Recap: Oral Health Day Part 2

Last week we had the opportunity to take an in-depth look at teledentistry at Oral Health Day Part 2. Three North Carolina dental directors and a panel of national experts took questions and presented to a crowd so large that we had to upgrade our Zoom subscription mid-event!

The dental directors at Kintegra Health, Piedmont Health, and Greene County Health Care (GCHC) kicked off the day, talking about the many ways their Federally Qualified Health Centers (FQHCs) use teledentistry to improve patient care. All three directors took questions from the audience.

“Know where you’re going and have a roadmap,” said Dr. Mattison-Chalwe, answering a question about the planning process to successfully begin using teledentistry technology in a practice.

The dental directors answered questions and discussed everything from the planning process, to tips and tricks, to getting diagnostic-quality patient information, and the ways that new technology has increased clinic efficiency.

“We got a lot closer to medical,” said Dr. Doherty, referring to the relationship GCHC’s dental facility was able to make with their medical counterparts as they implemented teledentistry protocols. “It is very easy for a provider to give us a call — a medical provider, and we just jump right in on the call and get those patients seen very quickly.”


Watch Drs. Donigan, Mattison-Chalwe, and Doherty in three live teledentistry demonstrations.


After the dental directors spoke, three nationally recognized teledentistry experts took the virtual stage. Dr. Paul Glassman, the “father of teledentistry” and professor and associate dean for research and community engagement at California Northstate University College of Dental Medicine, spoke about the process of actually “doing teledentistry,” and the future of remote care.

“This is really based on calibration and communication,” said Dr. Glassman. “It’s based on the idea that you’re going to trust the hygienist who is in the community.”

Dr. Scott Howell, assistant professor and director of teledentistry at the A.T. Still University Arizona School of Dentistry & Oral Health, walked the audience through several examples of the various ways he uses teledentistry in his clinical practice.

Dr. Howell mirrored Dr. Glassman, saying that collaboration and communication is key to successfully using teledentistry technology.

“The field team must be calibrated,” said Dr. Howell. “There has got to be trust. Trust between dentist and hygienist; the dentist has to trust the technology. And as I tell my students, this is not something that you develop overnight. It is something that takes time to develop.”

Brant Herman, CEO of MouthWatch — a provider of teledentistry software and equipment — spoke about the actual technology necessary to practice via teledentistry. He also covered common misconceptions about what it takes to incorporate remote care in a clinical setting.

One of the bigger misunderstandings highlighted by Herman is the idea that there is only one way to do teledentistry.

“It’s really just the tool. You’re just using the technology as the tool,” said Herman. “You’re facilitating the other approaches to care coordination, care delivery, through this technology. It can be all of these different services that really just use teledentistry as the backbone to connect patients, providers, and care.”

MouthWatch, LLC, was generous enough to donate four intraoral cameras for the event, which NCOHC raffled off live.

NCOHC has worked collaboratively alongside diverse stakeholders in jointly drafting teledentistry legislation, which is slated to be introduced during the 2021-2022 legislative session. This bill will work to improve providers’ ability to incorporate teledentistry technology in their practices, and will ensure that quality oral health services, aided by teledentistry, are delivered equitably throughout North Carolina.

Stay tuned as we move forward. We encourage and welcome all voices at the table, so please consider signing up to receive our newsletter, and help us create a more equitable oral health landscape in our state.

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!


Reducing the Rate of Childhood Caries in WNC

From the highest peaks east of the Mississippi to the unique sounds of bluegrass music, Western North Carolina is a one-of-a-kid region. But like many rural areas across North Carolina and the United States, the communities that make up WNC face pressing challenges when it comes to oral health.


Across the western region, children on Medicaid receive less preventive oral health care than their peers across the state. In Regions 1 and 2, as reported by the North Carolina Department of Health and Human Services Oral Health Section, only 43 and 42 percent (respectively) of children ages 1-2 receive any preventive oral health care.

We could rattle off statistics and conclude that there simply aren’t enough dentists in WNC, but the problems faced are not so simple. While the workforce numbers and the distribution of providers across our state are an important issue, there are several layers of barriers preventing many in WNC from accessing the care they need.

When looking at third grade students, the data suggests that initiatives to reach children outside of the traditional dental home are at least partially responsible for a higher-than-average rate of dental sealants among third graders. Across Regions 1 and 2, nearly 49 percent of third graders surveyed in the 2017-18 school year had received dental sealants, compared to a statewide average of 45.9 percent.

Even with the rate of sealants in Regions 1 and 2, however, only 41.8 percent of surveyed students had no tooth decay, compared to the statewide average of 54.5 percent.

So what do all these numbers mean?

There are unique issues that vary across WNC, and each individual community faces its own challenges. For example, if you look at Region 1, only 13 percent of the population is serviced by fluoridated water. For comparison, nearly 90 percent of North Carolinians have access to fluoridated water.

So, whether the problem be access to providers, adequate oral health education, access to basic preventive measures like fluoride, or any number of other issues, significant effort is needed to improve children’s oral health in WNC.

In 2017, the Duke Endowment, Mission Children’s Hospital, and the WNC Health Network partnered to conduct an oral health needs assessment and further explore the specific issues facing WNC communities. From there, stakeholders identified strategic focus areas and formed the WNC Children’s Oral Health Initiative.

Earlier this year, NCOHC absorbed the WNC Children’s Oral Health Initiative, now called the WNC Steering Committee, to help specifically tailor efforts to increase equity and access in the region.

Meet the steering committee and further explore the barriers to access in WNC here.

As we continue our work, keep an eye out for breakdowns of the issues that WNC communities face, and the innovative approaches leaders in dentistry are taking to tackle them.

Get started by exploring how Kintegra Health is pushing forward, even during the COVID-19 pandemic, with a plan to use teledentistry and school-based care to provide preventive services to more than 6,000 elementary school students in the counties west of Charlotte this year alone.

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!


NCOHC’s Policy Brief: Care Delivery

NCOHC released its first policy brief in the summer of 2020 to provide an overview of the many policy changes that could increase equity and access to oral health care in North Carolina. This is the second of three deep dives to further expand on the policies within the brief. You can read the first one here.

Read the full policy brief here

As North Carolina grapples with an oral health workforce imbalance, there are several opportunities to improve the efficiency and effectiveness of care delivery. The opportunities in this section are relatively simple—not requiring a change to scope of practice, but rather simply modernizing the Dental Practice Act to better utilize technology for patient care, and to open doors for collaboration between medical and dental providers.

Adoption of teledental service utilization

During the COVID-19 pandemic, teledentistry has proven to be an invaluable tool allowing patients and providers to connect in safe, socially distanced settings. Prior to the pandemic, teledentistry served as a vital tool for increasing access to oral health care, as well. Providers across North Carolina have effectively leveraged the use of technology in community-based and school-based settings, allowing those who traditionally would not see a dentist to receive care through teledentistry.

To learn more about teledentistry and the many ways it is used, join us for Oral Health Day Part 2 on Oct. 23 and hear from some of North Carolina’s dental directors and three renowned experts in remote care technology.

Although health clinics and other providers — in both public and private sectors — regularly have provided teledental services, NCOHC advocates that to ensure future use of teledentistry as a care modality, stakeholders need to take steps to codify its use in North Carolina.

First, NCOHC recommends permanently adopting language to include electronic service delivery within the definition of dentistry, under Chapter 90, Article 2. These changes would simply update the Dental Practice Act, since remote care technology wasn’t even on the radar when the original language was drafted. Not only will the addition of language to Article 2 further define and codify teledentistry as a care delivery modality in our state, but it will also add in consumer protections for the provisions of remote care.

Finally, and specifically to payment reform, NCOHC urges both NC Medicaid and the commercial dental benefit plans to allow for the reimbursement of teledentistry both synchronously and asynchronously. These codes, D9995 and D9996, respectively, have been a part of the national billing nomenclature since 2018. Because of the lasting impact that teledentistry could make — even beyond a pandemic setting — it makes prudent sense to permanently adopt these billing codes.

Integration of Care

NCOHC is a strong advocate for integrated care, another area where teledentistry technology could play an important role. Tools like intraoral cameras are easy to use, and simply capturing images of a patient’s mouth can assist in connecting that patient to the care they need. NCOHC sees a big opportunity for using teledentistry technology in primary care settings to capture supplementary patient information for referral to dental providers.

Finally, NCOHC outlined several options to expand the dental workforce, including the community care coordinator.

Check out what one of NCOHC’s interns, Parker Norman, recently wrote about care coordination, and take a look at how Kintegra Health, a Federally Qualified Health Center west of Charlotte, uses teledentistry and care coordination to complete a network of care for children in Title I schools.

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!


A Deep Dive into Care Coordination in North Carolina

At Kintegra Health, a Federally Qualified Health Center (FQHC) serving several counties west of Charlotte, care coordination is increasing access to oral health services. Today, Kintegra’s 11 dental navigators are helping families understand their oral health needs, recording an astonishing 70 percent treatment completion rate.

In a recent blog post, Parker Norman shared how dental care management workforce models use care coordination to help providers address social determinants of health and expand access to oral health care services. In this post, she explores two examples in North Carolina.

What is Care Coordination? A Quick Review

As a recap, through care coordination, patients are connected with the resources they need to access oral health care services, including reliable transportation, comprehensive oral health insurance coverage, providers who accept that insurance, and providers who speak the same language as their patients.

Communicating with patients in their native language is especially important.

By speaking the same language as the people in the communities they serve, care coordinators can often help patients feel more comfortable. Coordinators — often referred to as “navigators” — can also promote oral health literacy through patient education delivered in a patient’s native language. With an understanding of the importance of good oral health, people are more likely to seek and utilize oral health care services.

Dental Care Management Models

Dental care management models include dental navigator models and the ADA-formalized Community Dental Health Coordinator model (CDHC). Both models aim to employ culturally competent individuals from the communities they serve. These coordinators are better able to understand vulnerable patient needs and connect them with the resources necessary to access optimal oral health.

Dental navigator models and the CDHC model are already used in North Carolina, and both are expanding access to care. Dr. William (Bill) Donigan, dental director at Kintegra Health, and Crystal Adams, a registered dental hygienist and director of Catawba Valley Community College’s (CVCC) dental hygiene program, provide insight about these models and offer recommendations for North Carolina as more are put into practice.

Care Coordination Case Study: The Dental Navigator Model at Kintegra Health

Kintegra Health first began to use the dental navigator model in 2006 as part of a school-based program, with hygienists calling parents to schedule their children’s appointments. By 2010, dental navigators joined the hygienists at schools to help schedule appointments. Starting in 2012, Kintegra hired a dental navigator for every county served by its school-based program —one navigator each in Davidson, Lincoln, Catawba, and Iredell Counties, and two in Gaston County.

By 2016, Kintegra Health was placing dental navigators in other health care areas, including pediatric medical, OBGYN, and Women Infant Children (WIC) clinics. These navigators provide patient and parent education, schedule appointments in communication with parents, and apply fluoride varnish for children. Although this program primarily serves children, some adultOBGYN patients are also served. There is limited space for adults in Kintegra’s dental clinics, so teledentistry is often used during medical appointments to bridge this gap.

To learn more about teledentistry, join NCOHC for Oral Health Part 2 on October 23rd, watch how Kintegra and other clinics provide remote care, and hear from some of the nation’s leading experts.

At Kintegra Family Health in Statesville, the pediatric medical clinic and family dentistry clinic once shared a waiting room. Since the offices were side-by-side, it was assumed that a medical provider would give a dental referral to patients and their parents, who would then schedule the appointment. Because of this, no dental navigator was employed at that location.

In 2016, almost 970 new patients saw a dentist at Kintegra Health in Gaston County, where a dental navigator was employed in the pediatric medical clinic. During the same year, only 48 new dental patients were seen at Kintegra’s Statesville location. Howeer, after a navigator began working in the Statesville WIC clinic, more than 50 new patients saw a dentist in just one month. The figure below compares expected patient volumes during one year with dental navigators and one year without.

Graph displaying Kintegra Health's new patient volume with and without dental navigators. In Gastonia with a navigator (2016), 970 new patients; in Statesville with no navigator (2016), 48 new patients; projected new patient volume in Statesville with navigator, 600

Kintegra Health has measured a 70 percent treatment completion rate for patients receiving oral health care with the help of dental navigators, compared to about a 30 percent completion rate in private practice.

With statistics like that, it is clear to see that Kintegra Health’s dental navigator model is increasing access through care coordination. There are now a total of 11 navigators employed by Kintegra Health and, during the last eight years, these navigators have helped more than 9,500 patients access dental care.

If Dr. Donigan were to start a new clinic, he said he would first employ a CDHC, rather than a dental navigator. A CDHC is trained to present the program to key stakeholders, some of whom are outside of the clinic setting, such as at school board meetings. CDHCs are also trained to use motivational interviewing techniques to expand the program.

After patient volume began to increase, Dr. Donigan would then start employing dental navigators to speak one-one-one with parents and patients. As he already does at “Dr. Donigan’s School of Dental Navigation,” he would train the new dental navigators on-site in oral health education. He would also require that they complete the Smiles for Life program, which equips primary care providers to promote oral health for all age groups, and he would require that they become Dental Assistant IIs (DA2).

Catawba Valley Community College CDHC Program

Catawba Valley Community College’s CDHC program is a year-long program with specific curriculum, training, and internship requirements. Before entering the program, a CDHC candidate must also have a professional DA2, Child Development Associate, or Registered Dental Hygienist license. It often takes longer for a CDHC to be able to find employment, compared to a dental navigator, given the formalized criteria that must first be met. However, once employed, a CDHC is already equipped with education and training.

In North Carolina, there are no CDHC-title jobs available — most jobs are marketed as general dental navigators without a specific CDHC requirement. Because of this, most students in CVCC’s program complete it as part of their continuing education and go on to work in other oral health roles. The positive outcomes of the program need to be proven to stakeholders so that CDHC jobs are actually funded before CDHCs will be employed as CDHCs.

“Let’s not look at the dollar, let’s look at the people,” Adams said, referring to the important work CDHCs could do to help people navigate barriers and access oral health care.

Adams also mentioned that while the CDHC curriculum is nationally formalized, care coordination is not “cookie cutter,” and there is no one-size-fits-all model. Different dental offices serving different populations will go about care coordination differently. At CVCC, Adams is adapting the program to make sure it is up-to-date and applicable for target populations in North Carolina. This includes educating students on things that may vary across state borders, such as insurance coverage.

CVCC will enroll its third cohort of CDHC students this January.

Dental navigator and CDHC models in North Carolina expand access to oral health care for vulnerable populations, addressing oral health inequities and improving overall oral health outcomes. The positive consequences and areas for improvement for both models should be considered as we move forward to implement future models effectively.

Over the 2020-2021 academic year, Parker Norman will be conducting a formative process evaluation of the CDHC program at CVCC. The evaluation will confirm if the program is feasible, appropriate, and acceptable, as well as inform decision-making related to the program’s improvement and ensure long-term success. Be on the lookout for the outcomes of this research, which will be applicable to other current and future programs!