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PFAS: An Oral Health Perspective

From pizza boxes to shampoo, and even some dental floss, PFAS (per-and polyfluoroalkyl substances) are everywhere. These “forever chemicals” are so widespread that it is virtually impossible to avoid exposure. While they have been commercially used since the 1940s, the scientific community is just beginning to learn about the adverse health effects that PFAS exposure can cause.

PFAS are a group of manmade chemicals widely used in a variety of industries. The story of PFAS calls to mind the history of asbestos. While we are aware of the danger that asbestos poses today, decades of prior use exposed many to adverse health effects, and its ubiquity has made removing the substance from everyday life a difficult and still incomplete, task.

In 2016, North Carolina became the center of attention after a joint study published by scientists from North Carolina State University, the University of North Carolina at Charlotte, the EPA, and other local agencies shed light on PFAS pollution in the Cape Fear River.

The Chemours Company, a spin-off of DuPont, had been releasing PFAS pollutants into the Cape Fear River for decades.

More recently, Pittsboro and other communities along the Haw River in North Carolina have been added to the high exposure list.

The most-studied PFAS chemicals, PFOA and PFOS, have been linked to low infant birth weight, immune system deficiencies, multiple forms of cancer, thyroid hormone disruption, and they can negatively impact the liver and kidneys.

To underscore just how serious and widespread PFAS contamination is, an agreement reached by the Southern Environmental Law Center and the Chemours Company in 2018 includes the “largest fine ever levied by the North Carolina Department of Environmental Quality,” $12 million on top of funding for studies regarding the health impacts of PFAS chemicals.

From an environmental health perspective, PFAS are a nightmare. They were given the name “forever chemicals” because of their durability. They are so persistent that the EPA simply states that the chemicals don’t break down in the human body or in the natural environment.

From a public health perspective, PFAS pollution also underscores the importance of integrated care, especially when managing a health crisis.

It isn’t obvious at first glance that oral health providers have any significant role to play in responding to PFAS contamination. There are no known direct oral health impacts, after all.

However, one of the recommendations for anyone living in an area impacted by PFAS pollution is to install a water filter, specifically a reverse osmosis two-stage filter. Reverse osmosis filters remove around 99 percent of PFAS chemicals, a great preventive step for anyone in an impacted area. Unfortunately, those filters also remove fluoride from drinking water.

Preventing the negative health impacts of PFAS pollution is priority number one. But down the line, it would be tragic for tooth decay and gum disease to emerge as an adverse side-effect.

From simply adding discussion of water filtration devices to dental health questionnaires, to potentially boosting supplemental fluoridation programs in areas heavily impacted by PFAS contamination, dental providers have an important role to play.

NCOHC had the pleasure of working with Dr. Kelly Bailey as she completed her public health practicum for the UNC Gillings School of Global Public Health during the summer of 2021. Dr. Bailey created this toolkit to help the dental community better understand PFAS contamination and the role that oral health providers can play in helping impacted communities remain healthy, from head to toe.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

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How in the World Does Dental Insurance Work?

Let’s talk about annual maximums.

The difference between an annual maximum and a deductible is arguably the most significant distinction between a typical dental insurance plan and a typical medical insurance plan, especially when it comes to your wallet.

It is important to note that many of the aspects of dental and medical coverage discussed in this article do not pertain to Medicaid insurance. Medicaid insurance operates differently (even though in North Carolina it does cover medical and dental, for children AND adults). We will discuss Medicaid specifically in a future post.

Additionally, this blog post should not be taken as medical or dental advice. When considering personal care and the cost of that care, consult your provider and insurance company to ensure that you fully understand all costs associated with different treatment options.

A traditional medical insurance plan usually includes what’s known as a deductible. If your deductible is $1,000, for example, once you reach $1,000 in out-of-pocket medical expenses (meaning dollars that you, not your insurance company, pay for covered medical procedures), your insurance company pays 100 percent of in-plan procedures for the rest of your annual insurance period.

Dental insurance generally works in the opposite manner. Most dental plans have “annual maximums,” not deductibles. With a maximum of $1,000, once you reach $1,000 in expenses that the insurance company has paid, you as the individual are responsible for 100 percent of your oral health care costs for the remainder of the contract year.

If you were to enroll in a dental insurance plan today, it may look something like this:

Services Coverage
Type 1, Preventive
Oral exams (1 per 6-month period)
Cleanings (1 per 6-month period)
Bitewing x-rays (1 per 12-month period)
100% covered by insurer, up to contract year maximum
Type 2, Basic services
Fillings
Full mouth x-rays
Periodontal maintenance
Injection of antibiotic drugs
80% covered by insurer, up to contract year maximum
Type 3, Major Services
Endodontics
Anesthesia
Simple and Surgical Extractions
Oral Surgery
Periodontics and Periodontal Surgery
Crowns
Inlays/Onlays
Dentures
Bridges
50% covered by insurer, up to contract year maximum
Annual Contract Year Maximum $1,000

 

On first glance, the tiered system of dental insurance clearly incentivizes regular preventive care. This is good, because nearly all dental disease can be entirely prevented, and regular visits to an oral health care provider are important steps in warding off cavities and gum disease.

On the other hand, however, what happens when you do experience more serious dental issues? Take a scenario where an old cavity filling fails, a new cavity forms underneath the failed filling, and you now need a root canal.

A single root canal on average will cost between $700 and $1,400, depending on the tooth requiring treatment and varying by location and provider. Once you receive a root canal you will also need a crown — an additional $800 – $1,500, depending on the crown material.

Say you end up right in the middle of those cost ranges: $1,050 for the root canal and $1,150 for the crown. Both are Type 3 procedures under the hypothetical insurance coverage above, meaning the insurance company will pay for 50 percent and you will be responsible for the other 50 percent. For both procedures, the total cost would be $2,200.

But don’t forget the annual maximum. The insurance company only pays $1,000 (assuming no other costs have been paid by the insurance company prior to your root canal) and you would be responsible for the additional $1,200. And if you need any other work done for the rest of the contract year, you will pay 100 percent of the cost.

That is a large out of pocket cost for someone who has insurance!

Unfortunately, the solution is not as simple as increasing the amount an insurance company pays for. More extensive policies would cost more and would quickly become more expensive than would make sense for most individuals who do not experience severe oral disease.

Dental insurance poses a complex question — how do we keep insurance costs low enough to incentivize people to: 1) get insurance; and 2) use that insurance to receive regular care, without leaving those with more severe needs hanging out to dry?

On the other hand, how do we create a structure where people with severe needs can see those needs met without crippling bills, while simultaneously keeping costs low for preventive care?

Neglect absolutely leads to tooth decay, gum disease, and eventually more expensive treatments. Some may argue that you reap what you sow, but those of us at NCOHC believe that everyone, with no exceptions, should be able to access quality, affordable oral health care.

It is also important to consider the fact that people can end up with severe dental needs by no fault of their own. In a case like mine, your loyal NCOHC blog author, you could end up on the wrong end of a golf club in high school and need years of surgeries and restorative work to get your two front teeth back.

My case is an example of the stark difference between dental and medical insurance. I was fortunate enough to have great medical insurance through my mother’s state employee health plan, which at the time included a clause for “accidental dental” needs (an uncommon clause in medical insurance). All of my countless dental visits for root canals, bone grafts, restorative work, surgeries, implants… (the list goes on and on) were entirely covered by medical insurance once we reached our deductible.

Our luck was rare. If all of that work had instead been covered by dental insurance, which would be the common scenario, we would have paid tens of thousands of dollars after reaching our $1,000 annual maximum.

At NCOHC, we are curious about your thoughts as a reader. We truly believe that solutions to the biggest problems will be discovered through collaboration, and we want you to be a part of it! Have an idea, a thought, or a question about the future of dental insurance? Click here and let us know!

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

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A Conversation with Public Health Expert Extraordinaire, Dr. Rhonda Stephens

Dr. Rhonda Stephens, the North Carolina Department of Health and Human Services, Division of Public Health Oral Health Section’s Dental Public Health Residency Director, recently became the newest Dental Public Health Diplomate in North Carolina. A dedicated public health specialist, Dr. Stephens is well-known in the world of North Carolina dental public health for her dedication to improving the oral health status of all North Carolinians.

We sat down with Dr. Stephens to discuss her role in the Oral Health Section, access to care, and what it means to be a Dental Public Health Diplomate.

What do you do in your current position in the Department of Health and Human Services Oral Health Section?

This may be a long answer because my role has shifted quite a bit. I started off with the general title of a Public Health Dentist Supervisor, but I had many responsibilities under that: supervising some of our public health dental hygienists in the field, supervising our four program managers who are responsible for developing the programs that we implement in the field, and managing our grants.

In the last year or so I have shifted to doing all of that, except no longer supervising field staff, and I took on additional roles and responsibilities with our Dental Public Health Residency training program. I am now the Residency Director and will continue managing grants, in addition to temporarily still supervising our program managers.

Why did you choose a career in public health?

That’s a story that I tell quite often. I practiced in Federally Qualified Health Centers for 11 years as a dental director. That’s a safety-net setting, right, and we’re typically seeing the most vulnerable of the most vulnerable. It felt like a revolving door of the same issues day in and day out, and that I was only making an impact one person at a time, if that.

I think by about 2012 I felt like there had to be a better way — a way to impact change on a broader scale. So, I went back for my Master’s in Public Health while I worked part-time clinically, and then I knew from there that I wanted to move on to a more administrative role in dentistry.

You recently became an American Board of Dental Public Health Diplomate. What is a diplomate, and why did you pursue this distinction?

Each of the specialties in dentistry — like orthodontics, oral maxillofacial surgery, dental public health — all of these specialties require specialty training, and then there’s the opportunity to become certified as diplomates.

You can get any specialty training and opt not to become certified. For me, being certified was more of a personal professional desire, to get that final stamp or seal of approval. It’s a standardized test just like any standardized test, and it says that you have met the requirements established by the particular specialty board.

In dental public health, you can easily be just as qualified of a dental public health practitioner by having gone through a residency and not getting certified; but I wanted to be at the top of my professional game, having that seal of official approval.

Broadly, outside of my job, there isn’t yet a clear understanding among employers — whether its government employers, institutions, nonprofits — about the significance or the value of having the certification. But I wanted to be at that level so when employers do start to value the certification, I’m already there.

My job as the Dental Public Health Residency Director is the only role within our program that requires the certification. I’m fortunate that we have the residency, otherwise there honestly wouldn’t be a role for me to step into. It would just be an extra certification that I just happen to have.

Could you tell me a bit more about the role that dental public health plays within the broader network of dental professionals?

I’ll admit, many of our colleagues in dentistry don’t understand what it means exactly. Public health is very different than understanding how to provide clinical care to a patient. You’re focused on prevention first and foremost. Prevention at a community or population level.

So, some of the things that a clinician, a dental clinician, might do for a patient one-on-one in a clinical setting, aren’t actually effective at a population level. Going through the specialty training for dental public health helps you to understand that.

It’s a little-known specialty, like I said even within our own dental community. Then, more broadly, the general public really has no idea what dental public health specialists do. But we’re here, behind the scenes, working to help people prevent diseases that warrant them going in for emergency and urgent care.

I don’t know the raw numbers, but North Carolina in general seems to be a Mecca for dental public health specialists. We have quite a few who have played a major role in dental public health in North Carolina and beyond at some point. I think North Carolina is unique in a lot of aspects when it comes to dental public health.

NCOHC is a program of the Foundation for Health Leadership & Innovation. To get involved, find out more information, and to stay up to date, head over to NC4Change to sign up for our newsletter and see what events and other opportunities are on the horizon.

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Introducing Our New Associate Director, Crystal Adams

We are thrilled to introduce the newest member of the NCOHC team! Crystal Adams, a lifelong advocate for access and equity in oral health care, will join us as our Associate Director.

Crystal is a career educator, transitioning to NCOHC from her position as department head of Catawba Valley Community College’s (CVCC) dental hygiene program. Over the course of her career at CVCC, Crystal launched a dental assisting program, a Community Dental Health Coordinator program, and a school-based program allowing dental hygiene students to care for middle school-aged children in Alexander County.

Crystal brings with her a wealth of knowledge and experience in education, paired with years of statewide advocacy and representation on committees like the North Carolina Dental Society Council on Prevention and Oral Health. She is also the former president of the North Carolina Dental Hygienists’ Association (NCDHA).

We recently sat down with Crystal to talk about her career and experience in oral health, and her vision for increasing access and equity in North Carolina.

Can you tell us a bit about your career path in the dental field?

I started in dentistry as a dental assistant. My passion kept getting stronger and stronger, and I felt like I wanted to grow, so I went back to dental hygiene school. After working as a dental assistant for four years and a hygienist for almost ten years, I felt like there was something inside of me that I could share.

I love people — I love helping people. I started working in education to share my passion about oral health care. I wanted to help new graduates prepare for the dental field, and I felt like my experience as a dental assistant and a dental hygienist allowed me to go in and share my technical skills, as well as my personal knowledge working with patients.

I feel like everything begins with education, no matter what. And, with NCOHC, I am excited to work on initiatives and programs to ensure that dental literacy is continued, to help people see that they need that overall health, and that their teeth are part of their bodies!

Why did you choose a career in dentistry in the first place?

I always knew that I wanted to go into the health field. I did not have any dental care until I was 16 years old. Luckily, my family had great genes, so I was one of those lucky people who didn’t have a lot of dental issues.

Now, when I look back, I see that my personal story can help people. Especially when people come in and say, “Oh my gosh, I haven’t been to the dentist. I focused on my family, I focused on my children, and now I’m here and my mouth is a mess.” I have that personal story to share.

What is your vision for North Carolina’s oral health future?

I was born and raised in North Carolina, and I want to see my neighbors, my friends, my family throughout the state get the care that they need. My vision starts with a quality workforce. First, making sure that our stakeholders and partners are on board so that we’re all working toward the same goal. Everybody’s goal in dentistry is hopefully to help our residents in North Carolina to improve their oral health.

I envision collaboration with our stakeholders to ensure that we have a quality workforce delivering equitable oral health care to the residents of North Carolina. Working on the programs that I did at CVCC, I feel like a lot ties into the initiatives, vision, and mission of the North Carolina Oral Health Collaborative.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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Meet NCOHC’s Summer Interns Part 2: Hannah Archer

Hannah Archer is an MPH student at UNC-Chapel Hill with a passion for public health dentistry. This summer, she worked with us at NCOHC to develop a policy brief on postpartum health benefits, while continuing to develop a research project to study the value of online resources for oral health care.

Could you tell me a bit about your career/education path prior to pursuing your current degree?

I studied Education and Biology in undergrad and was always interested in healthcare. I knew I wanted to pursue a career in dentistry, but wanted to learn more about the social components that play a role in oral health outcomes prior to starting dental school. So, I decided to apply to the Master of Public Health program at UNC Gillings. While here, I fell in love with oral health policy, and learned about NCOHC during a class I took on Dental Public Health. In August, I will begin my final year of my MPH, and recently applied to dental school in the hopes of attending dental school following my MPH.

Where are you in school, what are you studying, and why did you choose that program?

I am at the UNC Gillings School of Global Public Health studying to receive my Master of Public Health with a concentration in Health Policy. I chose this program because of the incredible opportunities at UNC, ranging from the incredible faculty, diverse peers, community-based learning experiences, and connections to organizations with a dedicated mission to improve public health.

What’s one fun fact about yourself?

I played tennis in college.

Where did you first hear about the North Carolina Oral Health Collaborative, and why did you want to pursue an internship with NCOHC?

I first heard about NCOHC when Dr. Zachary Brian spoke in two different health policy courses I was taking at UNC Gillings. His presentations were incredibly interesting and encapsulating. Even with an already established interest in oral public health, Dr. Brian made me feel inspired and driven to advocate for change. Later in the semester, I established a research project with a UNC Adams School of Dentistry professor and had the fortune to also partner with NCOHC. Given the extensive work and incredible opportunities I had over the past year to work with NCOHC, I knew there was no other place I wanted to pursue an internship and I feel incredibly fortunate to be here.

What about public health dentistry is intriguing to you?

While I aspire to have a career in dentistry and to spend time in clinical settings, I appreciate the broader focus of dental public health. I want to make an impact on dentistry at both the individual and population level. I particularly appreciate the focus of dental public health on increasing equal access to oral health care for all individuals. Through my position at NCOHC, I have seen just how significant the disparities in oral health outcomes are across the state and I aspire to make significant changes in my professional career.

Tell me a little about what you have worked on as an NCOHC intern. What do you hope to take away from the work you have been doing?

My internship revolves around two primary projects. In my first project, I am learning about public health communication by establishing a website to provide oral health information to providers and patients across North Carolina. The website includes oral health education for various populations, including pregnant mothers, children, individuals with intellectual and developmental disabilities, adults, and older adults. In the next stages of this project, I hope to provide this website to a majority of safety net clinics across NC without dental services.

In my second project, I am writing a policy advocacy paper on Senate Bill S530 that was presented to the NC General Assembly in April. The bill proposes to increase postpartum Medicaid coverage from 0 days to 1 year for North Carolina mothers.. In my policy brief, I am advocating to pass this bill so that postpartum mothers can receive both medical and dental Medicaid benefits. Through my research, I am learning a lot about the legislative process and the necessary components of advocacy (i.e., stakeholder support, lobbying, grassroots mobilization, etc.) necessary to pass a bill like this. In addition, I am learning about the social determinants of health that influence poor oral health in mothers and children, along with the significant health implications a bill like this could have.

If you could tell North Carolinians one thing you have learned that you think is important for everyone to know, what would that be?

Oral health starts before birth. I did not realize what a profound impact a mother’s oral health can have on their child, and that a child should be going to the dentist as early as one year of age. Unfortunately, the presence of oral health care and education is severely lacking in North Carolina, and this is something I hope to advocate for and address in my future dental public health career.

What’s next for you?

I just completed my applications to dental school. I hope to hear back from schools in December and I intend to pursue a residency in dental public health (and potentially pediatrics) following dental school.

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What’s in Senate Bill 146, the Dental Legislation Recently Signed Into North Carolina Law?

A landmark piece of dentistry legislation became law in North Carolina on Friday, July 23, 2021. Senate Bill 146, sponsored by Senator Jim Perry, with a House counterpart sponsored by Representative Donny Lambeth, is a broad-reaching piece of oral health legislation that will allow North Carolina to take several steps toward a more accessible, equitable oral health care future.

There are four main parts of the legislation:

  1. It codifies teledentistry in North Carolina law.
  2. It allows dental hygienists with proper training and qualifications to administer local anesthesia.
  3. It further aligns two existing regulatory provisions that allow dental hygienists to more efficiently work in community-based settings.
  4. For the first time, it formally recognizes Federally Qualified Health Centers (FQHCs) in North Carolina statute.

All parts of the legislation went into effect when the bill was signed into law on July 23, except for the section allowing hygienists to administer local anesthesia. That portion of the bill is set to take effect on October 1, 2021.

Teledentistry is Codified in North Carolina Law

Teledentistry is an important tool in the dental professional’s toolbox. In addition to being an invaluable asset during the COVID-19 pandemic, remote care technology is a great way to expand access to patient evaluations, consultations, assessments, and education to those who may have trouble getting into a brick-and-mortar dental office.

While teledentistry has never been “illegal” in North Carolina, there have not been set standards defining its use.

Senate Bill 146 defines teledentistry, lays out the various ways it can be used, and sets standards for informed consent during remote patient encounters. It also establishes patient protections, authorizing the North Carolina State Board of Dental Examiners (NCSBDE) to take disciplinary action against dentists who allow fee-splitting or who limit a patient’s ability to file complaints or grievances when receiving teledental services.

Dental Hygienists Will Be Able to Administer Local Anesthesia

North Carolina joins 45 other states and Washington, D.C. in taking this important step.

Currently in North Carolina, dentists are the only oral health professionals authorized to administer local dental anesthesia. . Especially in public health settings — where providers routinely see high numbers of patients — the time it takes to administer local anesthesia and wait for it to take effect can create a bottleneck, limiting the dental team’s efficiency.

By allowing appropriately credentialed hygienists to perform this duty, dental teams can take steps to increase efficiency, reduce care costs, and ultimately expand their reach in treating additional patients. As mentioned above, this provision of the legislation will take effect on October 1, 2021.

To learn more about training requirements, refer to North Carolina General Statute 90-225.2. Licensed hygienists and hygienists with out-of-state certification can refer to NC General Statute 90-225.3 to find out how to become certified. Both laws can be found here.

Rules Pertaining to Public Health Hygienists and Limited Supervision Hygienists are Further Aligned

The regulatory rules within Dental Hygiene Subchapters 16W (defining what it means to be a public health hygienist) and 16Z (outlining eligibility to practice hygiene outside of direct supervision by a dentist) contained similar provisions, with a grey area where eligibility requirements were unclear. Senate Bill 146 aims to further align these provisions and the eligibility requirements that hygienists must meet to practice in limited supervision capacities.

For background, a 2020 update to Subchapter 16W allowed public health hygienists to perform preventive procedures in non-traditional settings under a written standing order from a dentist, rather than with a dentist having previously examined the patient.

Senate Bill 146 lays the groundwork for the same eligibility criteria to apply for hygienists practicing outside of direct supervision under Subchapters 16W or 16Z. For true alignment, a modification to rule 16W .0104 will need to be made.

If you would like more information to clarify 16W, 16Z, and the changes made by this recent legislation, NCOHC will be hosting informational sessions in the coming months.

Federally Qualified Health Centers are Recognized in Statute as Public Health Providers

Senate Bill 146’s passage marks the first time that Federally Qualified Health Centers (FQHCs) have been formally recognized in North Carolina law within the Dental Practice Act. While this may seem insignificant, it solves key barriers that many faced when trying to expand access to care.

When Rule 21 NCAC 16W .0104 was updated to allow public health hygienists to perform preventive procedures outside of direct supervision and based on a written standing order, FQHCs found themselves unable to efficiently take advantage of the change. Many FQHCs offer school-based oral health care services, but since their designation wasn’t clear, they were limited by legislative barriers in order to use the rule change to expand the services they offered most effectively.

Senate Bill 146 resolves this issue, identifying FQHCs as an integral component of the public health safety net.

There are many improvements for oral health access and equity contained within Senate Bill 146, and NCOHC will continue to break down all the ins and outs that you need to know. Stay up to date by joining us as a North Carolinian for Change today!

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Recap: Oral Health Day 2021

NCOHC hosted Oral Health Day 2021 on July 21st, featuring a speaker lineup with nationwide recognition, including a keynote address from the United States Assistant Surgeon General. If you missed the event, you can watch it in full here.

Keynote Address: Rear Admiral Timothy L. Ricks, DMD, MPH, FICD

RADM Timothy L. Ricks, DMD, MPH, FICD, Assistant Surgeon General and Chief Dental Officer of the United States Public Health Service (USPHS), gave the keynote address at this year’s event.

RADM Ricks started with an overview of the many roles the USPHS plays in advancing health and safety across the nation and abroad. He spoke about the different branches of the federal government where dentists serve, including the Department of Justice, the Department of Homeland Security, and the Department of Health and Human Services.

RADM Ricks went on to discuss the federal government’s COVID-19 response and how dentists have joined the effort to vaccinate the American public against the virus. He also discussed the impact that COVID-19 has had on dental care for the uninsured.

RADM Ricks gave the Oral Health Day audience an overview of equity and what it means in the dental world. Be sure to check out the 19-minute mark of the Oral Health Day recording for his breakdown of oral health disparities across the lifespan by race/ethnicity and income.

Amy Martin, DrPH, MSPH

Dr. Martin, Chair of the Department of Stomatology and Director of the Division of Population Oral Health at the Medical University of South Carolina (MUSC), spoke at Oral Health Day about the innovative ways MUSC is approaching community-based care.

Dr. Martin gave an overview of children’s oral health efforts in rural South Carolina, including how MUSC has engaged in partnerships to develop school-based oral health programs. She also discussed engaging school nurses as local champions to improve oral health services before discussing policy priorities, and the importance of advocacy and influence to improve oral health care.

William Donigan, DDS, MPH, and Melissa Boughman, RDH

Dr. Donigan and Ms. Boughman wrapped up the event, speaking about the success that Kintegra Health, a clinic in Gaston County, North Carolina, has experienced since they began employing patient navigators.

Dr. Donigan discussed patient navigators, giving the audience an overview of Kintegra Health’s patient flow before and after hiring a navigator toward the end of 2016. At their Statesville location, 47 new patients crossed over from Kintegra’s pediatric medical facility to its dental facility in 2016. After bringing on a patient navigator, they had 50 new patients in one month alone! Between 2012 and 2016, 4,584 new patients visited Kintegra’s Statesville dental facility.

There are significant distinctions between Community Dental Health Coordinators (CDHCs) and other types of patient navigators. Check out this paper for a deeper dive.

Boughman, who Dr. Donigan considers to be “the original CDHC in North Carolina,” followed up with a brief talk about some of the specific experiences she has had working with children through Kintegra Health’s school-based program.

 

 

Stay up-to-date on all things oral health in North Carolina, and be the first to know about future events! Join NCOHC today as an NC4Change member.

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Meet NCOHC’s Summer Interns Part 1: Dr. Kelly Bailey

Dr. Kelly Bailey is a student at UNC-Chapel Hill pursuing a Master of Public Health degree. She has a unique perspective on the intersection between the environment and health, and this summer she worked with NCOHC to develop educational resources for dental professionals on issues related to PFAS contamination and cannabis legalization.

Can you tell me a bit about your career/education path prior to pursuing your current degree?

I graduated from the University of Florida with a bachelors degree in Microbiology and then went on to complete professional training at the University of Maryland School of Dentistry. I was incredibly fortunate to receive a scholarship through the U.S. Navy Health Professions Scholarship Program (HPSP). After graduating from dental school, I went on to serve in the military for eight years.

Where are you in school, what are you studying, and why did you choose that program?

I am currently entering my second year in the Master of Public Health (MPH) program at UNC Gillings School of Global Public Health, with a concentration in Environmental Health Solutions (EHS).

I chose the EHS concentration based on my interest in environmental justice, which is entangled in many of the “wicked issues” of our time, including oral health inequities. The environment and humanity are interdependent, and I think we are becoming increasingly aware of our connectedness to the natural world and to each other on a global level. We are all impacted by the environments in which we live, work, learn, and play, and I believe that a shift toward whole-person healthcare must incorporate environmental determinants of health to comprehensively address these pressing public health issues.

Where did you first hear about the North Carolina Oral Health Collaborative, and why did you want to pursue an internship with NCOHC?

During a dental health policy and management course, I had the pleasure of hearing Dr. Zachary Brian speak on barriers to dental care access in NC. It didn’t take much research on NCOHC afterwards to realize that their team is a small but mighty coalition of innovators and change-makers! NCOHC has been a leader in the advocacy space, fighting systemic barriers to dental care access through policy reform and education, and their group has catalyzed some really impactful changes in NC. Who wouldn’t want to be a part of that movement!?

What about public health dentistry is intriguing to you?

The dental public health (DPH) community is fundamental to leading the dental profession outside of its traditional silo and into integrated healthcare. From utilizing teledentistry services, to administering vaccines, to playing a role in natural disaster response, I think the profession’s scope of practice will continue to evolve in ways that foster multidisciplinary collaboration and improve the wellbeing of all North Carolinians. It’s an exciting time to be in DPH!

What’s a fun fact about yourself?

While overseas with the military, I traveled by ship to eight different countries and even lived in the beautiful country of Japan for two years. It was the experience of a lifetime for sure.

Tell me a bit about what you have worked on as an NCOHC intern. What do you hope to take away from the work you have been doing?

First, I was able to take a deeper dive into the PFAS contamination issue in North Carolina as it relates to oral and systemic health. Although this is a very well-publicized situation, I think there are certain connections that dental providers and dental public health professionals should be guided in making. PFAS contamination in drinking water is affecting most, if not all, of our patients, so we need to understand what we’re up against and what we can do as individuals and as a profession.

Secondly, I explored the topic of cannabis use in North Carolina. With several bills in legislation in NC, and legalization having been pushed through in VA, I think it’s really important to get clinical providers and public health professionals talking about cannabis use as it relates to patient health and the dental practice. There are still many unknowns about the long-term effects of cannabis use, but we already know a lot about cannabis-related racial stigmatization and it needs to be addressed within our community. The education we provide to patients should always be driven by a desire to heal, not to impose political beliefs.

If you could tell North Carolinians one thing you have learned that you think is important for everyone to know, what would that be?

Despite being largely preventable, oral conditions like dental caries and periodontal disease continue to threaten the overall health of too many North Carolinians, with disparate access to oral care services being one driver of this “silent epidemic.” For those who want to learn more, NCOHC is doing a lot of work in this area and has reader-friendly posts on their website. Also, Mary Otto’s book, “Teeth: The Story of Beautify, Inequality, and the Struggle for Oral Health in America,” is a great reference for better understanding the issues.

Denial of, or ignorance about, oral health inequities is still pervasive, and the dental community is not immune to this occurrence. I think this sums it up nicely and is a good reminder to all of us:

“When we’re not hungry for justice, it’s usually because we’re too full with privilege.” – Carlos A. Rodriguez

What’s next for you?

I will be applying to the DPH residency program, based in the NCDHHS Oral Health Section, in hopes of joining the phenomenal community of DPH researchers, academics, and leadership professionals. Ultimately, I’m hoping to apply my skills within a community-based organization or at the state level.

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How Can Policy Impact My Teeth?

We can acknowledge it. “Oral health policy advocacy” is not exactly something you hear every day, right? Imagine meeting new people at a party (fully vaccinated and masked, of course) and telling them, “I work in oral health. Not in a dental office, but in structural reform and policy advocacy.” You would get a few quizzical head tilts.

However, policy advocacy is incredibly important in our work to increase equity and access to oral health care. Plus, to effectively impact policy, those of us who are already engaged need to bring more people into the conversation. We need broad coalitions working for change to see better policy take hold, so it’s worth asking the question:

“So, how can policy impact my teeth?”

Let’s start by laying out the ways you can keep your mouth healthy.

First is hygiene. Maintaining healthy habits at home is the best way to prevent tooth decay and gum disease.

Next comes professional care. Everyone should see a dentist at a regular interval for a cleaning and checkup. That interval may vary for some, but usually, it is recommended that you see a dentist twice each year.

These seem like simple steps, but everyone has different levels of access to oral health resources, and different levels of understanding when it comes to good oral health habits.

So, how does policy fit in?

What if you don’t have dental insurance or don’t have transportation to get to the dentist? Or, what if you want to improve your habits, but are struggling to wade through mountains of misinformation to figure out if you should use fluoride toothpaste?

Under our current structure, good oral health relies in so many ways on variables that one may not always be able to control. That’s where policy reform can make a difference.

Take school-based care as an example. In underserved communities across North Carolina, dental programs that go into schools at regular intervals can provide children with the regular oral health care services they may not otherwise receive.

That care can help maintain good oral health during a child’s formative years, and it can help build healthy habits that last a lifetime. And in these settings, transportation and many other barriers are taken out of the equation.

Unfortunately, however, there remain policy barriers to expanding school-based access. School-based oral health programs rely heavily on dental hygienists, and North Carolina law can limit the type and how these services are delivered.

Many duties delegated to hygienists require a dentist to be physically present on site. Dentists generally need to be in their brick-and-mortar facility, limiting opportunities for hygienists to get out into community and provide care in settings like elementary schools.

Policy changes that allow hygienists to practice with in community-based settings — an opportunity with increasing validity given advances in teledentistry technology — and policy changes to increase the number of hygienists a dentist can supervise, among others, could significantly expand access to oral health care in non-traditional formats.

For example, a regulatory rule change in 2020 now allows public health hygienists in provider shortage areas to offer more services in non-traditional settings such as schools, without a prior exam from a dentist.

Policy can also increase efficiency in the dental office. Currently, legislation in the North Carolina General Assembly would allow dental hygienists to administer local anesthesia. This clinical function, which has already been delegated to hygienists in 44 other states and Washington D.C., would help practices increase efficiency, reduce costs, and care for more patients.

Cutout of proposed Senate Bill 146

“But I have dental insurance and maintain good habits. Why should I care about policy?”

Proactive policy is not just a moral cause. Having more people experiencing good oral health is valuable in and of itself, but that reality carries positive impacts far beyond the individuals who are directly affected.

Treatments for preventable health conditions account for 75 percent of all health care spending in the U.S., and we only spend around 5 percent of health care dollars on preventive efforts. There is a huge opportunity to save money simply by boosting preventive efforts and warding off poor health conditions like tooth decay and gum disease before they can take hold.

What happens when someone with no insurance has a toothache? More often than not, that person will go to a hospital emergency department, where their pain may be managed but the source of the problem is not addressed. They may leave with a large hospital bill and likely another hospital visit in the near future if they are unable to seek care from a dentist.

If that individual can’t afford the hospital tab, the bill goes unpaid. Nationwide, uncompensated care costs add up to $42.4 billion every year. Nearly 80 percent of those dollars are eventually paid by taxpayers.

So, spending money up front to prevent poor health outcomes, both in our mouths and throughout our bodies, can significantly impact where our tax dollars go in the long run. Click here for more on the economics of preventive care.

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.

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Fear, Shame, Race, and Their Impacts on Access to Care


In the dental office, one experience, good or bad, can have a lasting impact. For too many people, negative experiences add up over time, travel through the grapevine, and lead to anxiety, fear, and shame that put up walls between entire communities and the care they deserve.

And as is the case for so many social determinants of health, race and racism are inextricably intertwined.

“We lived on the wrong side of the tracks being African American. There was only one dentist that I remember who was even available to us. I didn’t know what a dentist was. I didn’t know what a dentist did,” Carol said. “To the best of my memory, which was many years ago—in the mind of a child—I just remember his pulling on something in my mouth. Pulling back and forth with what looked like a pair of pliers. I screamed, I screamed at the top of my lungs because it hurt so much. And I didn’t want to go to the dentist anymore for the rest of my life.”

Carol’s Story

Carol had a traumatic experience in a dental office early in life that led to an unimaginable amount of pain. Pain that continued throughout childhood, perpetuated by a fear of returning to the dentist when cavities or other issues arose.

“Whenever I would have a toothache, I wouldn’t tell my mom. And if I had a cavity, I couldn’t sleep at night. I couldn’t rest well. It impacted my chewing, my swallowing, and my overall health because I would have pain in my ears and down the side of my neck,” she said. “But I was so scared. I was scared to experience the pain at the dentist again.”

In her community, Carol wasn’t the only one with a fear of the dental office.

“Stories travel. Stories travel really quickly. And bad stories travel much faster than the good ones. So not only did we know to be afraid of the dentist — and of course he was white, and we were all Black — not only to be afraid of this white man with this chair and this stuff in his office, but also that he hurt children, and he hurt adults. It really kept people from wanting to get the help they needed because of the physical pain.”

A Barrier to Access

Carol story isn’t a relic of the past. The same kind of fear she experienced as a child grips others today, and anxiety, fear, and shame around dental care is still a serious barrier preventing access.

“What I can tell you unfortunately is that there are many stories that are similar to mine in today’s time. That is true for dental care, and it is true across the board,” said Carol. “One, people are already afraid. Two, people don’t have to treat you well. This thing with Black Lives Matter, it’s not new. This thing with institutional and structural racism, it’s not new.”

But just as much as negative experiences can leave traumatic imprints, positive experiences can change entire outlooks on oral health care.

Carol said, “When I started going to the dentist here (in North Carolina), he had a sign in his office that said, ‘we cater to cowards.’ I said, ‘good, because that’s me!’ I told him about my experience, and he said, ‘you won’t experience anything like that here.’ His mannerisms were engaging, he would come into the room smiling and ask me what I had been up to. We would talk, and it was a whole different atmosphere. I started going twice a year, using my preventive care.”

Dentists can play an important role in helping those who are experiencing anxiety, fear, and shame, just by taking the time to understand the range of experiences that their patients may bring into the dental office.

A Willingness to Listen and Learn

“I think it’s really important for dentists to make sure they are getting outside of their comfort zone and their group, even if it’s a professional setting, to talk about things like structural racism,” said Carol. “It’s important to get into groups with folks like myself where we can talk openly and share stories and they can ask questions. And also, if they have patients who come in, just being willing to learn, being willing to listen, and being willing to talk.”

“Provide that openness, because when a person has been privileged, they really don’t know,” she said. “An example is in my family, education is a big deal. Everybody in my family did public speaking. So, when it was my turn and I was two or three I just jumped up and I did it too, because that’s what we do. I say that as an example of the fact that I didn’t know that I was supposed to be afraid of public speaking. I have been fortunate for something to be natural to me that may not be natural to most people. So just because someone has white privilege does not mean that there aren’t opportunities to learn. There are opportunities to learn.”

An Opportunity for Change

At NCOHC, we work to ensure that everyone — no matter their background, where they live, or who they are — has access to quality, affordable oral health care. We thought that Carol’s story was an important one to tell to highlight just how serious anxiety, fear, and shame as social determinants of health can be.

Is her story an indictment of dentists? No. But is it something we believe all dentists could learn from? Absolutely. The humility to step outside of your comfort zone and experience someone else’s truth can be difficult, but it can also help providers change patients’ lives.