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School-Based Dental Programs

Oral health providers: Make sure to scroll to the bottom of this post to learn more about a school-based oral health grant opportunity from The Duke Endowment, the Blue Cross and Blue Shield of North Carolina Foundation, and the Blue Cross and Blue Shield of South Carolina Foundation

The COVID-19 pandemic has offered many lessons for public health, one of the greatest being the importance of “meeting people where they are.” Whether it be serving patients remotely via teledentistry or enabling dentists to deliver COVID-19 vaccinations, the oral health care community has shown resilience and innovation in expanding access to care during the pandemic.

Yet there are many more opportunities to increase access and equity in oral health care, both during and post-pandemic. One of these opportunities is expanding school-based dental programs.

In this post, we’ll take a look at school-based dental programs — what they are, why they’re needed, and how they can transform overall health in North Carolina by increasing access to oral health care for some of our state’s most vulnerable populations.

What Are School-Based Dental Programs?

School-based dental programs provide a range of oral health care services directly to students. While the extent of services offered varies, every school-based dental program brings care into the community, providing access to oral health care that many vulnerable populations may otherwise be denied.

Some school-based dental programs utilize fixed equipment in schools, while others rely on mobile clinics parked on school property. Services provided may include, but are not necessarily limited to:

  • Oral screenings and risk assessments
  • Fluoride varnish applications
  • Dental sealant applications
  • Oral prophylaxes
  • Radiographs
  • Oral hygiene instruction
  • Nutrition and/or tobacco counseling

Above all, the configuration of school-based dental programs is flexible, and there are impactful ways to meet communities’ needs across all types of clinical models (more on this a little later).

In particular, school-based dental programs are uniquely positioned to address the social determinants of health, many of which present significant barriers to oral health care for school-aged children. The success of these programs in driving positive oral health outcomes is also well-documented, as we will explore further in this post.

“School-based health programs can level the playing field for children otherwise unable to access oral health care services,” says Dr. Zachary Brian, director of the North Carolina Oral Health Care Collaborative (NCOHC), a program of the Foundation for Health Leadership and Innovation (FHLI). “These programs offer an approach that can significantly increase access and equity for children across our state.”

The Need for School-Based Dental Programs

The need for improving access to oral health care for children in the United States is starkly evident, as is the opportunity for school-based dental programs to address disparities and barriers faced by at-risk populations.

Dental caries (cavities) is the most common chronic disease among U.S. children, according to the U.S. Department of Health and Human Services. According to the Centers for Disease Control and Prevention (CDC), roughly 52 percent of U.S. children have had a cavity in their baby teeth by the time they are eight years old.

In North Carolina, almost 50 percent of schoolchildren have tooth decay, according to the NC Department of Health and Human Services, Oral Health Section.

Disparities in oral health status between socioeconomic groups are also widespread. The CDC reports that low-income children are twice as likely to have cavities as higher-income children. In North Carolina, the picture is just as bleak. According to an analysis by NC Child, “children from poor, rural counties [in North Carolina] tend to have the highest rates of decay.”

“We have a high percentage of schools with students who get free and reduced lunches. We have some schools where 100 percent of our students receive that free lunch because of how many of them qualify under the federal poverty level,” said Dr. Elly Steel, dental clinical director at the Cabarrus Health Alliance, which has operated a school-based program since 1999. “With these children who aren’t getting access to care in other places, bringing the care to them at their schools is really helpful.”

Racial and ethnic disparities are extreme, as well. A study of more than 70,000 North Carolina kindergarteners found that “the prevalence of dental caries was 30.4% for White, 39.0% for Black, and 51.7% for Hispanic students.”

The Importance of Oral Health for Children

With an ever-increasing amount of evidence establishing a connection between oral health, overall health and wellbeing, the case for expanding access to oral health care for children is clear.

Oral health plays an important role, not only in children’s overall systemic health, but also in their well-being and social development. The CDC reports that, “on average, 34 million school hours are lost each year because of unplanned (emergency) dental care.”

The data in North Carolina is similarly damning, with an analysis finding that “children with poor oral health status were nearly 3 times more likely … than were their counterparts to miss school as a result of dental pain.” The study concluded that children with poor oral health status were also more likely to perform more poorly in school.

Oral health is also integrally connected with a child’s self-esteem and behavioral health: one recent study found that “various dental disorders … cause a profound impact on aesthetics and psychosocial behavior of adolescents, thus affecting their self-esteem.”

"There is no shame worse than poor teeth in a rich world." - Mary Otto, oral health researcher and journalist

Social Determinants of Health

The social determinants of health are significant factors driving disparities in access and outcomes for North Carolina’s school-age children. Parents and caregivers often lack access to reliable transportation to take children to and from dental appointments. And even when transportation is available, however, it may be impossible to get time off work.

Location also plays a major role, with access to oral health care significantly more limited for those living in rural areas. In North Carolina, dental providers are highly concentrated in urban centers; 98+ of the state’s 100 counties are designated as Dental Health Professional Shortage Areas (dHPSAs) by the Health Resources and Services Administration (HRSA).

Why School-Based Dental Programs for North Carolina?

The need is apparent, and while efforts to improve and sustain surveillance and evaluation in oral health care have been undertaken in North Carolina, the state lacks an adequate system to provide direct preventive services and closed-loop referral for comprehensive oral health care for at-risk populations. School-based dental programs can fill critical gaps in that system by meeting people where they are and reducing barriers to care influenced by the social determinants of health.

Increasing Access, Improving Outcomes

More than 2,500 school-based health centers (SBHCs) are operating in the United States, with only an estimated 28 percent having an oral health care provider on site, according to a report in Health Affairs.

The research increasingly supports the effectiveness of these programs improving access and oral health status among U.S. children. A 2021 study published in the Journal of the American Dental Association (JADA) determined that bringing cavity-prevention programs directly into school settings reduced cavities by 50 percent, after only six visits.

“Our hygienist who works more directly in the mouth is seeing a huge improvement in many of the children that are returning for repeat visits,” said Rachel Stewart, a registered dental hygienist who works for the East Carolina University School of Dental Medicine on a school-based initiative in Bertie County, North Carolina. “Their oral hygiene is improving, they’re taking more pride in their teeth, and their teeth are looking cleaner and better.”

A 2016 study of school-based dental sealant programs also demonstrated similar effectiveness among schoolchildren in low socioeconomic areas.

School-based dental programs are cost-effective, too. A recent report concluded that “the cost to place sealants on a child in a SBSP [school-based sealant program] is approximately $100 compared with the lifetime cost to maintain a tooth that develops caries, which can exceed $2,000.”

Researchers have also estimated that implementing a national school-based caries prevention program “could reduce Medicaid spending on children’s oral health by as much as one-half.”

Dental Hygiene Workforce

North Carolina’s oral health care workforce is well-equipped to provide preventive services in school-based settings. Dental hygienists in North Carolina are highly trained, skilled, and engaged, and there is ample opportunity to leverage this expertise and experience in school-based dental programs.

Recent regulatory changes, including a change to Rule 21 NCAC 16W .0104, co-sponsored by NCOHC in 2020, aims to provide greater opportunity for dental hygienists to deliver preventive services in high-need settings such as school-based programs. These changes allow for dental hygienists to deliver preventive services in high-needs settings without a prior examination by a dentist, therefore amplifying service delivery and decreasing administrative burden. Other potential legislative changes, such as increasing the dentist to hygienist supervision ratio, could also prove similarly helpful.

The Next Step

Recently, The Duke Endowment has partnered with the Blue Cross Blue Shield of North Carolina Foundation and the Blue Cross Blue Shield of South Carolina Foundation to expand school-based dental programs across the Carolinas. Collectively investing more than $35 million, these groups are supporting dental safety-net health centers in implementing school-based dental programs in North Carolina and South Carolina.

“This initiative is a revolutionary opportunity to increase access and equity and improve oral health outcomes among schoolchildren in the Carolinas,” says Dr. Brian. “With the support of The Duke Endowment, the Blue Cross Blue Shield of North Carolina Foundation, and the Blue Cross Blue Shield of South Carolina Foundation, North and South Carolina can make significant strides in reducing barriers to oral health care and improving oral health outcomes for at-risk populations.”

Get Involved

If you are an oral health care provider or administrator interested in learning more about expanding your practice to serve your communities’ children in school-based settings, we invite you to join us for a free online informational session on either July 27th or August 11th.

In these sessions, in addition to learning about opportunities for community impact through school-based oral health programs, participants will have a chance to learn about the application process and the deadline for funding, as well as hear directly from current grantees about their experiences.

In addition, following the live, interactive learning sessions, participants interested in applying for the next cohort will have an opportunity to engage in 1:1 coaching where you’ll dive into your program ideas and innovative approaches to strengthen your application.

To reserve your spot in a virtual informational session, please click here to register.

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Diversity in the Workforce: An Opportunity for Change

In order to build a more equitable oral health care system for all North Carolinians, it is paramount to pursue policies that encourage the development of a more diverse oral health care workforce.

The pursuit of equity can’t only focus on the patient side of the equation—those who either can or cannot access the care they need. The dental profession has historically struggled with equity, both among patients being able to access the care they need, and among those who train and enter the industry as dentists and other oral health professionals.

White males still represent the majority of dentists, while white females have long dominated the dental hygiene profession. Disproportionate representation by race, ethnicity, and gender is especially predominant among North Carolina dentists and hygienists.

In this blog post, we’ll take a look at the current demographic makeup of the oral health care workforce in the U.S., and in North Carolina specifically. We’ll discuss why provider diversity is so critical and outline potential policy solutions for developing a workforce that looks like the patients it serves.

The Importance of Diversity in the Oral Health Care Workforce

Why does diversity in the oral health care workforce matter?? The answers are many. Research suggests that more diverse racial, ethnic, and gender representation among dental providers can dramatically reduce barriers to access for the underserved and improve oral health care utilization and outcomes.

“Increasing diversity in the dental workforce is more than just the right thing to do,” said Dr. Zachary Brian, director of the North Carolina Oral Health Collaborative. “Its positive impact is also backed by evidence, with greater provider diversity helping increase access and improve utilization and outcomes, particularly for our most underserved communities.”

 

Beyond clinical outcomes

Diversity among dentists can help build equitable communities

 

Equity on the employment side of oral health care in and of itself will play an important role in increasing equity in society as a whole. In a previous NCOHC blog post, we spoke with Jen Zuckerman from the Duke World Food Policy Center. Zuckerman pointed out that equity pursuits in any industry shouldn’t be seen as solely aimed toward those able to access the industry’s services or goods.

 

Those pursuing equity should also ask who is financially benefitting from a given industry. What communities are benefiting from generational wealth accrued by those employed in that industry? For too long throughout American history, communities of color across the board have been structurally left out of many, if not most, opportunities to build generational wealth. From the GI Bill and red lining to college admissions, loans, and more, “the white community has continually gotten investment through policies, programs, and initiatives,” said Zuckerman. “And communities of color have continually gotten programs and services, which do not build wealth.”

 

At the end of the day, policies that would allow underserved communities to access care are vital, but the numerous social determinants of health that limit access in the first place must be structurally weeded out, too. Income is one incredibly important determinant of health that more diverse employment in high-paying industries like dentistry can significantly impact.

Racial Diversity: A Means to Improve Access, Utilization, and Outcomes

A recent report by the Oral Health Workforce Research Center found that “Improving the racial and ethnic diversity of the nation’s dentists is critical in efforts to reduce disparities in access to care and health outcomes and to better address the oral health needs of an increasingly diverse U.S. population.”

Research shows that dental health is worse in communities of color, and it has also been demonstrated that patients are more comfortable receiving care from a provider of their own race.

The impact of systemic and interpersonal racism on oral health care is also frequently overlooked: a 2019 study found that “dental visits were less common among those who reported racial discrimination while using the healthcare system or reported emotional impact of discrimination than those who did not.” The same study concluded that “those who experienced the emotional impact of racial discrimination were 25% less likely to have visited the dentist in the past year than those without such experience.”

Studies have also determined that non-white dentists care for a disproportionate number of at-risk patients in minority and underserved communities. Researchers have found that 53 percent of clinically active Black dentists reported primarily treating underserved patients at their primary practice, and another study concluded that “the Hispanic/Latino (H/L) dentist workforce is a critical component of our dental delivery system and is shown to contribute to improved access for H/L populations and underserved populations.”

Increasing racial diversity within the oral health care workforce is therefore imperative for eliminating access barriers, increasing utilization, and improving outcomes.

Gender Diversity: Increasing Access and Offering New Perspective

While there is less research concerning patient preference regarding provider gender (although we can reasonably infer an effect similar to the one revealed in studies on provider race), female dentists are noted for bringing different perspectives and approaches to the practice of dentistry.

For one, studies have shown that female dentists are more likely than male dentists to practice in urban and public health settings, and they are more likely to treat lower-income patients. These findings suggest that increasing gender diversity in the oral health workforce has the potential to improve access to care for our most vulnerable.

Research also suggests that female dentists may be better at encouraging preventive care than their male counterparts. A study published in the Journal of the American Dental Association found that “female dentists recommended at-home fluoride to a significantly larger number of their patients than did male dentists” and “female dentists also chose to use preventive therapy more often at earlier stages of dental caries.”

There is no question that female dentists bring a fresh perspective to a profession long dominated by men. Writing about the increase in female dentists, Dr. Cindy Roark, a dentist herself, notes in an article for Dentistry Today that “at its most basic level, a diverse leadership team means a healthcare organization will naturally have a greater understanding of the populations it serves.”

Where Do We Stand Today? Diversity Among Dentists and Hygienists

By Race and Ethnicity

People of color are greatly underrepresented among the dentist and hygienist workforces. A 2016 study by the American Dental Association’s Health Policy Institute (HPI) found that just 26.4 percent of U.S. dentists were non-white, despite people of color representing 38.7 percent of the total population.

The disparity is even more stark in North Carolina, where according to a recent study, 81.5 percent of dentists are white, despite white people representing only 64.1 percent of the population. Even more disproportionate, North Carolina’s dental hygienists are 92.5 percent white.

Recent trends are more encouraging. According to HPI, “from 2008 to 2018, the percentage of active white dentists [in the United States] decreased from 78.2% to 71.9%.” While Asian and Hispanic dentists made gains, however, alarmingly, the percentage of Black dentists was relatively unchanged.

By Gender

In addition to being disproportionately white, U.S. dentists are mostly male. According to data compiled by the American Dental Association (ADA), in 2020, 65.5 percent of professionally active dentists were male. Women made up just 35.5 percent. Data derived from the North Carolina State Board of Dental Examiners (NCSBDE) shows that the gap is narrowing in our state, but the disparity remains pronounced.

Among dental hygienists, the gender divide is flipped. While up-to-date data for practicing dental hygienists is hard to come by, the American Dental Education Association (ADEA) reports that 94.7 percent of students currently enrolled in an accredited dental hygiene program are female.

Opportunities for Growth: Supporting Diversity in the Dental Workforce

There is no silver bullet to improve racial and gender diversity in the oral health care workforce. That said, there is no shortage of common-sense, evidence-based policies to help bridge existing gaps and build a dental workforce reflective of the people it serves.

We’ll focus on just two such opportunities in this blog post: early educational interventions and improved recruitment efforts by dental schools.

Early Educational Interventions

Limited awareness of oral health care career opportunities and lack of support for early education and “pipeline” programs present significant barriers to racial minorities and women entering the dental workforce.

Pipeline programs in particular — which provide all-inclusive support in the form of mentorship, scholarships, externships, and/or other opportunities — are fundamental in helping introduce minority students and those from underrepresented communities about dental career opportunities.

Notably, a dental pipeline program funded by the Robert Wood Johnson Foundation made initial grants to 11 dental schools to support community-based education related to opportunities in dentistry for minority and low-income students. A less comprehensive but similar “Saturday Academy” program organized by the NYU School of Dentistry introduces underrepresented minority and low-income high school students to dentistry as a viable career option and offers mentorship.

Policymakers should consider support for similar programs in order to attract a new generation of diverse students to dental education and oral health care careers.

Dental School Recruitment

No less important than efforts to introduce minorities and women to career opportunities in dentistry are dental schools’ own recruitment policies. For too long, dental schools have done little to proactively seek diverse pools of applicants, let alone admit classes that reflect the populations they will one day serve. Researchers have recently noted that “U.S. dental schools’ admission practices present a critical gateway to increased diversity, but the current pipeline of qualified minority applicants is insufficient.”

This is not to say that change isn’t happening. Many dental programs — including North Carolina’s own UNC Adams School of Dentistry and East Carolina University School of Dental Medicine — have taken steps to increase diversity in their dental programs. Data indicate that North Carolina’s dental students more closely mirror the state’s racial composite than does the dental workforce itself. An analysis of dental classes graduating 2015-2019 showed that 36 percent of UNC dental students were non-white, as were 28 percent of ECU dental students.

Potential opportunities to increase recruitment of minority, women, and otherwise underrepresented students by dental schools include, but are not limited to:

  • Increasing diversity on the interviewing and admissions teams/committees
  • Increasing diversity among faculty and staff
  • Emphasizing cultural competency in dental curriculum
  • Support for dental pipeline programs
  • Mentorship opportunities
  • Increased financial assistance and scholarship opportunities

In Conclusion: Moral and Practical Imperatives for Diversity in the Dental Workforce

Policymakers have both moral and practical imperatives to increase diversity in the dental workforce. The cause is just, and the science is clear: racial and gender diversity among oral health care providers increases access and improves both utilization and outcomes.

If we are to build a more equitable and accessible oral health care system for all, it is critical that we support the development of a workforce that reflects the populations it serves.

The North Carolina Oral Health Collaborative (NCOHC) is actively working with stakeholders across North Carolina to help develop a more diverse oral health care workforce. For more information on NCOHC and to get involved, please become a member of our advocacy platform, NC4Change — membership is free and there are many opportunities to engage with our work. Together we can build a more equitable and accessible oral health care system for ALL North Carolinians.