Fluoride Access in Western North Carolina

In North Carolina, nearly 90 percent of the population is serviced by fluoridated water. This is not the case in Western North Carolina, where rates are estimated to be much lower. Limited access to fluoride means detrimental consequences for many people in the western region of the state, where people are more likely to suffer from tooth decay and other oral health complications. Without sufficient fluoride access, people are more vulnerable to these conditions.

Along with the lack of regular access to fluoridated water, there are other drivers that lead to the negative oral health conditions that are so prevalent in WNC. Consuming large amounts of sugar can be a major component for accelerating tooth decay. The acids in sugar damage the enamel on the outer layer of the teeth, leaving them more vulnerable to bacteria, which leads to cavities and gum disease.

Image of water taps

Fluoride, however, plays a significant role in overall oral health outcomes in a given area. Fortunately, even in places like WNC where access to fluoridated tap water is not as widespread, there are other means of accessing the preventive mineral.

Regular brushing is important to keep bacteria under control. There are many fluoridated options for toothpaste, which are more effective in protecting teeth than non-fluoridated options.

For children in North Carolina, physicians in primary care medical offices can apply fluoride varnish that sticks to hard-to-reach areas of the teeth. Dentists can also paint on sealants for patients to help shield teeth from bacteria and prevent cavities. Fortunately, the public health division in North Carolina has also trained dental hygienists to be able to provide some of these preventive services.

Click here to see how Kintegra Health is improving WNC children’s oral health with its Dental Access Program, sending hygienists into schools to provide preventive care, including dental sealants.

We recently spoke in a virtual interview with University of North Carolina Distinguished Professor Gary Slade about the consequences of inadequate access to fluoride. Dr. Slade, who has worked in the Division of Pediatric and Public Health at the Adams School of Dentistry since 1994, works largely on epidemiological research that focuses on oral health and dental diseases in populations.

Dr. Slade explained that data show that children with access to fluoridated water have 30 percent fewer cavities in their baby teeth. As adolescents, they have 12 percent fewer cavities. Fluoride provides clear preventive oral health benefits, which makes the low rates of fluoridated water in WNC especially alarming.

“Because fluoridation rates in Western North Carolina do not count well water or sources that are not from tap water, the numbers we have from data with regard to tooth decay and other oral health conditions are probably worse than they appear,” Dr. Slade said.

As is the case with many small towns in Western NC, cost plays an important role when it comes to providing fluoride for communities. After being accustomed to living without fluoridated water, introducing it is not always seen as a priority. Engineering obstacles in some of these rural areas may also be a deal-breaker for many.

So, what is being done to enact change?

The first and most important step is advocacy. Whether it be a dentist, engineer, public health agency, or parent who speaks up first, change must begin at a local level. Dr. Slade explained that change is not guaranteed to happen just because it seems like the right thing to do. An effort like increasing access to fluoridated water begins with someone championing the cause.

Dr. Slade also spoke about important research he will be conducting in 2021 in Kinston, North Carolina, on the preventive effects of fluoridated bottled water. It is estimated that 115 million Americans do not have access to fluoride in their drinking water at home. That is roughly one-third of the American population, a number that Dr. Slade says will not significantly change in the near future.

Image of bottles of water

Kinston resides in Lenoir County, located in eastern North Carolina. Dr. Slade described it as a prime example of a city that will not likely introduce fluoride into the public water system anytime soon.

Traditionally, dentists and oral health professionals have discouraged people from drinking bottled water due to the lack of fluoride, since most companies do not include it. However, with the rise in popularity of bottled water, Dr. Slade is taking a different approach. Rather than encouraging people to avoid bottled water, the upward trend in popularity would suggest that promoting the inclusion of fluoride in bottled water may be the best approach to improving access to better oral health.

There are many reasons why fluoride access is limited in some parts of the country, but one of them may be the criticism it receives. Dr. Slade suggested that some skepticism may be due to the fact that there has not been a randomized controlled trial of fluoridated water. His study in Kinston will be the first.

The study will include 200 participants, divided into two groups. One group will be given fluoridated bottled water, and the other will be given unfluoridated bottled water. After a period of three and a half years, each participant will receive a dental examination. Because of the true randomized design, no participant or researcher will know who had fluoridated water and who had unfluoridated water until the study is complete.

Dr. Slade expects the resulting data to speak for itself.

Today, it has become increasingly more difficult to implement public fluoridated water systems. There is a significant amount of advocacy from individuals and interest groups on both sides of the issue.

Dr. Slade said that with lower levels of health literacy, it is also more likely that misinformation will stick in people’s minds. Changing that starts with advocacy and education in schools at an early age. There are a lot of questions that surround the topic of fluoride in the United States, but more importantly, there are a lot of answers. Fluoridated water as we know today, provides the easiest and most efficient form of preventive care for lifelong oral health benefits.

Graphic titled "Fluoridated tap water & Toothpaste"

Want to get involved and elevate your voice? From fluoridated water and teledentistry to the rising cost of health care, NC4Change is a platform for a diverse, inclusive group of oral health practitioners, public health professionals, community members, and other stakeholders who share a common goal: increasing equity and access in oral health care.

Head over to the brand new NC4Change page today and sign up for a focus group, give us feedback on our policy brief, and more!


2020 Year in Review

"NCOHC Year in Review"

What a year…

Needless to say, 2020 has been a year for the history books. At NCOHC, we are so incredibly thankful for the front-line health care workers and essential workers who put their lives on the line day in and day out to keep communities healthy and safe. And our hearts go out to all who have lost loved ones and friends.

Despite its challenges, this year has also been a testament to the power of diverse coalitions oriented toward positive change. Here’s a brief recap of what was accomplished to improve oral health in North Carolina in 2020.

Rule 16W Change

NCOHC kicked off 2020 with a bang.

The North Carolina Rules Review Commission gave its final approval to a rule change that we co-sponsored with the North Carolina Dental Society. The change to Rule 16W eased restrictions on dental hygienists, increasing access to preventive oral health care in high-need settings, moving us one step closer toward a more equitable landscape.

You can read about the rule change and the incredible coalition that worked for decades to make it happen here.

COVID-19 & Access Map

…and yet, the 2020 we anticipated shifted dramatically in early March. As heroic health care workers across the globe turned on a dime to fight the COVID-19 pandemic, and our community partners adjusted their workplans for maximum support, NCOHC adjusted our services in support of NC’s our most vulnerable communities.

Picture of NCOHC's statewide provider access map

NCOHC quickly published and continues to maintain a COVID-19 information page. This page includes our interactive COVID-19 Access Resource Map, which connects at-risk communities with safety-net dental providers across the state. As of December, nearly 30,000 people have engaged with the map.

Read more about the access map here.

The NCOHC Teledentistry Fund

In the initial months of the COVID-19 pandemic, most dental offices closed for routine services, only seeing emergency patients. As offices began to grapple with reopening, we partnered with the Blue Cross and Blue Shield of North Carolina Foundation to launch an NCOHC Teledentistry Fund.

With $60,000 to purchase teledentistry software subscriptions, NCOHC has provided more than 15 safety-net clinics with an innovative tool to help maintain patient care while prioritizing patient and provider safety.

NC Medicaid Teledentistry Billing Changes

Prior to the pandemic, NCOHC intended to focus on teledentistry policy in 2020. While teledentistry has incredible potential in a pandemic-free world, COVID-19 made its application even more relevant.

In response to the pandemic, NC Medicaid modified its billing policies to temporarily allow providers to be reimbursed for services provided across asynchronous, synchronous and telephonic teledentistry modalities. You can read about the billing code updates here. NCOHC was thrilled when NC Medicaid announced its temporary teledentistry provisions and, as we move forward, we are hopeful that these payment changes will be made permanent.

Even in a post-pandemic world, teledentistry will play a critical role in increasing access and equity in oral health care.

Oral Health Day(s)

Graphic of Paul Glassman, the "father of teledentistry"

Despite having to cancel the in-person portion of our annual advocacy event, Oral Health Day, we were still able to host not one but two successful virtual events this year! Oral Health Day Parts 1 and 2 focused on teledentistry and its potential in North Carolina, convening 230+ participants. Catch up on the events and hear from our star-studded lineup of special guests here.

What’s Next?

In 2020, NCOHC and the communities we serve had many successes, but there is much to do as we dive into 2021. As we look forward to the New Year, we are ready to hit the ground running, and we need your help!

While 2020 was fruitful for our coalition’s expansion in size and diversity, we always have additional room for all who are interested in working together to create a more equitable oral health landscape. We believe access to quality, affordable oral health care shouldn’t be a privilege or luxury, but a right.

Will you join us in the movement?

To kick off 2021, we’re excited to announce our new online platform to provide a more efficient and effective way to join the movement — North Carolinians for Change! Please join us over at


10 Things You Should Know About Your Teeth

1. Brushing Your Tongue Can Help Bad Breath

The tongue may actually hold more bacteria than your teeth. With its many crevices, your tongue does a great job of trapping bacteria and can cause your entire mouth to smell bad. Similarly, the roof of your mouth can store bacteria, so make sure you brush them both. During the COVID-19 pandemic, “mask breath” can be a serious inconvenience. So, make sure you’re taking the necessary steps to maintain proper oral hygiene!

For more tips and tricks, download this helpful guide.

2. Keep a Routine

No matter what your habits may be, maintaining a dental routine is what really matters. While elaborate toothbrushes and other oral health tools each have their own function and benefits, they will not work without consistency. Similarly, a standard, run-of-the-mill toothbrush, if used for two minutes twice a day, can keep your mouth clean and healthy.

No matter the toothbrush or toothpaste you use, keeping up with a morning and evening routine for oral hygiene, along with healthy eating habits, are the most important steps to keeping your teeth happy and healthy.

3. Start Young

If you have children, the best time to visit a dentist is no later than their first birthday, or after their first tooth erupts. Taking preventive action early can help ensure that your children’s teeth stay healthy and strong as they grow, without major dental complications. Be sure to schedule regular dental examinations once every six months.

For more information on what to expect during your child’s dental appointments, visit this helpful page from the Mayo Clinic.

4. Oral Health Isn’t Just a Mouth Problem

Poor oral health disproportionately affects low-income families and people of color. Unfortunately, studies have shown that it is harder for people with underdeveloped hygiene or missing teeth to secure employment. Increasing education, access, and equity in oral health care can help mend some of these societal concerns.

5. Dental Anxiety

Fear and anxiety surrounding dental treatment is very common. As medical professionals begin to bridge the gap between health care services, therapists are able to work with patients to screen for common conditions like this. They can then implement breathing and relaxation techniques to provide a more comfortable visit. If you are not asked, but suffer from dental anxiety, tell your dentist and dental hygienist.

Anxious about the dentist? Try taking a stress ball with you to your next appointment. During your visit, implement mindfulness strategies, such as slowing and counting your breaths.

For more ways you can learn to cope with dental anxiety, visit

6. Be Wary of Acidic and Sugary Drinks

Fun fact: enamel is the hardest substance in the human body, but it isn’t invulnerable!

Too many acidic or sugary drinks may be harming your teeth. Some beverages have higher levels of acidity than others. These drinks can eat away at the enamel that covers the outer layer of your teeth, leaving them more vulnerable to plaque and bacteria.

Too much sugar can also lead to tooth decay, and soda is one of the easiest ways to consume large amounts. Try to limit your weekly number of sugary and acidic drinks to protect your enamel.

For more on how you can prevent tooth erosion, visit

7. Vaping and Cigarettes Can Damage Your Teeth

No smoking sign

Did you know that smokers are twice as likely to develop gum disease? Not only does smoking affect your breath, it can stain your teeth and lead to more serious complications, such as oral cancer. Similarly, the nicotine in both cigarettes and e-cigarettes can interfere with blood circulation and damage gum tissue.

Learn more about smoking and periodontal disease at

8. Your Saliva is Important

Your saliva is not just for drooling. It helps naturally wash away debris from the food you’ve eaten and can defend against the acid in some of those sugary drinks. You can also thank your saliva for killing some of those germs that cause bad breath.

Without saliva, your mouth would be more vulnerable to tooth decay and gum disease. Be sure to drink water and stay hydrated to maintain sufficient saliva production.

Got dry mouth? Visit for more information on xerostomia (dry mouth).

9. You Can Brush Too Hard

Most toothpastes contain abrasive ingredients such as calcium carbonate that help rid your teeth of plaque and bacteria. Similarly, the bristles on your toothbrush do a good job of scraping away these harmful elements. However, brushing too hard can actually damage the enamel on your teeth, leaving them more vulnerable to tooth decay.

When brushing, use about as much pressure as you would when writing with a pencil on paper. Make sure to use a soft-bristled brush instead of a medium- or hard- bristled brush. Brush in small circles for two minutes and don’t forget to floss.

10. Don’t Ignore Your Dentist

Regular dental appointments are not just for children. The recommended timeline for teeth cleanings is twice a year or once every six months. Even with good habits, consistent dental cleanings and checkups are essential. Oral health professionals will screen for oral cancers and other diseases in your mouth that are not easily caught. So, be proactive and keep your teeth and mouth healthy and safe.

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: Payment Reform

The North Carolina Oral Health Collaborative (NCOHC) released its first policy brief earlier this year, outlining a broad array of policy changes that, if enacted, would improve access and equity in oral health care for all North Carolinians.

Read the full policy brief here

Improving payment models can have a considerable impact on the care people receive, increasing efficiency and improving health outcomes. Payment reform refers to health care models that use reimbursement from insurers to providers to promote greater value for patients, purchasers, payers, and providers.

This third and final deep dive into NCOHC’s policy brief will focus on the payment reform section, elaborating on changes that can be made to make oral health care more efficient and affordable.

Teledentistry and Parity of Payment

Teledentistry has proven to be an effective means of connecting patients with their providers, especially during the COVID-19 pandemic. While remote care has proven to be invaluable in ensuring patient and provider safety, it is also a useful tool to increase equity in care, even in a post-pandemic world.

Unfortunately, some insurance plans do not reimburse for teledental services similarly to how they pay for in-person care.

Providers, especially in safety-net settings with thin profit margins, already frequently use teledentistry, sometimes without reimbursement. Safety-net providers will continue to use teledentistry to provide patients with essential care, and it is important that payment systems support this innovation in care delivery through equitable payment schedules.

Data suggest that patients receive the same quality of care via teledentistry as they do in person. For this reason, NCOHC recommends parity of payment across insurers.

Silver Diamine Fluoride

During the pandemic, there has been an increased focus on preventive care that reduces the amount of close-contact dental visits. One valuable resource in the realm of non-aerosolizing cavity management is the use of Silver Diamine Fluoride (SDF).

Aerosolizing refers to anything that can convert material into a fine spray that can be suspended in the air. Some dental procedures run the risk of aerosolizing the COVID-19 virus, leading providers to look to other, non-aerosolizing options.

When applied directly to a cavity, SDF can have a significant impact on reducing future urgent or emergent dental needs. As an efficient and cost-effective tool that doesn’t risk aerosolizing anything in the mouth, SDF is an ideal treatment to use during the ongoing pandemic.

Prior to COVID-19, payment for SDF varied widely. While NC Medicaid covered SDF, reimbursement was limited for patients five years old and younger. In vulnerable populations, however, many children may not even see a dentist before that age.

While NCOHC commends NC Medicaid for lifting all age restrictions for SDF reimbursement in response to COVID-19, it is important that these payment policies continue post-pandemic.

NCOHC recommends that NC Medicaid reimburse SDF placement for patients of any age. This will allow for more equitable access to this evidence-based treatment for both vulnerable children and adults.

NCOHC also recommends that the private payer sector incentivize SDF as a viable treatment through enhanced reimbursement policies.

Interim Therapeutic Restoration

Other viable options for non-surgical treatment of dental caries include Interim Therapeutic Restorations (ITRs). ITRs are non-permanent restorations placed on teeth to prevent cavities from progressing. Even though they are temporary, ITRs are effective reducing the negative impacts of caries until more permanent treatments can be administered.

Keeping in mind that many children rely on school-based care, this method of addressing tooth decay is particularly important because it could be delivered by hygienists, often at a lower cost. ITRs can dramatically help offset emergent needs in the immediate future. However, in North Carolina, this would be contingent on revision of delegated duties for dental hygienists.

Although many private payers currently reimburse for ITRs, a payment analysis should be done to ensure that they are incentivized as effective treatments through adequate payment models. Post COVID-19, NCOHC encourages NC Medicaid to also reimburse for ITRs.

Value-Based Oral Health Care Payment

As oral health care shifts toward a more value-based approach, focused on improving patient outcomes and lowering costs, it is necessary to think holistically about both the quality of care being delivered and how the care is delivered.

Care coordination management, addressing appointment compliance, motivational interviewing, and patient education to improve oral health literacy are services that should be covered by public and private payer sources to enhance patient-centered care.

These can be useful tools in helping people navigate treatment plans, coordinate transportation, and generally feel more comfortable engaging in social service support. All of these efforts can impact successful delivery of quality oral health care and improvement of patient outcomes.

Fact sheet titled "flip the incentive structure" about value-based care

Patient-centered care also means a patient-centered approach to financing.

When it comes to oral health management, emphasis should be placed on prevention. For vulnerable populations, it is often unknown when patients will be able to return for care. Bundling payment for services such as comprehensive oral health evaluations, prophylaxis for adults and children, topical application of fluoride and varnish, and sealants would incentivize providers to cover necessary services in a single visit.

NCOHC also recommends bundling nutritional counseling, tobacco counseling, and oral hygiene instruction as adjunctive non-paid services.

Payment reform and public policy must work in conjunction with one another to achieve long-lasting results. More often, payment reform drives changes in public policy. This means that Medicaid and private payers play a particularly important role in facilitation innovation in public health. As we begin to find new measures of success in value-based care, implementing these necessary changes will help improve peoples’ health and transform the oral health landscape.

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!