Access Public Health Teledentistry

Teledentistry in North Carolina: Lessons from COVID-19

Depending on how long it takes to effectively respond to COVID-19, NCOHC is planning to host its annual Oral Health Day on June 3, 2020. This year, the theme of our signature advocacy event at the North Carolina General Assembly is teledentistry, with a focus on its use as a tool to increase access and equity in oral health care.

Our primary focus has been on how teledentistry can allow dentists to provide assessments and diagnostic care remotely, allowing them to reach patients in underserved communities

The North Carolina Board of Dental Examiners and the American Dental Association have both recommended that dental offices postpone all elective procedures for two and three weeks, respectively. While dentists and hygienists obviously won’t be doing oral cleanings or other routine, elective procedures virtually—education, assessments, and other diagnostic care and consultation could be provided remotely while waiting to resume in-person care delivery.

Simultaneously, hospitals and doctors’ offices across the country are struggling to meet demand, and we are seeing medical professionals forced to isolate after coming in contact with patients who have COVID-19.

Last week, the Telehealth Resource Center hosted a webinar about how health care organizations can use telehealth in response to COVID-19. You can watch the recorded webinar here.

For health care organizations, telehealth technology offers the ability to remotely monitor potential COVID-19 patients. Through phone screenings, virtual visits, and remote patient monitoring (RPM), providers can keep track of patients’ health and symptoms without any person-to-person contact. The same applications could be used in oral health care delivery as well.

Additionally, providers can use live video and RPM to care for inpatients, reducing points of contact.

To learn more about telehealth and how it can be used in response to COVID-19, you can access TRC’s COVID-19 Telehealth Toolkit here.

And to find out more about Oral Health Day and the steps North Carolina can take to help teledentistry become a viable option for remote oral health care, visit the NCOHC Oral Health Day 2020 page.

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!

Access Public Health

Oral Health Around the World

This Friday, March 20, is World Oral Health Day. So, we decided to take a look at some of the oral health issues people face in a few countries and regions around the globe.

In 2016, 3.58 billion people worldwide were affected by oral diseases. In the U.S. and around the world, gum disease and tooth decay consistently rank among the most prevalent conditions impacting people’s health.

Oral Health on the African Continent

Residents of countries across Africa face a few unique oral health challenges. While common oral disease rates are fairly low compared to other regions—only 14 percent of 35- to 44-year-olds and 22 percent of 60- to 69-year-olds experience gum disease—other, sometimes fatal, issues are more prevalent.

Oral and Facial Trauma

Due in large part to political instability and conflict across the continent, oral and facial trauma—broken or chipped teeth and jaw injuries impact as many as one in five children in Africa.


Noma is a disease most prevalent in sub-Saharan Africa that primarily impacts children suffering from malnutrition. While the gangrenous disease can be stopped and reversed with basic hygiene, antibiotics, and proper nutrition, sadly it is currently fatal in about 90 percent of all cases. When properly treated with antibiotics, noma’s mortality rate decreases to around 8 percent, making the first statistic especially jarring.


Oral manifestations are some of the earliest visible signs of HIV, making them important indicators of the disease. About 26 million people living in Afria are HIV-positive, accounting for nearly 68 percent of global cases of the disease.

HIV is still uncurable at a large scale, but doctors in London appear to have recently cured the second patient in the world of HIV. The patient received a stem-cell transplant and has been HIV-free for more than 30 months. The first patient to be cured of HIV has been free of the disease since 2011 after receiving a similar treatment.

Healthy China 2030

China is experiencing an ongoing oral health crisis, with tooth decay and gum disease affecting more than half the country’s population. A 2019 study into the oral health status of Chinese residents found that fewer than half of China’s population brush their teeth twice a day.

To respond to its public health crisis, China has launched Healthy China 2030, an initiative to incorporate public health into all of the Chinese government’s policies. Healthy China 2030 includes specific campaigns focused on oral health education, and it aims to shift the focus of health care toward preventive measures. These measures include education, as well as an increased focus on social determinants of health.

Health Care in Brazil

In 1988, Brazil’s government began to implement a government-run healthcare system, making it the only country at the time with more than 200 million residents to implement a plan for universal health care. Funding shortages and other barriers hinder Brazil’s system, and an article in the British Medical Journal of Global Health describes how economic and political instability could reverse the progress made since the 1980s.

Despite the instability of its health care system, Brazil has successfully provided a significantly larger portion of its residents with health care, dramatically improving the overall health of its population.

Brazil’s universal health care system focuses on primary and preventive health care, including oral health. Since 1988, Brazil’s “DMFT” index, or the mean number of decayed, missing, or filled teeth, among its population has decreased considerably. For example, the DMFT index for 12-year-olds has changed from 6.7 to 1.3 since the 1980s.

Unique Challenges In India and Tiawan

Have you heard of the Betel Nut? Chewing a betel nut causes a sense of euphoria and heightened alertness on par with consuming six cups of coffee, and it is incredibly popular in countries like India and Tiawan. A simple tree nut may not seem threatening, but this particular one is a potent carcinogen that has created an oral health crisis among its users.

Betel nut chewing can lead to a variety of oral diseases, including oral cancer and pre-cancerous lesions. In fact, 80 to 90 percent of Tiawanese residents diagnosed with oral cancer or pre-cancer chew betel nuts.

The time it takes for negative effects to develop makes the betel nut especially dangerous. This article from the BBC details the journey of one nut chewer, Qui Zhen-huang, who started chewing betel nut because, “everyone at work did it.”

He chewed for ten years and then quit. Twenty years after quitting, he developed oral cancer in the form of a golf ball-sized tumor and a hole in his left cheek.

The first references to betel nut chewing appeared in ancient Greek, Sanskrit, and Chinese literature. The tradition’s span of two or more millennia makes it a hard one to break, so governments are having a hard time convincing their citizens to quit.

In Tiawan, the government actually pays people to voluntarily cut down betel nut palms. In India, on the other hand, betel nut production has tripled since 1961. Some states and territories in India have implemented bans on specific betel nut products, especially ones that combine the nut with tobacco. However, the bans haven’t seemed to have much of an impact on its production and consumption.

Make A Difference Locally

To learn more and get involved with oral health improvement efforts here in North Carolina, visit our Oral Health Day 2020 page to see what we are planning for our signature advocacy event on June 3rd. If you’d like to receive updates about stories like this directly to your inbox, be sure to sign up for NCOHC news.

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’re interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!


Highlights from the UNC Teledentistry Symposium

Last week, FHLI’s North Carolina Oral Health Collaborative attended the UNC Adams School of Dentistry’s Teledentistry Symposium, co-sponsored by the ECU School of Dental Medicine. Speakers from across the state joined oral health professionals in Chapel Hill to discuss technological innovations in oral health care and how they can be implemented to increase access across North Carolina.

The summit featured keynotes from experts in teledentistry as well as live demonstrations of the technology in action.

Dr. Rob Tempel and Dr. Andres Flores kicked off the demonstrations with a synchronous teledentistry consultation, followed by an example of asynchronous teledentistry from Dr. Shaun Matthews, the director of telehealth at UNC’s Adams School of Dentistry.

The 2020 Teledentistry Symposium follows UNC’s first ever Teledentistry Summit, which was held in October 2019. During his keynote address, Dr. Matthews reviewed the first summit and its goals, noting that oral health leaders have been successful in reaching those goals, including updating state-level dental hygiene regulations, visiting active teledentistry sites, and convening a statewide workgroup.

Dr. Shaun Matthews, director of telehealth at the UNC Adams School of Dentistry, giving his keynote address at the symposium.

NCOHC Director Dr. Zachary Brian also gave a keynote address, discussing the use of teledentistry as a tool to increase access for underserved communities and the policy changes necessary to make that happen.

Here are some highlights and takeaways from the day:

1. Rural North Carolinians Disproportionately Lack Access to Oral Health Care

Of North Carolina’s 100 counties, 74 are designated Dental Health Provider Shortage Areas (HPSAs). Dr. Brian discussed how this landscape leaves residents in most of the state with limited access to in-person oral health care. This barrier is further compounded when considering the disparities in access between those on Medicaid and those with private insurance.

Dr. Zachary Brian discussing NCOHC’s role in addressing access gaps and barriers during his keynote address.

Dr. Sy Saeed compared oral health care disparities to access gaps and barriers in psychiatry, highlighting legislative efforts to promote telepsychiatry across the state. Compared to the 74-county oral health care shortage, a whopping 90 counties are psychiatric HPSAs. In an effort to combat the access gaps and to reduce emergency department visits, the state legislature passed a law in 2013 to create NCSTeP, a statewide telepsychiatry program.

2. We Have a Growing Shortage of Dentists

Dr. Brian discussed how a decline in our state’s dentist population is compounding the access issues facing rural North Carolinians. Dentists are retiring at a faster rate than they are graduating and beginning to practice. More troubling still, this shortage is only expected to increase through 2025.

Meanwhile, North Carolina’s dental hygiene programs are consistently at or near capacity, so we are simultaneously experiencing a hygienist surplus. This could be a promising trend, but North Carolina’s regulatory landscape restricts hygienists’ ability to practice at the top of their licensure. Additionally, dentists in North Carolina can only supervise two hygienists. So even with the growing number of practicing dental hygienists, the dentist shortage limits the workforce’s ability to expand access to crucial preventive services.

A panel of students discussed their perspective on the dentist shortage, disparities, and the use of technology to bridge coverage gaps. Student groups at UNC and ECU have formed to advocate for curriculum changes to incorporate teledentistry so graduating dentists are better prepared to positively impact oral health outcomes in North Carolina through technology.

3. Teledentistry Can Expand Access

All summit speakers agreed that connecting dentists in central locations with hygienists and patients across the state is an effective path to expanding access to traditionally underserved communities.

With teledentistry, dentists can remotely provide diagnostics measures like exams, assessments, consultations, and direct education to patients. Dr. Brian noted that almost all oral health issues are preventable, so increasing access to preventive care is a high-impact, cost-effective strategy to improving overall oral health outcomes.

In his address to the symposium’s attendees, ECU School of Dental Medicine Dean Greg Chadwick said that, “teledentistry is a tool, not a goal.”

The goal is expanded access, covering North Carolinians equitably. Innovation in teledentistry is a promising way to achieve that goal.

4. Significant Barriers Still Prevent Teledentistry from Expanding

While North Carolina law doesn’t prevent the use of teledentistry, there is currently no reimbursement model for Medicaid patients to receive asynchronous teledental care, and the payment rate for synchronous teledentistry is prohibitively low.

Dr. Mark Casey, NC Medicaid’s dental director, joined a panel of health care providers to discuss payment models to ensure providers are reimbursed for their services. All panelists agreed that payment parity is necessary, and they said that asynchronous reimbursement should be a top priority moving forward.

To get there, Bobby White, the CEO of the North Carolina Board of Dental Examiners (NCBDE), said that the NCSBDE is willing and anxious to move forward with teledentistry, but out-of-date language in the Dental Practice Act needs to be updated by statutory change.

From left to right: Dr. Alec Parker, executive director of the North Carolina Dental Society; Sommer Wisher, past president of the North Carolina Dental Hygienists’ Association; Bobby White, CEO of the North Carolina State Board of Dental Examiners and Greg Chadwick, dean of the ECU School of Dental Medicine.

That’s why this year, NCOHC is dedicating its signature advocacy event, Oral Health Day 2020, to teledentistry.

On June 3, oral health professionals, community voices, and other oral health champions will convene at the North Carolina Legislature for a day of action and advocacy. We will engage and educate elected officials about the importance of teledentistry and the necessary legislative changes to allow it to expand into our state’s rural communities.

To learn more, visit our Oral Health Day 2020 page and register today!

To learn more and get involved, visit our Oral Health Day 2020 page to see what we are planning for our signature advocacy event on June 3rd . If you’d like to receive updates on stories like this directly to your inbox, be sure to sign up for NCOHC news.

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!

Equity Public Health Social Determinants of Health

How the World Around Us Impacts Our Oral Health: An Intro to the Social Determinants of Health

Only 20 percent of a person’s health is the result of clinical care in a medical or dental provider’s office. The other 80 percent comes from a variety of non-medical factors. To reach equity in oral health, our health care system must address that 80 percent, which means accounting for external influences in patients’ lives.

From the food we eat to our housing and transportation options, many aspects of our daily lives can impact our health. Social determinants of health, also known as non-medical drivers of health, refer to the wide variety of influences outside the provider’s office that can directly or indirectly impact health outcomes.

Take food option-driven obesity as an example. If fast food makes up most of our mealtime options, the high-sugar, high-carb food we consume regularly will likely contribute to obesity, risk for heart disease, and increase the risk of tooth decay.

When it comes to oral health specifically, there are clear disparities in access to care and outcomes in North Carolina. Race, economic status, and geographic location are all important oral health determinants. For example, while around 20 percent of all children in our state experience tooth decay, roughly 50 percent of children in low- income families are affected.

Social determinants of health broadly fit into five categories: economic stability, physical environment, education, food, and structural and governmental influences. Each of these categories contains several specific factors. For example, employment, income, insurance, debt, and financial support all fall under the economic stability umbrella.

To better understand social determinants of health and how they can impact oral health outcomes, NCOHC will dive deep into each of these five categories over the coming months. We will discuss how the income an individual earns and the county in which they reside can directly impact their oral health, and we will explore how the state and federal policies cascade down to the local level, affecting health care opportunities among communities that traditionally lack access.

At the end of the day, policy change is a vital step in the process of addressing social determinants of health to create a truly equitable landscape for oral health care in North Carolina. That is why NCOHC engages elected officials and regulatory bodies to enact positive policy changes like that of the recent regulatory amendment to rule 16W .0104.

To learn more and get involved, visit our Oral Health Day 2020 page to see what we are planning for our signature advocacy event on June 3rd . If you’d like to receive updates on stories like this directly to your inbox, be sure to sign up for NCOHC news.

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!