Background: In 2017, the SMILES Dental Project was implemented in five Colorado communities (21 counties). Dental hygienists (DHs) working in community settings collected and store-forwarded clinical, x-ray and digital-image data which was asynchronously reviewed by virtual dentists. DHs provided interim therapeutic restorations (ITRs) if treatment planned by the dentists.

Methods: We conducted a multilevel, mixed-methods evaluation of the project which included 1) monthly process and disease metrics (2017-2019); and 2) qualitative, semi-structured interviews with 4-6 key team members (N=29) of all participating communities, a convenient sample of parents (N=17) whose children received ITR, and an addition random sample of parents (N=9) whose children received SMILES care. Interviews were in English/Spanish, recorded, transcribed, translated, and analyzed through an iterative process for recurring themes using Atlas.ti©.

Results: DHs provided 10,938 SMILES visits in community settings between 2/2017 and 12/2019: ages (years) 0-5 (19%), 6-18 (71%), > 18 (10%); Medicaid (51%), uninsured (29%), SCHIP (10%), private (10%). DHs provided ITRs at 10% of patient visits. A third (37%) of SMILES visits were new (first DH visit in community setting) and two-thirds (63%) were established visits. Over all visits, the unadjusted proportion of established visits with untreated decay was 14.6% lower (-7.8 percentage points) than the proportion of new visits (established: 44.9% vs new: 52.6%). Team members reported various challenges to store-forward, asynchronized dental care but most were overcome. Parents overwhelmingly favored SMILES care.

Conclusions: The virtual dental home model has potential to expand access to dental care and fill dental gaps.