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Access Blog Equity Public Health

Envisioning Teledentistry in North Carolina

Let’s take a moment to review an all-too-familiar scenario for many North Carolinians.

Martha lives in rural Tyrrell County, North Carolina, where there are no practicing dentists. She works a full-time job while raising her two children. So, she decides against making the hours-long round trip to the nearest dental office one county over to receive a cleaning and checkup.

Let’s face it: for Martha, the cost of transportation, the dental service itself, and the pay lost while she is away from work make for a steep price for care. On top of that, she knows that she may have to schedule a follow-up visit—and take time off from work again, find someone to pick up her children from school again, pay for gas again—if she has any cavities that need filling.

So Martha waits.

Sadly, what started as a bit of sensitivity develops into an unbearable toothache, which lands her in the emergency department (ED). In the ED, she is prescribed an opiate to deal with the pain and an antibiotic for the infection, and she is told to “follow up with your dentist.”

In a month or so, however, Martha, like so many others, ends up right back in the ED when her infection, which has never been directly treated, flares up again

Martha isn’t alone in this situation.

This story is reality for hundreds of thousands of North Carolinians who, for various reasons, cannot access oral health care.

A Better Way: The Promise of Teledentistry

Teledentistry is a promising innovative tool that could play a critical role in increasing access, especially in rural areas like Tyrrell County.

What is Teledentistry?

The use of telecommunications for dental exams and assessments, consultations between dental providers, and direct education for patients, among other uses. Teledentistry is a treatment tool that has incredible potential for increasing access to quality dental care in communities that traditionally lack access, especially in rural areas without practicing dentists.

Imagine this:

The next time Martha winds up in the hospital for her toothache, she is connected with a dentist in Chapel Hill via a live video feed. A medical professional takes digital x-rays of Marhta’s mouth and uses an intraoral camera to allow the remote dentist to take a look at her teeth. The dentist quickly diagnoses her abscessed tooth, prescribes Martha the correct antibiotic to help fight the infection, and helps her schedule an appointment for treatment.

With her oral health issue resolved, Martha finally breaks the cycle of hospital visits that she would have otherwise endured.

While Martha had never seen a dentist up until this point, she has always kept up a good habit of visiting her local federally qualified health clinic for an annual checkup. The next time she visits, she learns that the clinic now offers asynchronous teledental services in partnership with East Carolina University.

Synchronous and Asynchronous Teledentistry

Synchronous is a fancy word that means “at the same time.” In synchronous teledentistry, a dentist is connected via a live video feed to review material, assess the patient in real time, and provide direct patient counsel, if needed.

Dentists who practice asynchronous teledentistry are sent diagnostic information such as digital x-rays and pictures from intraoral cameras to review at a later date, giving them time to look at all the material and put together a comprehensive treatment plan based on the patient’s unique needs.

Digital x-rays and pictures from an intraoral camera are sent to a dentist who works through East Carolina University. She reviews Martha’s records later that week. Fortunately, this time there is no need for further treatment, but the dental provider does advise that Marhta floss more regularly.

Martha’s children have also never seen a dentist. Luckily for them, a dental clinic was recently established at their school and a dental hygienist provides them the same asynchronous teledental services that their mother received at the medical clinic.

The hygienist provides Martha’s children with fluoride treatments, dental sealants, and a thorough cleaning. The dentist who reviews their digital x-rays and other diagnostic information determines that they have no cavities, but that they both do have moderate gingivitis. The hygienist learns that the two have had to share a toothbrush, so the clinic provides them with two new toothbrushes and tubes of fluoride toothpaste.

From in-school clinics to emergency departments, teledentistry is a promising asset that could significantly improve access and equity in oral health care across North Carolina. For families like Martha’s, simple diagnostic services completed through teledentistry could drastically increase tangible access points to dental services, and in return prevent significant oral health burdens downstream.

The Tools of Teledentistry

Teledentistry can seem daunting, especially when it comes to modernizing an office to meet the technological needs of remote care. Unlike many variations of telehealth, however, the tools of teledentistry are actually quite simple. The basic necessities are:

  1. A digital x-ray system

  2. An intraoral camera

  3. Electronic patient records

Most dental practices already use digital x-rays and intraoral cameras, and practices across the country are rapidly making the switch to electronic record-keeping. Compared to other telehealth services, the startup cost for teledentistry is relatively low.

By helping break the cycle of emergency department visits for oral health crises, medical costs for patients and the healthcare system as a whole could be significantly reduced. This is especially important in our rural communities. Cutting the uncompensated care costs burdening rural hospitals across the state could go a long way in attaining financial solvency. Additionally, inserting a dental professional into the hospital setting via teledental services could be an important way to combat the opioid crisis, reducing the number of unnecessary opiate prescriptions often given to patients with oral health emergencies.

Want to Know More?

NCOHC is taking a trip later this week to tour the state-of-the-art Center of Excellence for Telehealth at the Medical University of South Carolina. Stay tuned for our report from the trip!

Also, join us on June 3, 2020, for Oral Health Day! Oral Health Day is NCOHC’s annual advocacy event at the North Carolina General Assembly. This year we will focus our discussion on pathways to successful teledentistry in our state. Click here for more information and to register today!

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NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Healthy Mouth, Healthy Body: Oral Health During Pregnancy

Recap: The Oral-Systemic Connection

Parts one and two of our series, “Healthy Mouth, Healthy Body,” focused on heart disease, diabetes, and how the two are linked to oral disease

Gum disease, or periodontal disease, can allow harmful bacteria to enter the bloodstream and cause chronic inflammation. This inflammation is linked to conditions like atherosclerosis, an artery disease that can lead to heart attacks and strokes.

Diabetes is connected to gum disease in several ways. Dry mouth caused by diabetes can lead to suboptimal oral health, and gum disease itself can increase the prevalence of risk factors for diabetes like elevated blood glucose levels

To catch up, be sure to read parts one and two of this series.

Healthy Mouth, Healthy Pregnancy

Even though this follows posts about heart disease and diabetes, to be perfectly clear, we are NOT calling pregnancy a disease! (And, brushing your theeth, well, cannot prevent pregnancy.)

Pregnant mothers experience significant changes in their bodies during pregnancy, and some of these changes can impact oral health. For example, hormone imbalances can lead to gingivitis in the expecting mother. Increased vomiting from morning sickness, too, can increase the likelihood of developing cavities and tooth erosion (stripping of the tooth’s enamel).

Additionally, the research into the oral-systemic connection during pregnancy draws a connection between gum disease and low birthweight in newborns. Bacteria from gum disease can release toxins in the mother’s body that causes the body to produce chemicals that may stimulate contractions prematurely.

Research also reveals that gum disease may be linked to pre-term birth, but that connection is much less certain for now.

What Does This Mean?

For expecting mothers, it is important to work dental care into the already busy health care routine during pregnancy. For individuals who qualify for Medicaid while pregnant, NCOHC is working to support the extension of dental benefits post-partum to match perinatal health care coverage, which currently lasts 60 days after birth in North Carolina. You guessed it — currently, oral health coverage for the mother ends at time of delivery.

The oral-systemic connection during pregnancy also underscores a notion we have mentioned in all three parts of this series: integrated health care models are key to optimal outcomes. Expecting mothers have a lot do deal with, including a plethora of health care needs, from OB-GYN visits to primary care, birth counseling, and more. This takes time (and time off from work), which is hard to come by for many. We understand that adding oral health care into the mix can be easier said than done.

Integrated health care models, however, offer a way to make care during pregnancy easier on the expecting mother. Clinics and medical practices equipped to serve all the needs of a mother, from oral health care to OB-GYN services, could help ensure that pregnant women receive full-spectrum care to ensure as healthy a pregnancy as possible.

For more on the oral-systemic connection, be sure to read parts one and two of this series, and check out the resources below.

Sign up for NCOHC’s newsletter list to receive updates on stories like this one directly to your inbox.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

Additional Sources for Information on the Oral-Systemic Connection

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Access Equity Public Health Social Determinants of Health

Takeaways From the North Carolina Public Health Leaders’ Conference

The North Carolina Public Health Association recently hosted its 2020 Public Health Leaders’ Conference, drawing professionals from across North Carolina to discuss pressing issues and the public health landscape as we look ahead to 2030 and beyond.

In many ways, this year’s conference marks a turning point in North Carolina, so we sat down with Foundation for Health Leadership & Innovation President and CEO Anne Thomas to talk about the conference and her takeaways.

The theme of the 2020 Public Health Leaders’ Conference was “Shifting the Trajectory: Advancing Equity in Public Health.” According to Thomas, the importance of equity is not a new concept in public health, but the unified focus across public health leaders in North Carolina marks a promising change.

Putting Health Equity Front and Center

“We haven’t always spoken with the language of equity,” said Thomas. “I became a public health director in 1996, and we always talked about disparities, but the conversations used to be, ‘If we just tell people to change what they eat and how they live, they will be healthier.’ We can tell people how to be healthy, but if they don’t have insurance, transportation, or the proper food, and if we don’t address root causes like structural racism and poverty, we aren’t really going to make much of a difference.”

Thomas said that the intentional shift toward an equity-focused landscape in public health is significant. While disparities in health have always been a top priority for public health leaders, the focus has generally been from a clinical frame, leaving non-medical drivers like food, transportation, and housing out of the picture.

At the conference, the North Carolina Institute of Medicine (NCIOM) and the North Carolina Department of Health and Human Services (DHHS) unveiled their “Healthy North Carolina 2030” strategy, which lays out priorities to improve health in the new decade.

The focus on health equity and the overall drivers of health outcomes speaks to the new transformational vision for public health in our state to improve the health and well-being of all North Carolinians.

This excerpt from “Healthy North Carolina 2030” highlights non-medical factors like incarceration rate, reading proficiency, and suspensions as important indicators of health.

Using Social Determinants of Health to Understand Equity

Want to Know More About Social Determinants of Health?

Read our analysis of the most pressing systemic barriers to access where we break down how geography, income, language, race, and more can impact health outcomes.

To highlight health inequities, speakers at the conference discussed the importance of understanding and tackling non-medical drivers of health. Instead of simply treating patients, the speakers championed a more encompassing approach, understanding that health starts in homes, schools, and communities, not once you walk through the doors of a doctor’s office.

“The thing that has really changed is that we are talking about the non-medical drivers of heath, the root causes that have caused health inequities, and evidence-based strategies to address them,” said Thomas.

Thomas said that 20 percent of a person’s health is the result of clinical care, and 80 percent comes from other factors known as social determinants of health. To address that 80 percent, providers will pay attention to social determinants of health, and the health care systems will provide mechanisms to make things like food, housing, and transportation accessible to those who need them to be healthy.

Buying Health: Equity in Action

The concept of “buying health” is where equity becomes operationalized. Buying health refers to a value-based model where health outcomes are measured and paid for, versus the current fee-for-service model, where the cost of care is determined by the service(s) provided.

“Right now, if I go to the doctor, the office gets paid. It doesn’t matter if my health improves because there was an office visit,” said Thomas. “The concept of buying health means screening for these non-clinical factors, and if it is food that they need, or transportation, that food or transportation will actually be paid for.”

NCCARE360, a partnership between FHLI and the Department of Health and Human Services, was also an important topic of conversation at the conference, specifically regarding buying health. NCCARE360 is the first statewide network to unite health care and human services, using shared technology to coordinate person-centered care that provides for both medical and non-medical needs.

By the end of 2020, NCCARE360 will be available in all 100 counties in North Carolina.

Thomas said that buying health was an important topic at the conference, especially as North Carolina prepares for Medicaid Transformation, the state’s plan to transition from Medicaid’s fee-for-service model to “Medicaid Managed Care.” Under Managed Care, the state government will work with insurance companies to create a system that incorporates physical and behavioral health to address both the clinical needs and social determinants of health for Medicaid recipients.

“I feel like we are at a tipping point now,” said Thomas. “Equity is no longer something we just talk about. We are developing real strategies to achieve it.”

Our Oral Health Takeaways

The major themes of this conference—implementing equity, understanding social determinants of health, and transitioning towards value-based care—all apply to oral health care as well as traditional medical care. In fact, these new points of focus highlight the importance of breaking down the siloes that traditionally separate oral health from the rest of the body.

“This new focus is helping communities and providers realize that we really can’t separate the head from the mouth from the body, and we need to stop thinking in a siloed mentality,” said Thomas.
At NCOHC we believe that integrated care models that address all of a patient’s needs, incorporating oral health, medical health, and non-medical needs all under one roof, are integral in creating an equitable health future for all North Carolinians.

As we head into 2020 and plan for the decade ahead, we are excited to work hard to address social drivers of health and pave an equitable path to a healthier future for all North Carolinians.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!