now, and what will it be Accessed May 9, 2012. #$%$#$&'$( tomorrow? J Calif Dent Assoc 28(2):121-7, February 2000. 1. The Center for Connected Health Policy, Advancing 19. Birnbach JM, The future of teledentistry. J Calif Dent Assoc )* #$+,$() - .#/&)$0 '*.1 *% )2/( -#)/'3$, .3$-($ '*&)-') California’s leadership in telehealth policy: a telehealth model 28(2):141-3, February 2000. Paul Glassman, DDS, MA, MBA, Arthur A. Dugoni School of statute and other policy recommendations, February 2011. 20. Kopycka-Kedzierawski DT, Bell CH, et al, Prevalence of Dentistry, 2155 Webster St., San Francisco, Calif., 94115. connectedhealthca.org/sites/default/files/TelehealthModel- dental caries in Early Head Start children as diagnosed using StatuteReportFeb2011.pdf. Accessed May 9, 2012. teledentistry. Pediatr Dent 30(4):329-33, July-August 2008. 2. The California Health Care Foundation, Telemedicine in 21. Kopycka-Kedzierawski DT, Billings RJ, McConnochie KM, California: progress, challenges, and opportunities, July 2008. Dental screening of preschool children using teledentistry: a 3. Centers for Medicare and Medicaid Services, Telehealth. feasibility study. Pediatr Dent 29(3):209-13, 2007. h)p://www.medicaid.gov/Medicaid-CHIP-Program-Infor- 22. Mandall NA, Qureshi U, Harvey L, Teledentistry for screening mation/By-Topics/Delivery-Systems/Telemedicine.html. new patient orthodontic referrals. Part 2: GDP perception of the Accessed May 23, 2012. referral system. Br Dent J 99(11):727-9; discussion 723, 2005. 4. The Children’s Partnership. Meeting the Health Care Needs 23. Elfrink ME, Veerkamp JS, et al, Validity of scoring caries of California’s Children: The Role of Telemedicine. Digital Op- and primary molar hypomineralization (DMH) on intraoral portunity for Youth Issue Brief. Number 3, 2nd ed., March 2008. photographs. Eur Arch Paediatr Den 10 Suppl 1:5-10, November 5. California Statutes, Chapter 864 (1996), Telemedicine 2009.
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