Author: NC Oral Health Collaborative

If you’ve ever experienced pain or discomfort in your jaw, you might have heard someone casually refer to it as “TMJ.” But what does that really mean? And is it accurate? It’s common for people to mix up TMJ, which refers to the temporomandibular joint itself, with TMD, which stands for temporomandibular joint disorders.

Understanding the difference is crucial because while everyone has a TMJ, not everyone experiences the pain and complications that come with TMD. Let’s dive into what these terms mean, how to recognize a TMD, and what you can do if you’re suffering from jaw pain.

TMJ vs TMD

TMJ stands for temporomandibular joint, which is a joint in our mouths. There is one TMJ on both sides of your mouth, and it connects the jawbone to the skull. TMJ Disorders (TMD), on the other hand, may cause pain in your jaw or mouth.

How Do You Know if You Have a TMD?

Signs of TMJ Disorders (TMD) may vary from person to person. The Mayo Clinic provides the following list of symptoms for TMJ Disorders:

• Pain or tenderness in the jaw
• Pain in the TMJ joint
• Pain in the ear area
• Pain while chewing
• Pain or ache in the face
• Locking of the jaw
• A clicking sound in the jaw accompanied by pain

There are many causes of TMJ Disorders, including injuries, teeth grinding, arthritis, or general wear on the joint, and every case is unique.

Diagnosing & Treating TMD

If you have any signs of TMD, you should see your dentist. They can evaluate your jaw and determine the best course of action. During your appointment, they will examine your jaw, feel for pain, and check the alignment of your jaw bones. If necessary, they may order an X-ray, MRI, or scan to examine your jaw more closely.

According to The Cleveland Clinic, there are many treatments for TMD, and your dentist will determine which is best for you. These include cold/heat therapy, bite guards/night splints, medications, and/or dental treatments. If needed, the dentist may recommend other treatments for more severe cases of TMD, such as injections, ultrasound or radio wave therapy, or surgery.

How Long Does TMD Pain Last?

According to the experts at the Mayo Clinic, most TMD pain is temporary. It can range from mildly annoying to severely painful, but the good news is that it’s often treatable, especially when caught early.

While it’s easy to confuse TMJ with TMD, understanding the distinction can help you better identify and describe the pain or discomfort you might be experiencing in your jaw. If you have jaw pain, clicking, or locking symptoms, contact your dentist or doctor for an evaluation. They can suggest at-home care or recommend more advanced treatments to get you feeling better!

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

Natural disasters impact every aspect of our lives in obvious and unexpected ways—oral health is no exception. As the climate crisis continues, we see increasingly catastrophic storms worldwide, and areas such as Western North Carolina (WNC) that were previously considered climate-safe face levels of destruction never experienced before.

In the aftermath of Helene, a remarkable combination of community response and federal and state support has coalesced to aid recovery across the region. Despite monumental effort across the board, the disaster has exposed vulnerabilities and existing disparities that will take significant time to fix.

While oral health might not be among the most pressing needs immediately after a natural disaster like Hurricane Helene, addressing dental needs as Western North Carolina recovers will be vital for overall health and ensuring people have access to the care they deserve.

In this blog post, we’ll discuss common effects of natural disasters on oral health, short- and long-term responses, and opportunities for meeting dental needs across WNC.

How Natural Disasters Can Impact Your Oral Health

Hurricane Helene exceeded all storm damage predictions, and many people found themselves unprepared, trapped, or otherwise suddenly cut off from the world. When a natural disaster shuts down everything from power to the internet and access to drinkable (also known as potable) water for an unknown amount of time, simple daily tasks like teeth brushing and oral hygiene routines quickly get upended.

Here are a few ways events like natural disasters can affect oral health:

• Disrupted Oral Hygiene Routines: Disasters can restrict access to clean water, including municipal water systems that provide fluoride and hygiene products, impacting oral care routines. These interruptions increase the risks of developing cavities, gum disease, and infections, especially in prolonged emergencies.
• Stress-Related Dental Issues: High-stress situations often lead to teeth grinding (bruxism) or jaw clenching, which can cause worn enamel, cracked teeth, and TMJ (temporomandibular joint) pain.
• Reduced Access to Dental Care: Disaster-impacted areas may have limited or no access to dental clinics, causing minor dental issues to worsen over time due to a lack of immediate treatment options. This is especially true in communities already facing various barriers to accessing oral health care before the event.
• Nutritional Challenges: Emergency food supplies often contain processed, sugary items, elevating the risk of decay and gum issues over time, especially without clean water to wash away excess sugar particles.

Daily routines like oral health may be forgotten in the immediate aftermath of a disaster, but that doesn’t mean it is any less critical. Preparing a dental hygiene kit with an extra toothbrush, toothpaste, floss, and water bottle for yourself and your family can help you maintain your oral hygiene routine during a natural disaster or other emergency.

Remember to drink water during and after eating, especially sugary and processed foods, when possible.

Addressing Oral Health Needs During a Natural Disaster Public Health Emergency

As we learned during the COVID-19 pandemic, systems-level measures can help mitigate risks and support long-term well-being during a public health emergency (PHE).

After Hurricane Helene, traditional and non-traditional points of care stopped in Western North Carolina. Without access to reliable electricity and water, dental offices were forced to suspend services, and with schools shut down and roads closed, mobile dentistry was (and in many places remains) an unfeasible option to access care.

Delays in otherwise routine care will create backlogs, especially in public health settings where providers already face heavy patient caseloads.

Temporary NC Medicaid Direct Flexibilities

Part of North Carolina’s state response has been to implement temporary NC Medicaid Direct flexibilities for dental providers during the Hurricane Helene PHE, including:

• Teledentistry
  • Adds a code for telephone or audio-only encounters that don’t result in a diagnosis
  • Expands a code for synchronous encounters, with or without a dentist present
  • Allows a code for asynchronous encounters using recorded video or photos
• Radiographic Images
  • Allows an override for the one-year limit for bitewing radiographic images and the five-year limit for panoramic radiographic images
• Denture Replacement
  • Allows an override of the 8-year limit on partial dentures and the 10-year limit on complete dentures for appliances lost in the hurricane
• Fluoride Varnish
  • Allows topical application of fluoride varnish for all ages

Keep an eye out for more information from the NC Department of Health and Human Services regarding Hurricane Helene recovery measures.

Mobile Dental Clinics & Teledentistry

In the coming months, deploying more mobile dental clinics and using teledentistry whenever possible will be important in addressing the long-term oral health care needs of impacted communities.

These access points are already vital for people in rural and underserved areas. Expanding them even further is crucial as the impacts from Helene pose additional barriers, exacerbating access and equity issues even more.

As roads re-open, classes resume, and internet access is restored, mobile dentistry and teledentistry will play essential roles in providing care missed during the immediate aftermath of the hurricane.

Trauma-Informed Oral Health Care

Natural disasters are traumatic to live through. “There is no right or wrong way to feel when a disaster hits, and people will continue to experience the emotional impact long after the storm has passed,” said NC Health and Human Services Secretary Kody H. Kinsley. “Helping western North Carolinians rebuild means also helping them heal.”

In the wake of a disaster, trauma-informed care becomes especially important across disciplines to support whole-person health. For oral health providers, it will continue to be critical to account for additional layers of dental fear and anxiety that patients may experience.

Trauma-informed care is an approach that acknowledges the impact of trauma and its effects on health and well-being. Oral health providers can take steps to support themselves, their patients, and their staff, aimed at avoiding re-traumatization. Here are a few ideas:

• Maintain open communication with patients and engage them throughout the treatment process, including asking what they need to feel more comfortable (e.g., wearing earplugs, headphones, or sunglasses, taking breaks when needed, etc.)
• Schedule trauma-informed training for all staff members (e.g., dentists, hygienists, assistants, technicians, receptionists, and security personnel)
• Consider making sensory-friendly changes to the office environment (e.g., calming music, soothing scents, etc.)
• Collaborate with local organizations and other providers, share valuable information about accessing resources, and make helpful referrals to address pressing needs

You can learn more in the Trauma-Informed Care and Oral Health: Recommendations for Practitioners from the Illinois ACEs Response Collaborative.

Stay Tuned for More on Oral Health Care in WNC Post-Helene

In the coming months, NCOHC and our partner organizations at the Foundation for Health Leadership & Innovation will publish more information about Hurricane Helene and access to care in Western North Carolina. Stay tuned for more about:

• Food and nutrition after a natural disaster.
• Lessons learned from past natural disasters.
• Future implications and opportunities for public health.
• How Hurricane Helene has further exposed existing Internet access and equity gaps.

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

Resources

• NCRHA Hurricane Helene Relief Resources
• Donate Oral Health Care Supplies to WNC
• NC Medicaid Direct Temporary Flexibilities
• How Natural Disasters Can Affect Your Oral Health
• Guidance on How to Safely Reopen Your Practice
• Trauma-Informed Care and Oral Health: Recommendations for Practitioners [PDF]
• Trauma-Informed Care in Oral Health Care: The role of dental hygienists

Related Content

• Children’s Dental Health Post-COVID 19
• Dental Anxiety and The Role of Providers in Facilitating Approachable Care
• Oral Health Care Integration Case Study Part I: Social Work in Dentistry
• Oral Health Care Integration Case Study Part 2: Social Work in Dentistry

Visiting the dentist can be anxiety-inducing, leading people to avoid seeking care. The common fear of the unknown, financial concerns, and past negative experiences can intensify these worries. Luckily, there are many ways to address dental anxieties and help improve access to oral health care.

Trust and Communication

Whether stories come from family and friends or social media, adverse experiences at the dentist are easy to find. This reality is important for providers to understand. There will be patients who come to an appointment afraid of what may happen. There will also be people who never seek out care due to dental anxiety, fear, and shame about the condition of their oral health.

A provider who actively builds patient relationships can create a more comfortable environment that puts people at ease. Through genuine, trusting relationships, dentists can better understand patient concerns, answer questions with kindness and compassion, and clearly explain dental terminology. This dialogue and information exchange can help people weigh the pros and cons of proposed treatments.

Individuals who trust their dentist will also feel more comfortable sharing personal information without fear of judgment. These additional details can give the provider a better idea of which treatments to recommend and identify any potential obstacles. Establishing a relationship will increase the patient’s willingness to seek help from their provider to improve any conditions that may develop and keep existing ones in check.

Understanding Treatments

Quality patient-centered care is paramount. Not everyone knows why fluoride is beneficial, why teeth become sensitive, how a cavity gets filled, or the root canal process. However, understanding these procedures can help people feel safe when receiving care.

Dentists, hygienists, and assistants can often explain these treatments. Clear explanations can help patients build trust with the entire dental team by ensuring they have a positive experience throughout the ongoing process of receiving care.

When thinking of ways to develop positive relationships with patients, providers should consider the following:

1. Make sure to thoroughly explain procedures before the appointment day, if possible. 
2. Allow adequate time for patients to ask any follow-up questions.
3. Offer guidance on at-home hygiene practices and product recommendations.
4. Discuss key ingredients to look for in toothpaste and mouthwash to equip patients with the information they need to look for the best products.
5. Learn about, seek training in, and incorporate trauma-informed care and motivational interviewing practices.

Over time, as treated conditions improve, patients will feel more confident in their provider, encouraging them to follow any routine adjustments they recommend.

A trusting, collaborative patient-provider relationship is essential for positive outcomes. The role of a health care provider is to educate patients while providing high-quality care aimed at improving overall quality of life in the short- and long-term.

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

Related Content & Resources

• Dental Anxiety and The Role of Providers in Facilitating Approachable Care
• Oral Health Care Integration Case Study Part I: Social Work in Dentistry
• Oral Health Care Integration Case Study Part 2: Social Work in Dentistry
• NCIOM Task Force: 14 Recommendations for Patient-Centered Oral Health
• Trauma-Informed Care in Oral Health Care: The role of dental hygienists
• Using Motivational Interviewing in Dentistry Video Series

Dentists, dental assistants, and dental hygienists work together as a team, making sure a dental office functions like a well-oiled machine. Have you ever considered a career as a dental assistant? If you have, NCOHC has some tips for you!

As a dental assistant, you can fill plenty of different roles. Some work chairside, helping dentists and hygienists care for patients. You can also work as:

• An office manager, helping schedule appointments, handling day-to-day activities, and managing the business side of dentistry.
• A sterilization technician, keeping dental instruments and treatment rooms clean and ready to use.
• A treatment plan coordinator, working with providers and patients to map out health care needs and keep track of appointments and follow-up care
• And more!

Becoming a Dental Assistant

There are several paths you can take to become a dental assistant. If you enroll in a program at an accredited school, you can graduate and enter the workforce as a DAII (Dental Assistant II).

Proprietary school programs also provide a condensed form of dental assistant training. You graduate ready to enter the workforce as a DAI (Dental Assistant I) through these programs or programs offering National Entry Level Dental Assisting (NELDA) certification.

Alternatively, dental assistants can jump in and train chairside, taught by a dentist in a dental office.

What’s the difference?

A DAI is an entry-level assistant. While the training is quicker for DAIs, DAIIs earn higher salaries and have more options for the roles they can fill in a dental office.

If you want to learn more, check out our interview with Kati Garrett, a dental assistant and educator overseeing Catawba Valley Community College’s dental assisting program.

This blog post was originally written by NCOHC intern Sydney Patterson and later edited by Allison Hackman

“It’s uncomfortable to think of a social worker in your space, and it’s uncomfortable to think about asking patients the questions that we ask. So, if it feels uncomfortable, lean into it because there’s going to be something good that comes from it.”

The University of North Carolina (UNC) Chapel Hill School of Social Work and Adams School of Dentistry (ASOD) partnered to provide dental and social work students with interprofessional workforce development and learning opportunities related to social drivers of health (SDOH). Integrating dental and social work education provides students from both cohorts with valuable experiences they will carry into their future practices.

Jamie Burgess-Flowers, MSW, LCSW, Kelsey Yokovich, MSW, and Lisa de Saxe Zerden, MSW, PhD published a research paper titled “The social determinants of health, social work, and dental patients: a case study” to document the first-year implementation of this model at the dental school. If you haven’t already, read part one of this case study for more background information to join us in the conversation with Burgess-Flowers and Yokovich from the beginning.

In this blog post, Burgess-Flowers and Yokovich share insights into the value of social work integration in dental care, the need for buy-in to promote sustainable systems-level changes, and the importance of continual learning.

Case: Social Work Consultation at a Dental Clinic

Burgess-Flowers told a story about one of her first days working in a dental clinic that demonstrates how integrating dental education and social work can transform patient and provider experiences for the better. A dental student approached her seeking guidance after completing a young adult patient’s health history intake. He noticed significant decay throughout their whole mouth, “I’m really concerned because this patient in their health history interview said that they don’t do any drugs.”

Although that patient had a level of decay often seen in patients with methamphetamine substance use disorder, Burgess-Flowers consulted with the student. She encouraged him to continue asking questions rather than jumping to conclusions. As it turned out, the patient worked extended Emergency Medical Services (EMS) shifts, drank Mountain Dew for the caffeine and hydration without water, and had little to no time for personal oral hygiene.

Though a patient may be struggling with a substance use disorder, this dental student learned to challenge his assumptions and remain open to other possibilities. Social drivers of health (SDOH) come in many forms, including employment type, dietary choices, and more, as this patient experienced.

The student will carry what he learned from this firsthand work experience long after graduating from dental school. “Having [this] foundational educational piece is going to be important for shaping a generation of providers that really think about the care of an individual as whole rather than siloed,” said Yokovich.

Buy-in: Driving Sustainable Change

Social work and oral health integration remains a fairly new concept that Yokovich and Burgess-Flowers hope will expand in the future. They discussed the importance and challenges of getting buy-in from students, educators, university leaders, providers, policymakers, and anyone else involved in the care system.

Burgess-Flowers spoke about the challenge of getting buy-in from some folks in dental education who have yet to see value in integrating social work into the curriculum. “When I started at UNC, one of the faculty members who was an oral medicine specialist looked at me, and he said, ‘You need to understand that what you’re doing is incredibly valuable. You are also asking a group of folks who have been trained to use a two-millimeter point of view to look at a tiny piece of disease on the surface of a tiny tooth to back up to a two-thousand-foot view of a patient,” she said.

Yokovich, the final and only macro (aka community management policy practice) social work student to participate in the UNC School of Social Work and ASOD program, said, “There was a lot of push-back, especially when I was talking about racism and the influence that has over practice.” Building on that, Burgess-Flowers said, “Now, social work is more synonymous with social justice, and people think that we’re going to be bringing up the uncomfortable things.” She told us it takes time to overcome “people’s perceptions of what a social worker is and what we bring to the table.”

When it comes to integrating social work and dental education, Burgess-Flowers said, “Buy-in is a really slow process for me, but it’s also all about that end goal that requires a lot of patience to get there.” Her vision is that as social work becomes embedded into dental education and dental practices, the holistic approach will trickle down until new employees, faculty, and students “say, well, this is just the way we do things.”

Key Takeaways: Lean in & Keep Learning

In their closing statements, Yokovich and Burgess-Flowers encouraged anyone in health care and education to stay open to continual learning. “An overarching message is for providers and folks who are in the educational space to keep an open mind when they feel uncomfortable. Usually, good things come out of that,” said Yokovich.

“It’s uncomfortable to think of a social worker in your space, and it’s uncomfortable to think about asking patients the questions that we ask,” said Burgess-Flowers. “So, if it feels uncomfortable, lean into it because there’s going to be something good that comes from it.”

They both hope to see this interdisciplinary work continue and care integration implemented across all areas of health care.

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

Related NCOHC Blog Posts

• Oral Health Care Integration Case Study Part I: Social Work in Dentistry
• Diversity in the Workforce: An Opportunity for Change
• Racism, Food, and Your Mouth: Parallels Between Food and Oral Health Equity
• How the World Around Us Impacts Our Oral Health: An Intro to the Social Determinants of Health
• Social Determinants of Health: How the World Around Us Impacts our Mouths
• Social Determinants of Health – Structural and Governmental Influences

Thank you to all who joined us for Oral Health Day 2024! We’re excited to share that we had our highest participation yet. This year, NCOHC presented two new awards and we heard from expert speakers, including a “North Carolina’s Oral Health Workforce, by the Numbers” presentation and panel discussion.

If you couldn’t make it, you can watch the full recording. Below, you will also find details about our awardees, NC oral health workforce data, panel discussion highlights, and resources from our speakers.

Oral Health Advocate Awardees

NCOHC staff presented two awards during this year’s event. Dr. Katrina Mattison-Chalwe received the Oral Health Community Award, and Dr. Frank Courts received the Oral Health Champion Award.

Dr. Katrina Mattison-Chalwe: Oral Health Community Awardee

Dr. Katrina Mattison-Chalwe is the dental director for Piedmont Health Services. She received the award for her outstanding contributions to improving oral health access in the communities she serves.

In addition to her full-time job leading a public health dental team and a mobile dental unit, Dr. Mattison-Chalwe also finds time to lead a nonprofit called Smiles for Jesus. She was instrumental in co-chairing the recent North Carolina Institute of Medicine Oral Health Transformation Task Force and has proven herself to be an important voice in the work to improve access and equity in care in North Carolina.

Dr. Frank Courts: Oral Health Champion Award

Dr. Frank Courts is the chair of the North Carolina Dental Society Council on Oral Health and Prevention and co-chaired the recent NCIOM Oral Health Taskforce. He received his award in recognition of an outstanding career expanding access and equity in oral health across North Carolina.

Dr. Courts was the first dentist in North Carolina to pilot a school-based oral health program. He is a frequent participant in task forces aimed at improving care, and he is an accomplished mentor of oral health professionals, encouraging the workforce to center patients in the care they provide.

“North Carolina’s Oral Health Workforce, by the Numbers”

Connor Sullivan, PhD, presented data from the Cecil G. Sheps Center for Health Services Research at UNC, which informs state, regional, and national workforce policy. Independent of government and health care professionals, the NC Health Professions Data System (HPDS) has 43 years of continuous, complete licensure (not survey) data on 21 health professions from 11 boards. The system is a collaboration between the Sheps Center, NC Area Health Education Centers (NC AHEC), and the health professions licensing boards.

During his presentation, Dr. Sullivan broke down the statewide movement of dentists, the concentration of dentists by county, the concentration of dentists by county per dental school, the top five dental schools in the NC workforce, race/ethnicity of dentists and registered dental hygienists (RDH) versus population diversity, and the number of active RDHs over time (2000 to present). A few highlights include:

• 5.5% net gain in number of NC dentists after imports and exports
• 60% of newly graduated dentists went to just 5 out of 100 counties in NC
• Eastern Carolina University (ECU) graduates are nearly two times more likely than all other NC programs to serve rural areas

One of the big takeaways from his talk was that the number of dentists in North Carolina is improving, but distribution and diversity remain challenges.

Oral Health Workforce Panel Discussion

This year, Hugh Tilson, JD, MPH, moderated the Oral Health Workforce panel discussion and asked about NC’s dental workforce challenges and opportunities.

Dr. Courts highlighted the importance of community-based recruitment and introducing young people to oral health opportunities when considering their career options. He reported that the NC Dental Society (NCDS) awarded 16 dental assisting scholarships and 20 stipends for dental assistants to take the certification exam. He also shared that:

• A new high school program focused on introducing students to the dental field is coming soon.
• There are two new dental assisting programs at Alamance and Southwestern community colleges.
• There are two new dental hygiene programs at Isothermal and Southwestern community colleges.

Andy MacCracken, MPA, discussed the need for critical health workforce coordination, longer-term workforce development, and community-based, non-licensed, non-certified oral health team members.

Stephanie McGarrah, MPP, shared about the $110B that NC received from across six bills in 2020, which is still being directed toward dental practices, businesses, and health systems. She also highlighted the growing trends in high schools to encourage students to explore career opportunities that do not require a four-year college degree.

Melissa Smith, MSEd, RT-R, CT (ARRT), CNMT, spoke about NC’s 13 hygiene programs and 19 CODA-accredited DAII programs. She also shared that the General Assembly provided funds to start and expand health care programs statewide. So far, $4M has gone to expanding dental assisting programs at two schools, starting dental assisting programs at five schools, and starting dental hygiene programs at two schools, including one evening program.

What Keeps You up at Night?

For Smith, the need for qualified faculty, the funding to pay them adequately, and clinical space are top priorities.

McGarrah said recruitment for oral health professionals remains a crucial piece of addressing the ongoing workforce challenges.

MacCracken emphasized the need for supporting and increasing the number of non-licensed, non-certified oral health team members who are also part of the communities they serve.

Dr. Courts thinks it is vital to build and maintain strong community relationships, focus on recruitment in the community, and prioritize introducing young adults to the oral health field.

How Can Oral Health Professionals Engage in NC Workforce Initiatives?

McGarrah shared a new tool from the Department of Commerce called Reality Check. It enables folks to build a budget for things they want and then matches them with jobs that can provide a salary that supports their budget and details about the education required. She emphasized that there is a shifting focus in high schools for students to consider future careers that do not require four-year college degrees.

Smith said it is important to start the workforce pathway as young as elementary school by introducing students to opportunities within oral health.

Tilson shared that the NC Dental Society (NCDS) does outreach at high schools and needs volunteers to speak with students. He also mentioned the importance of more public health hygienists with the potential to embed them into the school systems.

Dr. Courts supported the idea of embedding dental hygienists in schools, like school nurses, to increase access to care for children and teenagers.

Stay Connected & Engaged to Oral Health Workforce Development Initiatives in NC

Thank you again to everyone who made Oral Health Day 2024 a success! As our expert speakers discussed, we must invest the necessary time, energy, and resources into oral health workforce development and increasing access to care for communities across our state.

To stay informed about our ongoing programs and initiatives, including those related to workforce development in NC, we invite you to sign up for our monthly newsletter. Stay connected, stay informed, and continue to be a part of our mission to improve oral health for all North Carolinians. We are grateful for your ongoing advocacy and partnership!

Resources from Our Speakers

• NC dentist US vs NC 2001-2022 (American Dental Association (ADA)-member exclusive content)
• ADA Health Policy Institute (includes NC’s rank compared to other states, as well as import and export data)
• UNC Sheps Center
• UNC Program on Health Workforce Research and Policy
• NC DHHS Health Professional Shortage Area (HPSA) 2023 data
• KFF Dental Care Health Professional Shortage Areas (HPSAs)
• NC Dental Society work opportunities
• NC Department of Commerce Reality Check tool

“I love our pediatrician, but I pray that he doesn’t leave our area because there are so many providers leaving,” said Rachel, a mother of two who lives in Wayne County, North Carolina. “It’s going to be hard for our family if he does.”

“For me personally, if my son were sick, I would not be able to get an appointment today. I would have to wait for an emergency appointment or take him to the emergency room,”
said Rachel. “We just have a lack of providers here, and we’re losing providers. They’re leaving our state to get paid better elsewhere, to get treated better elsewhere.”

Rachel’s sons have had Medicaid insurance for their entire lives, but Rachel herself went uninsured until recently. She qualified for Medicaid in 2020 after a severe case of COVID-19 that left her with long-COVID symptoms.

Gaining access to Medicaid insurance has allowed Rachel to focus on her own health, which she had to deprioritize partly due to the cost of accessing care without insurance.

“I wasn’t able to work much of the year as a result,” said Rachel. “So, I got Medicaid, and I didn’t lose it when I went back to work because of the pandemic supports. And I would have lost it if North Carolina hadn’t expanded Medicaid last year.”

Gaining access to Medicaid insurance has allowed Rachel to focus on her own health, which she had to deprioritize partly due to the cost of accessing care without insurance.

“I’ve transformed these past three years because I’ve finally been able to care for myself,” she said.

Rachel grew up with a single mother. Family financial constraints made dental care and primary care luxuries throughout her childhood. To get to where she is today, Rachel faced a long journey navigating a health care system often ill-equipped and, at times, seemingly hostile to her needs.

“I had to be very sick to see a doctor or dentist,” she said. “Even though I wasn’t seeing a dentist, I was very good about brushing. I wasn’t flossing like I should, but I was brushing. And what got me into it was preschool. They were all about dental care. They gave us visuals, and we brushed our teeth at school.”

In her early 20s, Rachel decided to see a dentist for the first time. Her wisdom teeth were causing pain and needed to be removed. She had never been to a dentist for a cleaning or any other service, but she had to address the pain she felt.

“The dentist referred me directly to an oral surgeon, and I will never forget how mean he [the oral surgeon] was,” said Rachel. “I think he thought I wanted pain medicine. I didn’t, I wanted to understand why I was in pain. I couldn’t eat, I was losing weight. And that experience scared me. I didn’t want to go back for that next cleaning with a dentist because of what I experienced with the oral surgeon.”

After that, Rachel avoided returning to a general dentist for her first cleaning. When she did make an appointment, her provider laughed at her for being scared in the office.

“At first I kind of brushed it off,” said Rachel. “But then they brought another dentist in, and one of them pointed at me and said, ‘Look how red she gets.’ I let them do the cleaning and fix one cavity, but I didn’t go back for several years after that.”

In 2020, Rachel needed to see a dentist again. She had an infected tooth that needed to be removed. She credits the dentist she saw then with helping her overcome her fear in dental offices.

“I said, ‘Would your staff be willing to talk me through everything? Walk me through it like I’m a toddler because I’m so scared,’” said Rachel. “The lady that he had assist him during the procedure had been through my experience herself. I thank God he did that because I needed someone with that experience to know what I felt.”

Today, Rachel and her entire family continue to see that same dentist. She credits his caring approach with helping her adjust to regular appointments and improve her overall oral health.

“After that experience, I stopped being scared of dentists,” she said. “I’ve been going to the dentist ever since.”

“Our partners in this effort helped us form one of the most unlikely bipartisan, cross-industry coalitions ever assembled in North Carolina–and we succeeded.”

— Care4Carolina Executive Director Abby Emanuelson speaking about Medicaid Expansion in North Carolina

Medicaid Expansion is one of the greatest public health achievements in North Carolina’s history, even though it is far from the end of the road toward truly healthy communities across our state. In honor of this week of recognition, we’re providing you with an update on Medicaid Expansion since it went into effect last December.

In this blog post, you can learn about the impact of Medicaid Expansion to date and considerations for oral health access and equity for newly eligible beneficiaries.

NC Medicaid Expansion

To recap, Medicaid Expansion extended coverage to people ages 19 through 64 years old who previously fell in the health care coverage gap, meaning they earned too much to qualify for Medicaid but too little to access the Affordable Care Act marketplace. Since expansion began on December 1, 2023, nearly 400,000 newly eligible recipients have already enrolled (about 1,000 daily), which is over half of the 600,000 expected to enroll over the next two years.

After launching Medicaid Expansion, NCDHHS, county health departments, and local social services departments have enrolled recipients faster than other states in the past (all states had the option to expand Medicaid beginning in 2014). Community-based organizations and partners have been essential in spreading the word and helping people enroll in the best plan to meet their needs.

NCDHHS Medicaid Data Dashboard

The NC DHHS Medicaid Expansion data dashboard provides monthly updates on how many people have enrolled through Medicaid Expansion, including statistics by health plan, demographics, and county. During a January 2024 interview, NCDHHS Secretary Kody Kinsley reported that Medicaid Expansion had already covered over $4.8 million in claims for dental services.

Highlights from the dashboard reports through March 2024 include:

• New enrollees disproportionately live in rural communities (96,318 enrollees as of March 2024)
• Over half of enrollees are under 40, with most between 19 and 29 years old
• Anson, Edgecombe, Richmond, Robeson, and Swain counties have seen the highest enrollment rates

Oral Health Provider Shortage & Access to Care

While we celebrate the milestone achievement of NC Medicaid Expansion, we have more work to do. While North Carolina offers all Medicaid recipients oral health coverage, it is not currently listed as a benefit on the Medicaid insurance cards. Many people, from newly eligible recipients to health directors, remain confused about what Medicaid covers.

We also need more oral health providers who accept Medicaid to meet the growing demand. The physician shortage, especially in rural communities, affects beneficiaries and frontline workers alike. During our 2023 Oral Health Day event, keynote speaker Kathy Colville, former President and CEO of the North Carolina Institute of Medicine (NCIOM), put it clearly: “We have truly amazing and exceptional people holding up an inadequate system.”

Only 28 percent of dentists in North Carolina accept meaningful volumes of Medicaid patients. Of those who do, many accept just a few recipients and are not currently accepting anyone new. A contributing factor to this low acceptance rate is that Medicaid dental reimbursement rates remain at the same level as they were in 2008.

Long before NC Medicaid Expansion, dentists advocated for higher Medicaid reimbursement rates for oral health, which falls around 34 cents on the dollar today. Many more providers need to accept Medicaid to meet the demand. “They [Medicaid providers] are woefully underfunded,” said NCOHC Vice President Dr. Steve Cline.

Some estimates among oral health care providers suggest that reimbursement rates need to be at least 75 cents on the dollar to build an adequate private provider network to meet the need. Our incredible public health oral health providers do not have the necessary time, capacity, or resources to serve every Medicaid recipient in the state.

Unless our state and federal governments commit to a massive expansion of public health funding, we need private practice dentists to begin accepting new Medicaid patients as soon as possible.

What’s Next?

Alongside an overhaul of NC Medicaid reimbursement rates, as we continue to enroll communities across our state, we need to both incentivize and make it economically viable for oral and health care providers to practice in rural areas. One path forward is expanding loan forgiveness options for dental professionals in rural communities.

We must also continue to advocate for policies and programs to expand the use of teledentistry. To do this, we need a robust rural broadband infrastructure.

Last year, NCOHC partnered with the North Carolina Institute of Medicine, with support from The Duke Endowment, to launch the Oral Health Transformation Task Force. Their full report with recommendations to transform our current oral health system will be released to the public soon. Stay tuned for more information!

Resources

• NC Medicaid Enrollment Reports
• Medicaid Expansion FAQs
• NC Medicaid Expansion Data Dashboard
• Medicaid.nc.gov
• NCDHHS Medicaid Expansion Portal: Information on eligibility, FAQs, how to apply, and sign-up form for news and updates
• Safety Net Dental Clinic Locations

“I don’t just want whole-person care happening in the clinic, I want to see whole-person education as well.”

Research shows that up to 80 percent of a person’s overall health can be attributed to non-medical factors. These social drivers of health (SDOH)* pose intractable barriers for countless North Carolinians when accessing oral health care. Care integration has been shown to increase access and equity in oral health and benefit both patients and providers.

*Although still widely used, recently, there has been a shift in language from ‘social determinants’ to ‘social drivers’ of health. This change acknowledges that a wide range of nonmedical factors can impact a person’s overall health; however, they do not determine what a person’s health outcomes will be, but rather have the potential to drive them.

The University of North Carolina (UNC) Chapel Hill School of Social Work and Adams School of Dentistry (ASOD) partnered to provide dental and social work students with interprofessional workforce development and learning opportunities related to SDOH. Integrating dental and social work education provides students from both cohorts with invaluable experiences that they will carry into their future practices.

Jamie Burgess-Flowers, MSW, LCSW, Kelsey Yokovich, MSW, and Lisa de Saxe Zerden, MSW, PhD published a research paper titled “The social determinants of health, social work, and dental patients: a case study” to document the first-year implementation of this model at the dental school.

UNC Chapel Hill School of Social Work & Adams School of Dentistry

Dr. Zerden created the program, Burgess-Flowers served as the clinical social work faculty member, and Yokovich contributed as the final and only macro (aka community management policy practice) social work student. Burgess-Flowers built the program and established clinical workflows in the dental settings. When Yokovich joined, she helped develop the programmatic integration, conducted research, and attended the dental school’s research day.

Currently, Burgess-Flowers is an Assistant Professor and the Director of Integrated and Applied Behavioral Sciences at High Point University and Yokovich is the Community Voice Program Coordinator at the Foundation for Health Leadership and Innovation (FHLI).

Before leaving for High Point University, Burgess-Flowers wanted to document their work and hopefully contribute to creating more opportunities for social workers to integrate into oral health care spaces. Yokovich had social work experience as well as working in both oral health spaces and wanted to help develop a model for integrating the two fields.

Burgess-Flowers and Yokovich shared their experiences and vision for integrated care in oral health settings. Join us in the conversation…

Why is this topic important to you?

“I came from a primary care setting, and I was working in integrated care with patients. I thought to myself, ‘This is whole-person care,’ but I wasn’t asking patients about their oral health.” said Burgess-Flowers. “As social workers, we talk a lot about how people need to realize that the brain is part of the body. But we’re just as guilty of leaving out the mouth.”

“I worked in a dental office as a treatment coordinator and saw the lack of resources for folks who might not be able to go to different health care offices because they don’t have the time, transportation, resources, or financial means,” said Yokovich. “If you’re going to go into integrated care, it can’t just be physical, it can’t just be behavioral outpatient, it has to be the whole-health picture.”

Can you speak about the influence of SDOH on oral health disparities and the effectiveness of addressing them through social work integration?

“Dental offices are incredibly, historically, traumatizing and can be very over-stimulating for folks with trauma histories,” said Burgess-Flowers. “One thing I’m big on is being able to explain to [oral health providers] how social determinants of health relate back to something like filling a cavity or placing a crown. That is what dentists have been historically trained [to do]. They’re procedure-based, so they really want to know how what you’re talking about or offering to assist with has an impact on what [they] do or why a patient is here.”

“The demographic of oral health providers does not match the demographics of the United States at large. There’s a very stark contrast between those providing care and those receiving care,” said Yokovich. “Something that Jamie and I tried to do while I was at the dental school was educating oral health providers to think about these systemic issues a little bit differently because they’re the ones who are then going to be taking that into practice.”

How did you see care integration help both students and patients?

“It (dental-social work integration) opened so many doors for patients to receive referrals that they might not have been able to receive before,” said Yokovich. “And being able to express concerns about different areas of their lives as well, which is super interconnected and interwoven into their whole health.”

“We’re seeing less turnover, less no-shows,” said Burgess-Flowers. “We see a lot of improvement with dental students and learners, we see their perspective on patients change. We see their burn-out rates improve. We see them feeling like they have a team of people they can lean on and work with inter-professionally and not have to take everything on themselves.”

What ideal changes do you foresee in dentistry and social work?

“I would love to see the model be standard in dental education. I want to see more social workers, and not just clinical social workers, but also your macro social workers, in dental education,” said Burgess-Flowers. “I want dentists and dental hygiene folks in social work education. I don’t just want whole-person care happening in the clinic, I want to see whole-person education as well.”

“I would love to see buy-in from every aspect of oral health care, whether that’s from the dental education perspective or private practice. And I would love to see providers start getting credentialed with Medicaid and accepting patients who they would not have traditionally accepted in their past practice,” said Yokovich. “Having that foundational educational piece is going to be really important for shaping a generation of providers that think about the care of an individual as whole.”

How do you see this research contributing to your work moving forward?

Burgess-Flowers said, “This [role] really is a beautiful blend of being able to teach dental students clinical skills, communication skills, and being trauma-informed, all the way up to self-wellness, preventing burn-out, thinking about our community, the social systems, and racism, and all of the things that come into health care and interfere with patient outcomes being what we want them to be.”

“In a perfect world,” said Yokovich, “I would love to see integrated care across the board, but I think that just starts with us being advocates now where we’re at in order to make small systemic changes happen, so this paper kind of sets a foundation for hopefully this to be replicated at different schools across the United States.”

NCOHC, a Foundation for Health Leadership & Innovation program, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. Sign up for our monthly newsletter to join the network and get involved!

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