Social Determinants of Health – Structural and Governmental Influences

The heart of oral health equity is a blend of improving actual health care delivery, modifying public policy, and influencing structural change. Approximately 80 percent of a person’s health is the result of factors outside the doctor’s office, so it is necessary to account for all three. Each plays an important role in addressing systemic barriers to oral health care access.

We recently published an introduction to social determinants of health—the environmental conditions that impact a person’s health—outlining several categories of systemic barriers that prevent people from achieving optimal oral health.

Graphic depicting five social determinants of health: physical environment, structural & governmental influences, education, food, and economic stability

From the physical distance between a patient and provider to the policy that governs dental practice, this week we’re diving into structural and governmental influences to see how they impact oral health outcomes.

Where can I go to access oral health care?

Depending on where you live, this can be a difficult question to answer. North Carolina ranks 37th in dentists per capita, with just 49 practicing dentists for every 100,000 residents.

To put that in context, if all North Carolinians were to receive standard cleanings and check-ups every six months, every single practicing dentist in the state would need to field 4,080 appointments every year. And that doesn’t even account for emergency visits, restorations, and other care beyond regular preventive appointments.

Graph comparing nationwide average patient volume of 3,505 per year to the needed patient volume of 4,080 per year to actually meet demand in North Carolina

Most of North Carolina’s practicing dentists are consolidated in just one fifth of the state’s 100 counties, compounding this shortage in rural communities. Seventy-four, predominately rural, counties are designated dental Health Provider Shortage Areas (HPSAs).

For many in North Carolina, the answer to, “Where can I go to access oral health care?” includes additional childcare, time off from work or school, and long drives (if they have access to a vehicle).

How do I pay for oral health care?

Even if every person in North Carolina could afford to see a dentist, it is clear from the statistics above that there isn’t the infrastructure in place to meet that demand. Everyone can’t afford to see a dentist, though. Oral health care is prohibitively expensive for many, especially those without insurance.

Many private practice dentists in North Carolina don’t accept Medicaid. However, for the uninsured and those on Medicaid, there is a great network of public health providers across the state. These clinics accept Medicaid and offer care on a sliding fee scale for those without insurance or who can’t afford to pay. Specifically, Federally Qualified Health Centers, local health departments, free and charitable clinics, among other entities across the state, offer these care options for those who lack access.

Unfortunately, the existing network of public health providers still doesn’t meet demand. Many patients simply aren’t familiar with what options are available in their communities, and those with urgent oral health needs often seek care in a hospital’s emergency department.

Emergency department physicians are not dental health professionals, so patients won’t get the needed treatments such as root canals, extractions or fillings when they go in for toothaches. Generally, an emergency department patient will receive a prescription for an antibiotic and an opiate, which will just calm the pain until the meds run out.

North Carolinians visit emergency departments at twice the national rate, and operating room costs for dental procedures exceed $40 million annually.

Increasing Visibility of Safety-Net Access Options During COVID-19

To help reduce emergency department demand for urgent oral health concerns during COVID-19, NCOHC has published an interactive map of oral health care safety nets across the state. The map is meant to serve as a tool to divert patients with urgent needs from emergency departments to nearby local health departments, Federally Qualified Health Centers, free and charitable clinics, and other safety nets.

The Collaborative is currently outlining strategies to re-purpose this map and develop additional tools that will help those with oral health needs find affordable care providers after the COVID-19 pandemic.

Picture of NCOHC's statewide provider access map

So, how do we change North Carolina’s oral health care structure to better meet the needs of those in our state?

The answer to this question in many ways lies in public policy. North Carolina is one of the four most restrictive states when it comes to allowing dental hygienists to practice to the full extent of their education and licensure.

While we have a serious, and growing shortage of dentists, we simultaneously have a growing surplus of dental hygienists. Unfortunately, state law only allows a dentist to supervise two hygienists at a time, preventing the growing workforce from having the opportunity to expand access to care, especially in remote areas where the dentist shortages are the most severe.

Earlier this year, NCOHC and the North Carolina Dental Society co-sponsored a change to Rule 16W.0104 of the Dental Practice Act. This change allows public health dental hygienists in Dental Health Provider Shortage Areas (HPSAs) to practice in community-based settings such as schools and long-term care facilities based on a written standing order from the supervising dentist, in lieu of a physically present dentist on site.

In one of our recent interviews, dental hygienist, educator, and advocate Crystal Adams said that if she could change anything in North Carolina’s regulatory framework, allowing dentists to supervise more than two hygienists would be at the top of her list.

There are many other policy proposals that could also increase access, like introducing postpartum Medicaid dental coverage, or modernizing the Dental Practice Act to allow providers to bill for telehealth care delivery.

Stay tuned as we break down other social determinants of health and the work being done to address them in the coming weeks.

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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!


FHLI’s New Office Mates

The North Carolina Oral Health Collaborative’s parent organization, the Foundation for Health Leadership & Innovation, moved to remote work back in March. Social distancing can be a difficult transition, so we decided to check in on our co-workers, and their new office mates, to see how they’re doing.

Ava O., Foundation for Health Leadership & Innovation

Picture of dog Ava with her head on a pillow

Ava is tired after a very long day helping her mom at the office. She waits patiently but is delighted about the work-from-home situation. She has put in a formal request for more belly rub breaks during the workday.

Ava S., NCCARE360

Picture of dog Ava asleep on a couch

Ava is frustrated that her office isn’t warmer, but she has found that sleeping on the job is a solution she can work with.

Blu, North Carolina Oral Health Collaborative

Picture of dog, Blu, with a bow tie in front of a laptop

Blu has really stepped up to the plate since FHLI moved to remote work. He retains some sense of normalcy by dressing up for Zoom calls, and he loves screening emails in his outdoor office. He’s very glad to have so much company during the day.

Diesel, Center of Excellence for Integrated Care

Picture of dog Diesel sleeping on a carpet.

Diesel is an older fellow. He just turned 11 in January. He’s grateful that his workmates moved their office to the first floor, so he doesn’t have to navigate the stairs.

Edie and Pearl, Practice Sights

Picture of cats Edie and Pearl sitting in front of laptops.

Edie (left) doesn’t take “no” for an answer. She will grind her office’s work to a halt and refuse to move until she gets her pets. Pearl (right) is the more intellectual of the two. You can often find her searching for deeper meaning in her computer’s screen saver.

Freya Jane, M.E.O.W., Center of Excellence for Integrated Care

Picture of cat Freya Jane standing menacingly in front of a computer

Freya Jane, M.E.O.W., supervises and reviews all of her human’s reports before they can be submitted. She is the boss of her virtual office, and she is known for ruling with an iron fist.

Frida Pawlo, Rural Forward NC

Picture of cat Frida Pawlo stretching on her human's bed

Frida Pawlo has finally accepted that her coworker is not leaving the house any time soon—on the condition that she gets the bed during daytime hours.

Ila and Abbey, North Carolina Oral Health Collaborative

Picture of dogs Ila and Abbey sleeping next to each other

Ila and Abbey enjoy sleeping on the job most of the day. They have been referred to HR to work on their productivity, as well as their video chat etiquette.

Lydia, Center of Excellence for Integrated Care

Picture of dog Lydia asleep on her back

Lydia is busy adapting to her new shared workspace—humans can be so disruptive when they’re home all day—so she sent in a picture from her younger years.

Peanut, Rural Forward NC

Two picture of a dog, Peanut, at a desk in front of a computer and sleeping outside

Peanut is busy adapting to her new work environment. She misses getting out in the community and meeting her partners where they are.

Since moving to remote work, Peanut has been caught sleeping on the job a few times. We understand how tempting the sun can be, but we’ve had to refer her to HR to develop a pupformance improvement plan.

Pepper and Marley, Center of Excellence for Integrated Care

Picture of two dogs, Marley and Pepper, snuggling each other on a bed

Pepper and Marley have finally grown to accept that there will be no dog park adventures in the future, but they find consolation in the fact that their owners are home. All. The. Time. They sleep on the job, yell during calls and video meetings, and have a bizarre fascination with all squirrels and birds that quite frankly is becoming a little entertaining to the rest of us. TBD on how their performance evaluations will be next month…

Phoebe, Rural Forward NC

Picture of dog Phoebe sitting in a field

Phoebe, aka Feebs, Feebo, or Sneako, works at the Graham-based FHLI satellite office. Phoebe has quickly demonstrated her effectiveness as a footwarmer, and she has a knack for team-based work, playing a critical role in her office’s fetch and lap-sitting duties.

Phoebe’s performance in the last month has been spectacular, and her supervisor has recommended her for a promotion.

Sheldon Lee Schribman, B.S., M.S., M.A., Ph.D., Sc.D., FHLI Communications

Picture of dog wrapped in curtains he tore down

Dr. Sheldon Lee Schribman, B.S., M.S., M.A., Ph. D., Sc. D, is by far the best educated member of the FHLI team. He has been social distancing since before it was cool. Dr. Schribman does not appreciate being around anyone other than his mom, so this remote work situation is really working out well for him. He spends his days eating his weight in treats and “greeting” the UPS guy at the front window.

Now, if only those pesky drapes would get out of his way…


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!


Dental Hygienists Week – An Interview with CVCC’s Crystal Adams

Picture of Crystal Adams, Department Heat at Catawba Valley Community College, with quote pulled from text

Last week was National Dental Hygienists Week, so we sat down (virtually) with Crystal Adams, a dental hygienist and dental hygiene program director at Catawba Valley Community College (CVCC), for a conversation about her career path and the importance of hygienists in the dental home.

Adams is a passionate advocate for oral health care with an inspiring drive to improve the lives of those who traditionally cannot access care. She has important insight into the role that hygienists play in the dental home, and she has worked in several capacities to modernize North Carolina’s regulatory framework.

In our interview, we discussed Adams’ path to becoming a dental hygienist, the important services that hygienists provide, and changes that could be made to better allow hygienists to serve their communities.

When did you decide that you wanted to be a dental hygienist?

When I graduated high school, I knew I eventually wanted to be a dental hygienist, but first I went the dental assisting route. I graduated from Wilkes Community College with my dental assisting diploma and then I worked for four years in a private practice as a dental assistant.

I had the urge to continue my education, though, and the dentist I worked for allowed me to leave work early to take prerequisite courses at CVCC to prepare for the dental hygiene program. I attended the Dental Hygiene Program at Central Piedmont Community College (CPCC) in Charlotte — I commuted from Alexander County to Charlotte for two years — and graduated in 2001. From there I went back, as a dental hygienist, to the practice I had worked at before my education at CPCC.

What are the education requirements to become a dental hygienist?

A dental hygienist has to take prerequisite courses — they have about a year and a half of prerequisites that they have to take, in addition to the two-year dental hygiene curriculum. Most programs like for students to take those prerequisites prior to starting the dental hygiene curriculum because it is so demanding. It’s a lot of work.

So, it’s a year and a half of prerequisites and then two years of curriculum. It’s very close to being a bachelor’s degree. I think that’s something that is important for people to understand. It’s more than just a two-year program. It’s really closer to three and a half with the prerequisites.

Why did you want to pursue dental hygiene for your career?

I didn’t have dental care when I was young. My parents didn’t have that oral health literacy. So, this was an area where I knew that I could help, especially in my community. There are a lot of people in my community that don’t understand oral health care.

In your view, what is a dental hygienist? What role do they serve in the dental office, and how has that allowed you to serve your community and improve patients’ understanding of oral health care?

I believe a dental hygienist is an educator. We can clean someone’s teeth, but the biggest part of our job is making sure that patients understand what to do at home. We make sure they’re taking care of their needs so that whenever they come in we can focus on preventing things from happening instead of treating something that has already gone wrong. So, I feel like we are prevention specialists, and our number one role is education.

So, education was a big part of your role in private practice. Now you are full-time at Catawba Valley Community College. Is the role of educator what led you to the community college setting?

Once I started practicing as a dental hygienist, I still had that drive to help even more. I started working part time at Catawba Valley Community College and I just loved sharing my knowledge and skills, and I loved seeing the students grow.

Once I started teaching, I decided to continue my education and get my bachelor’s degree and master’s degree. I was able to get a full-time teaching position at CVCC, and eventually I became the director of the program, which has allowed me to serve in several capacities at the state level, as well as serving as the president of the North Carolina Dental Hygienists Association.

Something that we have been putting a lot of thought into at NCOHC is the disparity between dentists and hygienists in terms of volume. There is a growing shortage of dentists as they are aging out and retiring faster than our universities are graduating new dentists. Simultaneously we have a growing surplus of hygienists. How is this impacting the hygienist workforce?

I think this is a big problem, and I think the most important thing here is that hygienists aren’t able to use the skillset in North Carolina that they are taught to use. They could be serving local communities where there aren’t many dentists, and we could be providing care to individuals who don’t normally get care.

I think if we could go to more of a general supervision model and actually use the skills we are taught, then we would be able to serve more of the underserved communities in our state that don’t get care.

The recent change to Rule 16W seems to be a step in that direction, to allow dental hygienists to go into underserved areas and provide care with a written standing order from a dentist, without the dentist being physically present. Could you speak briefly from the hygienist’s perspective about what the rule change means for oral health care in North Carolina?

I think it is a really positive direction for our state. The rule change allows hygienists to get more involved in school settings, nursing homes, and long-term care settings where we can actually use our skills to the full extent of our training. It gives us the ability to serve communities when dentists are not as available to be physically present, and I think it is a step toward allowing us to be the professionals we are intended to be.

Are there other skills that hygienists are taught in school that you are not allowed to practice under North Carolina’s regulatory framework?

Yes. So, that’s a bit of a tricky question because we are taught the theory of local anesthesia, but since it is not a delegable duty in North Carolina, we don’t teach the skill portion. But we are taught local anesthesia.

Hygienists in other states can administer local anesthesia. If North Carolina began to allow this here, what change would need to happen on the education level? Would beginning to teach the skill portion be a big change?

We already incorporate pretty much all of the education into the dental hygiene program because our students have to test on the national level. Anesthesia is included in that testing because so many states do allow hygienists to administer local anesthesia.

The extra step of teaching the skill portion would not be difficult to incorporate into our programs at all, because the foundation is already there.

If you could snap your fingers and change anything in North Carolina’s regulatory framework, what would it be?

If I could change anything, I would allow hygienists to administer local anesthesia. Additionally, I would expand the change that has already been made to rule 16W for indirect supervision to allow hygienists to use their skills when the dentist is not on the premises in more settings.

I think those changes would allow us to actually perform what we are taught in school and to be the professionals we are meant to be. So, local anesthesia and relaxation on supervision to allow us to treat more people when the dentist is unavailable.

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!

Education Oral Cancer Public Health

Should I Be Worried About Vaping?

With youth-oriented advertising depicting e-cigarettes as not only a cigarette alternative, but a clean, fun, and popular choice to make, an increasing number of teens and young adults are picking up the habit, often without having ever smoked cigarettes in the first place.

Graphic depicting the potential risks of e-cigarettes, including gum disease, tooth decay, and oral cancer

The quick adoption of e-cigarettes among young users is especially alarming because experts still don’t know what long-term health outcomes may result. Because of that, no one can say for sure what will happen to young people who habitually smoke e-cigarettes, even though initial research suggests that many negative health impacts are possible.

April is Oral Cancer Awareness Month, so we’re taking a look at e-cigarettes and what existing research suggests about their impact on the mouths and throats of users.

Here are some of the health outcomes discovered so far.

Gum Inflammation

A study in Oncotarget, a peer-reviewed oncology and cancer research journal, found that flavored e-cigarettes induce gum inflammation. The study found that e-cigarette use causes a form of DNA damage that re-enforces chronic inflammation, an important contributor to the spread of oral disease.

Bone Loss, Oral Disease, and Tooth Decay

Several studies (cited below) have found connections between e-cigarette use and bone loss, oral disease, and tooth decay.

One study of 18,289 participants found that those with no history of gum disease who used e-cigarettes regularly for one year had increased odds of being diagnosed with gum disease.

Another study of 456,343 adults found an independent association—meaning the association persisted even when other risk factors were controlled—between e-cigarette use and the likelihood of having at least one permanent tooth removed because of tooth decay.


Oral Cancer

A study in the International Journal of Molecular Science compared e-cigarettes and traditional cigarettes, focusing on their impacts on the mouth at a cellular level. Broadly, this study found similarities between cigarettes and e-cigarettes when it comes to the cellular damage that has the potential to lead to oral cancer.

Additionally, other studies cited below found potent carcinogens and carcinogenic trace metals in e-cigarette vapor and the saliva of e-cigarette users.


What does all this mean?

What do we know E-cigarettes have been associated with poor oral health outcomes, from tooth decay and gum disease, to a potentially increased risk of oral cancer.

What don’t we know Without further research, oral health care experts cannot say how often poor outcomes will happen, how often an individual must use an e-cigarette to be impacted by negative health outcomes, or how severe the impacts could be.

Long-term studies must be conducted in order to obtain more representative data.

However, what we do know is important: The risk is present, and e-cigarette users must ask themselves,
“Is it worth the risk?”

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!


Oral Cancer Awareness

Every year, an average of 53,000 Americans are diagnosed with some form of oral cancer, killing one person every hour.

When detected in its early stages, oral cancer is highly treatable and, in many cases, curable. Unfortunately, oral cancer often goes undiagnosed until late in development, significantly elevating its death rate.

Here are a few steps you can take to make sure you aren’t increasing your chances of developing a form of oral cancer.

Choose a lip balm with sunscreen, and use it whenever you are outside

Lip balm isn’t just for chapped lips. We should shield our lips from the sun just like we protect the rest of our skin, as overexposure increases the chance of oral cancer of the lip. Many brands offer lip balm with SPF that you could add to your sunny day routine.

Eat your fruits and vegetables

It may seem like an urban myth that parents tell their children to make them finish their dinner, but low intake of fruits, vegetables, vitamin C, and fiber has been associated with increased cancer risk. Inversely, high consumption has been shown to cut the risk of oral cancer in half.

Avoid tobacco, and use alcohol in moderation

While not as significant as the link between cigarettes and lung cancer, smoking tobacco products has been linked to oral cancer. Additionally, heavy consumption of alcohol—which is generally defined as more than three drinks per day—increases the risk of oral cancer.

According to the Oral Cancer Foundation, cell wall dehydration from alcohol makes it easier for carcinogens from tobacco smoke to penetrate oral tissue cells. When alcohol and tobacco are combined, which is often the case for people who refer to themselves as “social smokers,” the risk of oral cancer skyrockets to more than 15 times that for non-users of the two substances.

Don’t use smokeless tobacco products either

Smokeless tobacco products like chewing tobacco are a major risk factor for oral cancer. Additionally, new research is highlighting risks associated with vape and e-cigarette products. More research still needs to be done in this area, but initial studies suggest that e-cigarette use increases risk of gum disease, tooth decay, and oral cancer.

Get an HPV Vaccine

Human Papillomavirus (HPV) has been linked to an increased risk of developing oral cancer. Because the sexually transmitted virus goes largely undetected in most carriers, getting an HPV vaccine is a good practice to both avoid the virus and reduce the risk of HPV’s impact on the oral cavity. For further guidance on HPV vaccination, please discuss with your primary care or dental provider.

HPV is the leading cause of the oropharyngeal cancers of the tonsils and base of the tongue. While there are nearly 200 strains of HPV, strain 16 is of concern as it relates to your oral cavity. Please review the Oral Cancer Foundation’s website to learn more.

Visit your dentist

The Oral Cancer Foundation suggests that patients receive an oral cancer screening annually, especially if they fit any of the common risk factors for the disease.

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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!