Depending on how long it takes to effectively respond to COVID-19, NCOHC is planning to host its annual Oral Health Day on June 3, 2020. This year, the theme of our signature advocacy event at the North Carolina General Assembly is teledentistry, with a focus on its use as a tool to increase access and equity in oral health care.
Our primary focus has been on how teledentistry can allow dentists to provide assessments and diagnostic care remotely, allowing them to reach patients in underserved communities
The North Carolina Board of Dental Examiners and the American Dental Association have both recommended that dental offices postpone all elective procedures for two and three weeks, respectively. While dentists and hygienists obviously won’t be doing oral cleanings or other routine, elective procedures virtually—education, assessments, and other diagnostic care and consultation could be provided remotely while waiting to resume in-person care delivery.
Simultaneously, hospitals and doctors’ offices across the country are struggling to meet demand, and we are seeing medical professionals forced to isolate after coming in contact with patients who have COVID-19.
For health care organizations, telehealth technology offers the ability to remotely monitor potential COVID-19 patients. Through phone screenings, virtual visits, and remote patient monitoring (RPM), providers can keep track of patients’ health and symptoms without any person-to-person contact. The same applications could be used in oral health care delivery as well.
Additionally, providers can use live video and RPM to care for inpatients, reducing points of contact.
To learn more about telehealth and how it can be used in response to COVID-19, you can access TRC’s COVID-19 Telehealth Toolkit here.
And to find out more about Oral Health Day and the steps North Carolina can take to help teledentistry become a viable option for remote oral health care, visit the NCOHC Oral Health Day 2020 page.
This Friday, March 20, is World Oral Health Day. So, we decided to take a look at some of the oral health issues people face in a few countries and regions around the globe.
In 2016, 3.58 billion people worldwide were affected by oral diseases. In the U.S. and around the world, gum disease and tooth decay consistently rank among the most prevalent conditions impacting people’s health.
Oral Health on the African Continent
Residents of countries across Africa face a few unique oral health challenges. While common oral disease rates are fairly low compared to other regions—only 14 percent of 35- to 44-year-olds and 22 percent of 60- to 69-year-olds experience gum disease—other, sometimes fatal, issues are more prevalent.
Oral and Facial Trauma
Due in large part to political instability and conflict across the continent, oral and facial trauma—broken or chipped teeth and jaw injuries impact as many as one in five children in Africa.
Noma
Noma is a disease most prevalent in sub-Saharan Africa that primarily impacts children suffering from malnutrition. While the gangrenous disease can be stopped and reversed with basic hygiene, antibiotics, and proper nutrition, sadly it is currently fatal in about 90 percent of all cases. When properly treated with antibiotics, noma’s mortality rate decreases to around 8 percent, making the first statistic especially jarring.
HIV
Oral manifestations are some of the earliest visible signs of HIV, making them important indicators of the disease. About 26 million people living in Afria are HIV-positive, accounting for nearly 68 percent of global cases of the disease.
HIV is still uncurable at a large scale, but doctors in London appear to have recently cured the second patient in the world of HIV. The patient received a stem-cell transplant and has been HIV-free for more than 30 months. The first patient to be cured of HIV has been free of the disease since 2011 after receiving a similar treatment.
Healthy China 2030
China is experiencing an ongoing oral health crisis, with tooth decay and gum disease affecting more than half the country’s population. A 2019 study into the oral health status of Chinese residents found that fewer than half of China’s population brush their teeth twice a day.
To respond to its public health crisis, China has launched Healthy China 2030, an initiative to incorporate public health into all of the Chinese government’s policies. Healthy China 2030 includes specific campaigns focused on oral health education, and it aims to shift the focus of health care toward preventive measures. These measures include education, as well as an increased focus on social determinants of health.
Health Care in Brazil
In 1988, Brazil’s government began to implement a government-run healthcare system, making it the only country at the time with more than 200 million residents to implement a plan for universal health care. Funding shortages and other barriers hinder Brazil’s system, and an article in the British Medical Journal of Global Health describes how economic and political instability could reverse the progress made since the 1980s.
Despite the instability of its health care system, Brazil has successfully provided a significantly larger portion of its residents with health care, dramatically improving the overall health of its population.
Brazil’s universal health care system focuses on primary and preventive health care, including oral health. Since 1988, Brazil’s “DMFT” index, or the mean number of decayed, missing, or filled teeth, among its population has decreased considerably. For example, the DMFT index for 12-year-olds has changed from 6.7 to 1.3 since the 1980s.
Unique Challenges In India and Tiawan
Have you heard of the Betel Nut? Chewing a betel nut causes a sense of euphoria and heightened alertness on par with consuming six cups of coffee, and it is incredibly popular in countries like India and Tiawan. A simple tree nut may not seem threatening, but this particular one is a potent carcinogen that has created an oral health crisis among its users.
Betel nut chewing can lead to a variety of oral diseases, including oral cancer and pre-cancerous lesions. In fact, 80 to 90 percent of Tiawanese residents diagnosed with oral cancer or pre-cancer chew betel nuts.
The time it takes for negative effects to develop makes the betel nut especially dangerous. This article from the BBC details the journey of one nut chewer, Qui Zhen-huang, who started chewing betel nut because, “everyone at work did it.”
He chewed for ten years and then quit. Twenty years after quitting, he developed oral cancer in the form of a golf ball-sized tumor and a hole in his left cheek.
The first references to betel nut chewing appeared in ancient Greek, Sanskrit, and Chinese literature. The tradition’s span of two or more millennia makes it a hard one to break, so governments are having a hard time convincing their citizens to quit.
In Tiawan, the government actually pays people to voluntarily cut down betel nut palms. In India, on the other hand, betel nut production has tripled since 1961. Some states and territories in India have implemented bans on specific betel nut products, especially ones that combine the nut with tobacco. However, the bans haven’t seemed to have much of an impact on its production and consumption.
Make A Difference Locally
To learn more and get involved with oral health improvement efforts here in North Carolina, visit our Oral Health Day 2020 page to see what we are planning for our signature advocacy event on June 3rd. If you’d like to receive updates about stories like this directly to your inbox, be sure to sign up for NCOHC news.
Last week, FHLI’s North Carolina Oral Health Collaborative attended the UNC Adams School of Dentistry’s Teledentistry Symposium, co-sponsored by the ECU School of Dental Medicine. Speakers from across the state joined oral health professionals in Chapel Hill to discuss technological innovations in oral health care and how they can be implemented to increase access across North Carolina.
The summit featured keynotes from experts in teledentistry as well as live demonstrations of the technology in action.
Dr. Rob Tempel and Dr. Andres Flores kicked off the demonstrations with a synchronous teledentistry consultation, followed by an example of asynchronous teledentistry from Dr. Shaun Matthews, the director of telehealth at UNC’s Adams School of Dentistry.
The 2020 Teledentistry Symposium follows UNC’s first ever Teledentistry Summit, which was held in October 2019. During his keynote address, Dr. Matthews reviewed the first summit and its goals, noting that oral health leaders have been successful in reaching those goals, including updating state-level dental hygiene regulations, visiting active teledentistry sites, and convening a statewide workgroup.
Dr. Shaun Matthews, director of telehealth at the UNC Adams School of Dentistry, giving his keynote address at the symposium.
NCOHC Director Dr. Zachary Brian also gave a keynote address, discussing the use of teledentistry as a tool to increase access for underserved communities and the policy changes necessary to make that happen.
Here are some highlights and takeaways from the day:
1. Rural North Carolinians Disproportionately Lack Access to Oral Health Care
Of North Carolina’s 100 counties, 74 are designated Dental Health Provider Shortage Areas (HPSAs). Dr. Brian discussed how this landscape leaves residents in most of the state with limited access to in-person oral health care. This barrier is further compounded when considering the disparities in access between those on Medicaid and those with private insurance.
Dr. Zachary Brian discussing NCOHC’s role in addressing access gaps and barriers during his keynote address.
Dr. Sy Saeed compared oral health care disparities to access gaps and barriers in psychiatry, highlighting legislative efforts to promote telepsychiatry across the state. Compared to the 74-county oral health care shortage, a whopping 90 counties are psychiatric HPSAs. In an effort to combat the access gaps and to reduce emergency department visits, the state legislature passed a law in 2013 to create NCSTeP, a statewide telepsychiatry program.
2. We Have a Growing Shortage of Dentists
Dr. Brian discussed how a decline in our state’s dentist population is compounding the access issues facing rural North Carolinians. Dentists are retiring at a faster rate than they are graduating and beginning to practice. More troubling still, this shortage is only expected to increase through 2025.
Meanwhile, North Carolina’s dental hygiene programs are consistently at or near capacity, so we are simultaneously experiencing a hygienist surplus. This could be a promising trend, but North Carolina’s regulatory landscape restricts hygienists’ ability to practice at the top of their licensure. Additionally, dentists in North Carolina can only supervise two hygienists. So even with the growing number of practicing dental hygienists, the dentist shortage limits the workforce’s ability to expand access to crucial preventive services.
A panel of students discussed their perspective on the dentist shortage, disparities, and the use of technology to bridge coverage gaps. Student groups at UNC and ECU have formed to advocate for curriculum changes to incorporate teledentistry so graduating dentists are better prepared to positively impact oral health outcomes in North Carolina through technology.
3. Teledentistry Can Expand Access
All summit speakers agreed that connecting dentists in central locations with hygienists and patients across the state is an effective path to expanding access to traditionally underserved communities.
With teledentistry, dentists can remotely provide diagnostics measures like exams, assessments, consultations, and direct education to patients. Dr. Brian noted that almost all oral health issues are preventable, so increasing access to preventive care is a high-impact, cost-effective strategy to improving overall oral health outcomes.
In his address to the symposium’s attendees, ECU School of Dental Medicine Dean Greg Chadwick said that, “teledentistry is a tool, not a goal.”
The goal is expanded access, covering North Carolinians equitably. Innovation in teledentistry is a promising way to achieve that goal.
4. Significant Barriers Still Prevent Teledentistry from Expanding
While North Carolina law doesn’t prevent the use of teledentistry, there is currently no reimbursement model for Medicaid patients to receive asynchronous teledental care, and the payment rate for synchronous teledentistry is prohibitively low.
Dr. Mark Casey, NC Medicaid’s dental director, joined a panel of health care providers to discuss payment models to ensure providers are reimbursed for their services. All panelists agreed that payment parity is necessary, and they said that asynchronous reimbursement should be a top priority moving forward.
To get there, Bobby White, the CEO of the North Carolina Board of Dental Examiners (NCBDE), said that the NCSBDE is willing and anxious to move forward with teledentistry, but out-of-date language in the Dental Practice Act needs to be updated by statutory change.
From left to right: Dr. Alec Parker, executive director of the North Carolina Dental Society; Sommer Wisher, past president of the North Carolina Dental Hygienists’ Association; Bobby White, CEO of the North Carolina State Board of Dental Examiners and Greg Chadwick, dean of the ECU School of Dental Medicine.
That’s why this year, NCOHC is dedicating its signature advocacy event, Oral Health Day 2020, to teledentistry.
On June 3, oral health professionals, community voices, and other oral health champions will convene at the North Carolina Legislature for a day of action and advocacy. We will engage and educate elected officials about the importance of teledentistry and the necessary legislative changes to allow it to expand into our state’s rural communities.
To learn more, visit our Oral Health Day 2020 page and register today!
To learn more and get involved, visit our Oral Health Day 2020 page to see what we are planning for our signature advocacy event on June 3rd . If you’d like to receive updates on stories like this directly to your inbox, be sure to sign up for NCOHC news.
Only 20 percent of a person’s health is the result of clinical care in a medical or dental provider’s office. The other 80 percent comes from a variety of non-medical factors. To reach equity in oral health, our health care system must address that 80 percent, which means accounting for external influences in patients’ lives.
From the food we eat to our housing and transportation options, many aspects of our daily lives can impact our health. Social determinants of health, also known as non-medical drivers of health, refer to the wide variety of influences outside the provider’s office that can directly or indirectly impact health outcomes.
Take food option-driven obesity as an example. If fast food makes up most of our mealtime options, the high-sugar, high-carb food we consume regularly will likely contribute to obesity, risk for heart disease, and increase the risk of tooth decay.
When it comes to oral health specifically, there are clear disparities in access to care and outcomes in North Carolina. Race, economic status, and geographic location are all important oral health determinants. For example, while around 20 percent of all children in our state experience tooth decay, roughly 50 percent of children in low- income families are affected.
Social determinants of health broadly fit into five categories: economic stability, physical environment, education, food, and structural and governmental influences. Each of these categories contains several specific factors. For example, employment, income, insurance, debt, and financial support all fall under the economic stability umbrella.
To better understand social determinants of health and how they can impact oral health outcomes, NCOHC will dive deep into each of these five categories over the coming months. We will discuss how the income an individual earns and the county in which they reside can directly impact their oral health, and we will explore how the state and federal policies cascade down to the local level, affecting health care opportunities among communities that traditionally lack access.
At the end of the day, policy change is a vital step in the process of addressing social determinants of health to create a truly equitable landscape for oral health care in North Carolina. That is why NCOHC engages elected officials and regulatory bodies to enact positive policy changes like that of the recent regulatory amendment to rule 16W .0104.
To learn more and get involved, visit our Oral Health Day 2020 page to see what we are planning for our signature advocacy event on June 3rd . If you’d like to receive updates on stories like this directly to your inbox, be sure to sign up for NCOHC news.
Last week, FHLI’s North Carolina Oral Health Collaborative travelled with North Carolina oral health leaders to Charleston, South Carolina, for a tour of the Medical University of South Carolina’s (MUSC) Telehealth Center of Excellence.
Front row, left to right: Shaun Matthews, DDS, MD (UNC Adams School of Dentistry); Crystal Adams, MA, CDA, RDH (Catawba Valley Community College); Nancy St. Onge, RDH (NC State Board of Dental Examiners) Second row, left to right: Mark Casey, DDS, MPH (North Carolina DMA); Zachary Brian, DMD, MHA (NCOHC) Third row, left to right: Kelsey Ross Dew, MPH (NCOHC); Lisa Ward, CAE (NC Dental Society).
The MUSC Telehealth Center of Excellence, one of only two HRSA-designated sites in the U.S., is home to state-of-the-art facilities, including an impressive array teledentistry technologies. To help North Carolina’s oral health leaders understand teledentistry and how the technology can benefit patients in our state, the group toured the facility and spoke with leading medical providers and dentists at the forefront of innovations in telehealth.
Dr. Walter Renne demonstrating cutting edge intraoral camera technology to the tour group.
Dr. Walter Renne, Assistant Dean of Innovation and Digital Dentistry at MUSC, demonstrated the process of scanning a patient’s teeth via an intraoral camera, one of the key tools of teledentistry.
The camera that Dr. Renne used can produce a 3D image of the patient’s teeth, and it can even render the gums as well. The scan produced can highlight potential points of decay to help a dental provider decide whether the patient needs further treatment or a more traditional in-person exam.
A 3D model of a patient’s teeth and gums created by an intraoral camera.
Unlike many fields of telehealth, teledentistry is a relatively affordable venture. The equipment required is minimal—primarily limited to a digital x-ray machine, an intraoral camera, and digital patient records (all of which are already used in many dental offices).
The MUSC tour group debriefing with MUSC leadership.
In addition, the telehealth services provided by MUSC extend far beyond just teledentistry. Patients across South Carolina can meet with doctors virtually for a wide variety of health services, from stroke and neurology care to psychiatry, pediatric care, and more.
Through its telehealth services, MUSC is able to reach patients in non-traditional settings such as schools, nursing homes, and correctional facilities—reducing costs and limiting time burdens on patients and care providers alike.
With 74 of North Carolina’s 100 counties designated as Dental Health Provider Shortage Areas (HPSAs), teledental services could make a significant impact in addressing access gaps. Teledentistry has the potential to increase access to basic oral health screening and diagnostic services in communities that disproportionately lack access to optimal oral health services.
While teledentistry is already used in a variety of settings, North Carolina’s regulatory framework limits its use from expanding into areas where it may be most impactful.
North Carolina’s Dental Practice Act, which regulates the practice of dentistry in the state, was written long before teledentistry was a viable opportunity for care. Additionally, a dentist who currently provides “synchronous” teledental care (i.e. live dental consultation, education, or examination provided in real-time) would be limited in their compensation. Equally as important, there currently is no reimbursement model for asynchronous teledentistry (i.e. “store-and-forward” care in which x-rays and other diagnostic information is taken and later reviewed by a dentist off-site).
That’s why this year, NOCHC’s Oral Health Day 2020 will focus on teledentistry and the opportunities it brings to North Carolina. Visit our Oral Health Day page to find out more about teledentistry’s potential in North Carolina, and register today!
Click here to see the rest of the photos from our trip to MUSC.
Sign up for NCOHC’s newsletter list to receive updates on stories like this one directly to your inbox.
Let’s take a moment to review an all-too-familiar scenario for many North Carolinians.
Martha lives in rural Tyrrell County, North Carolina, where there are no practicing dentists. She works a full-time job while raising her two children. So, she decides against making the hours-long round trip to the nearest dental office one county over to receive a cleaning and checkup.
Let’s face it: for Martha, the cost of transportation, the dental service itself, and the pay lost while she is away from work make for a steep price for care. On top of that, she knows that she may have to schedule a follow-up visit—and take time off from work again, find someone to pick up her children from school again, pay for gas again—if she has any cavities that need filling.
So Martha waits.
Sadly, what started as a bit of sensitivity develops into an unbearable toothache, which lands her in the emergency department (ED). In the ED, she is prescribed an opiate to deal with the pain and an antibiotic for the infection, and she is told to “follow up with your dentist.”
In a month or so, however, Martha, like so many others, ends up right back in the ED when her infection, which has never been directly treated, flares up again
Martha isn’t alone in this situation.
This story is reality for hundreds of thousands of North Carolinians who, for various reasons, cannot access oral health care.
A Better Way: The Promise of Teledentistry
Teledentistry is a promising innovative tool that could play a critical role in increasing access, especially in rural areas like Tyrrell County.
What is Teledentistry?
The use of telecommunications for dental exams and assessments, consultations between dental providers, and direct education for patients, among other uses. Teledentistry is a treatment tool that has incredible potential for increasing access to quality dental care in communities that traditionally lack access, especially in rural areas without practicing dentists.
Imagine this:
The next time Martha winds up in the hospital for her toothache, she is connected with a dentist in Chapel Hill via a live video feed. A medical professional takes digital x-rays of Marhta’s mouth and uses an intraoral camera to allow the remote dentist to take a look at her teeth. The dentist quickly diagnoses her abscessed tooth, prescribes Martha the correct antibiotic to help fight the infection, and helps her schedule an appointment for treatment.
With her oral health issue resolved, Martha finally breaks the cycle of hospital visits that she would have otherwise endured.
While Martha had never seen a dentist up until this point, she has always kept up a good habit of visiting her local federally qualified health clinic for an annual checkup. The next time she visits, she learns that the clinic now offers asynchronous teledental services in partnership with East Carolina University.
Synchronous and Asynchronous Teledentistry
Synchronous is a fancy word that means “at the same time.” In synchronous teledentistry, a dentist is connected via a live video feed to review material, assess the patient in real time, and provide direct patient counsel, if needed.
Dentists who practice asynchronous teledentistry are sent diagnostic information such as digital x-rays and pictures from intraoral cameras to review at a later date, giving them time to look at all the material and put together a comprehensive treatment plan based on the patient’s unique needs.
Digital x-rays and pictures from an intraoral camera are sent to a dentist who works through East Carolina University. She reviews Martha’s records later that week. Fortunately, this time there is no need for further treatment, but the dental provider does advise that Marhta floss more regularly.
Martha’s children have also never seen a dentist. Luckily for them, a dental clinic was recently established at their school and a dental hygienist provides them the same asynchronous teledental services that their mother received at the medical clinic.
The hygienist provides Martha’s children with fluoride treatments, dental sealants, and a thorough cleaning. The dentist who reviews their digital x-rays and other diagnostic information determines that they have no cavities, but that they both do have moderate gingivitis. The hygienist learns that the two have had to share a toothbrush, so the clinic provides them with two new toothbrushes and tubes of fluoride toothpaste.
From in-school clinics to emergency departments, teledentistry is a promising asset that could significantly improve access and equity in oral health care across North Carolina. For families like Martha’s, simple diagnostic services completed through teledentistry could drastically increase tangible access points to dental services, and in return prevent significant oral health burdens downstream.
The Tools of Teledentistry
Teledentistry can seem daunting, especially when it comes to modernizing an office to meet the technological needs of remote care. Unlike many variations of telehealth, however, the tools of teledentistry are actually quite simple. The basic necessities are:
A digital x-ray system
An intraoral camera
Electronic patient records
Most dental practices already use digital x-rays and intraoral cameras, and practices across the country are rapidly making the switch to electronic record-keeping. Compared to other telehealth services, the startup cost for teledentistry is relatively low.
By helping break the cycle of emergency department visits for oral health crises, medical costs for patients and the healthcare system as a whole could be significantly reduced. This is especially important in our rural communities. Cutting the uncompensated care costs burdening rural hospitals across the state could go a long way in attaining financial solvency. Additionally, inserting a dental professional into the hospital setting via teledental services could be an important way to combat the opioid crisis, reducing the number of unnecessary opiate prescriptions often given to patients with oral health emergencies.
Want to Know More?
NCOHC is taking a trip later this week to tour the state-of-the-art Center of Excellence for Telehealth at the Medical University of South Carolina. Stay tuned for our report from the trip!
Also, join us on June 3, 2020, for Oral Health Day! Oral Health Day is NCOHC’s annual advocacy event at the North Carolina General Assembly. This year we will focus our discussion on pathways to successful teledentistry in our state. Click here for more information and to register today!
Sign up for NCOHC’s newsletter list to receive updates on stories like this one directly to your inbox.
Parts one and two of our series, “Healthy Mouth, Healthy Body,” focused on heart disease, diabetes, and how the two are linked to oral disease
Gum disease, or periodontal disease, can allow harmful bacteria to enter the bloodstream and cause chronic inflammation. This inflammation is linked to conditions like atherosclerosis, an artery disease that can lead to heart attacks and strokes.
Diabetes is connected to gum disease in several ways. Dry mouth caused by diabetes can lead to suboptimal oral health, and gum disease itself can increase the prevalence of risk factors for diabetes like elevated blood glucose levels
To catch up, be sure to read parts one and two of this series.
Healthy Mouth, Healthy Pregnancy
Even though this follows posts about heart disease and diabetes, to be perfectly clear, we are NOT calling pregnancy a disease! (And, brushing your teeth, well, cannot prevent pregnancy.)
Pregnant mothers experience significant changes in their bodies during pregnancy, and some of these changes can impact oral health. For example, hormone imbalances can lead to gingivitis in the expecting mother. Increased vomiting from morning sickness, too, can increase the likelihood of developing cavities and tooth erosion (stripping of the tooth’s enamel).
Additionally, the research into the oral-systemic connection during pregnancy draws a connection between gum disease and low birthweight in newborns. Bacteria from gum disease can release toxins in the mother’s body that causes the body to produce chemicals that may stimulate contractions prematurely.
Research also reveals that gum disease may be linked to pre-term birth, but that connection is much less certain for now.
What Does This Mean?
For expecting mothers, it is important to work dental care into the already busy health care routine during pregnancy. For individuals who qualify for Medicaid while pregnant, NCOHC is working to support the extension of dental benefits post-partum to match perinatal health care coverage, which currently lasts 60 days after birth in North Carolina. You guessed it — currently, oral health coverage for the mother ends at time of delivery.
The oral-systemic connection during pregnancy also underscores a notion we have mentioned in all three parts of this series: integrated health care models are key to optimal outcomes. Expecting mothers have a lot do deal with, including a plethora of health care needs, from OB-GYN visits to primary care, birth counseling, and more. This takes time (and time off from work), which is hard to come by for many. We understand that adding oral health care into the mix can be easier said than done.
Integrated health care models, however, offer a way to make care during pregnancy easier on the expecting mother. Clinics and medical practices equipped to serve all the needs of a mother, from oral health care to OB-GYN services, could help ensure that pregnant women receive full-spectrum care to ensure as healthy a pregnancy as possible.
For more on the oral-systemic connection, be sure to read parts one and two of this series, and check out the resources below.
Sign up for NCOHC’s newsletter list to receive updates on stories like this one directly to your inbox.
The North Carolina Public Health Association recently hosted its 2020 Public Health Leaders’ Conference, drawing professionals from across North Carolina to discuss pressing issues and the public health landscape as we look ahead to 2030 and beyond.
In many ways, this year’s conference marks a turning point in North Carolina, so we sat down with Foundation for Health Leadership & Innovation President and CEO Anne Thomas to talk about the conference and her takeaways.
The theme of the 2020 Public Health Leaders’ Conference was “Shifting the Trajectory: Advancing Equity in Public Health.” According to Thomas, the importance of equity is not a new concept in public health, but the unified focus across public health leaders in North Carolina marks a promising change.
Putting Health Equity Front and Center
“We haven’t always spoken with the language of equity,” said Thomas. “I became a public health director in 1996, and we always talked about disparities, but the conversations used to be, ‘If we just tell people to change what they eat and how they live, they will be healthier.’ We can tell people how to be healthy, but if they don’t have insurance, transportation, or the proper food, and if we don’t address root causes like structural racism and poverty, we aren’t really going to make much of a difference.”
Thomas said that the intentional shift toward an equity-focused landscape in public health is significant. While disparities in health have always been a top priority for public health leaders, the focus has generally been from a clinical frame, leaving non-medical drivers like food, transportation, and housing out of the picture.
At the conference, the North Carolina Institute of Medicine (NCIOM) and the North Carolina Department of Health and Human Services (DHHS) unveiled their “Healthy North Carolina 2030” strategy, which lays out priorities to improve health in the new decade.
The focus on health equity and the overall drivers of health outcomes speaks to the new transformational vision for public health in our state to improve the health and well-being of all North Carolinians.
This excerpt from “Healthy North Carolina 2030” highlights non-medical factors like incarceration rate, reading proficiency, and suspensions as important indicators of health.
Using Social Determinants of Health to Understand Equity
Want to Know More About Social Determinants of Health?
Read our analysis of the most pressing systemic barriers to access where we break down how geography, income, language, race, and more can impact health outcomes.
To highlight health inequities, speakers at the conference discussed the importance of understanding and tackling non-medical drivers of health. Instead of simply treating patients, the speakers championed a more encompassing approach, understanding that health starts in homes, schools, and communities, not once you walk through the doors of a doctor’s office.
“The thing that has really changed is that we are talking about the non-medical drivers of heath, the root causes that have caused health inequities, and evidence-based strategies to address them,” said Thomas.
Thomas said that 20 percent of a person’s health is the result of clinical care, and 80 percent comes from other factors known as social determinants of health. To address that 80 percent, providers will pay attention to social determinants of health, and the health care systems will provide mechanisms to make things like food, housing, and transportation accessible to those who need them to be healthy.
Buying Health: Equity in Action
The concept of “buying health” is where equity becomes operationalized. Buying health refers to a value-based model where health outcomes are measured and paid for, versus the current fee-for-service model, where the cost of care is determined by the service(s) provided.
“Right now, if I go to the doctor, the office gets paid. It doesn’t matter if my health improves because there was an office visit,” said Thomas. “The concept of buying health means screening for these non-clinical factors, and if it is food that they need, or transportation, that food or transportation will actually be paid for.”
NCCARE360, a partnership between FHLI and the Department of Health and Human Services, was also an important topic of conversation at the conference, specifically regarding buying health. NCCARE360 is the first statewide network to unite health care and human services, using shared technology to coordinate person-centered care that provides for both medical and non-medical needs.
By the end of 2020, NCCARE360 will be available in all 100 counties in North Carolina.
Thomas said that buying health was an important topic at the conference, especially as North Carolina prepares for Medicaid Transformation, the state’s plan to transition from Medicaid’s fee-for-service model to “Medicaid Managed Care.” Under Managed Care, the state government will work with insurance companies to create a system that incorporates physical and behavioral health to address both the clinical needs and social determinants of health for Medicaid recipients.
“I feel like we are at a tipping point now,” said Thomas. “Equity is no longer something we just talk about. We are developing real strategies to achieve it.”
Our Oral Health Takeaways
The major themes of this conference—implementing equity, understanding social determinants of health, and transitioning towards value-based care—all apply to oral health care as well as traditional medical care. In fact, these new points of focus highlight the importance of breaking down the siloes that traditionally separate oral health from the rest of the body.
“This new focus is helping communities and providers realize that we really can’t separate the head from the mouth from the body, and we need to stop thinking in a siloed mentality,” said Thomas.
At NCOHC we believe that integrated care models that address all of a patient’s needs, incorporating oral health, medical health, and non-medical needs all under one roof, are integral in creating an equitable health future for all North Carolinians.
As we head into 2020 and plan for the decade ahead, we are excited to work hard to address social drivers of health and pave an equitable path to a healthier future for all North Carolinians.
New research is revealing the intricate connections between the health of our mouths and the health of our bodies. Conditions like cardiovascular disease (heart disease), diabetes, osteoporosis, Alzheimer’s Disease, and many others have significant connections to oral health.
If you missed it, be sure to read part one of our three-part series, “Healthy Mouth, Healthy Body,” where we cover the connections between gum disease and heart disease. In this post, we’ll travel from the hart through the blood vessels to explore diabetes adn its connections to oral health.
Review: The Oral-Cardiovascular Connection
Gum disease, or periodontal disease, can allow harmful bacteria to enter the blood stream and can cause chronic inflammation. Chronic inflammation is linked to many harmful diseases, like atherosclerosis, an artery disease that can lead to heart attacks and strokes.
Healthy Mouth, Healthy Blood
Gum disease and diabetes are complexly intertwined. Gum disease can increase the risk of diabetes, AND diabetes can increase the risk of gum disease.
Here’s how it breaks down:
To start, diabetes can cause dry mouth (xerostomia). Your saliva is a powerhouse, defending against cavities by cleaning your mouth and controlling its pH balance. So, if you have dry mouth, reduced levels of that cavity-fighting saliva decreases the impact of its antimicrobial functions. And, your mouth’s pH may even become imbalanced, increasing how quickly plaque can develop and build up.
Additionally, since diabetics have delayed healing, one with active oral disease can be at a greater risk of infection following a tooth extraction and other surgical procedures.
On the flip side, gum disease is also linked to multiple causes of diabetes. Unmanaged gum disease can lead to chronic inflammation and increased blood glucose levels, both of which are important risk factors for diabetes.
What Does This Mean?
Our Habits Play a Role in the Oral-Systemic Connection
When thinking about oral-systemic connections, it is important to consider the causes, as well as the connections and outcomes. For example, increased sugar intake is both a risk factor for developing diabetes and a risk factor for developing cavities and periodontal disease. There are many other habits, such as tobacco use, that also impact your oral health and the health of other parts of the body.
Emerging research into the oral-systemic connection and the prevalence of these diseases highlight just how important it is that everyone have access to both oral health care and general health care.
Gum disease and diabetes are both incredibly common conditions. Gum disease affects 75 percent of adults in the United States, and nearly all Americans (about 91 percent of adults over 20) have tooth decay, according to the CDC. More than 100 million (about 33 percent) of Americans have either diabetes or prediabetes.
At NCOHC, we focus especially on those who lack access to optimal oral health care. The demographic characteristics of communities that chronically lack access are very similar to those with higher rates of diabetes. (For more on this, see our post about systemic barriers and oral health equity).
It is incredibly important that we address systemic barriers to oral health care, and to health care in general, to make sure that vulnerable populations get the care they need to live healthy lives.
Additionally, given the links between diabetes and oral disease, medical practices that treat patients with diabetes should understand how to recognize symptoms of oral disease. Conversely, dental practices should be aware of how diabetes plays a role in oral health outcomes.
This is why we support advancing integrated care models, where dental practices and medical practices alike are equipped with the tools necessary to positively impact both sides of the oral-systemic connection.
Stay tuned for the final part of this three-part series, focusing on the connection between oral health and pregnancy. We will publish this final post on February 11.(Follow us on our brand new Facebook page and we’ll let you know when we publish new content!)
Sign up for NCOHC’s newsletter list to receive updates on stories like this one directly to your inbox.
On Thursday, January 16, 2020, the North Carolina Rules Review Commission gave its final approval of a rule change to ease restrictions on dental hygienists, increasing access to oral health care for children in high-need settings.
Last week we sat down with Sarah Vidrine, the policy analyst for NC Child, to discuss this rule change and how it will impact children in North Carolina.
What Exactly Does This Rule Change Do?
“It removes barriers to oral health care for kids in school-based settings, and it will ease the burden on the provider community,” said Vidrine. “For dentists and hygienists, it eliminates unnecessary barriers to allow providers to do the work they are trained to do.”
The change to Rule 16W allows hygienists located in Dental Provider Shortage Areas (HPSAs) to provide preventive care based on a written standing order from the supervising dentist rather than a dentist’s in-person exam. By decreasing the administrative burden of a prior exam, more children will have access to preventive dental care.
With 74 percent of North Carolina counties designated as HPSAs, this change opens doors for children across the state and is an important first step toward more equitable access to preventive care.
How Will This Help Children Access Oral Health Care?
Vidrine said that one of the exciting impacts of this rule change will be the increased ability for dental hygienists to go into schools to provide preventive treatment.
“School-based programs are promising because they let us meet kids where they are,” Vidrine said. “It’s a more efficient and cost-effective way to get kids dental care.”
“We treat cavities as if they are a rite of passage, but they really are preventable. The earlier we can get to kids and provide preventive treatment like fluoride and sealants, the bigger overall improvement I think we will see,” she said.
What Makes School-Based Care Different?
In schools, versus traditional care in a dental office, all kids have the opportunity to directly access care.
“School-based clinics reach kids instead of relying on parents to be able to take time off work, get their child out of school, and get them to a dentist,” said Vidrine. “Especially for families on Medicaid and families without insurance, it can be very difficult to get care, develop a treatment plan, and follow through. In school-based clinics, a lot of those barriers are removed.”
Why Is It Important That Dental Hygienists in Schools Be Able to Provide This Treatment in High Need Settings?
It really boils down to the numbers, according to Vidrine.
“In North Carolina we have both a shortage and a maldistribution of dentists. So, we have too few dentists to meet the need of the population we have, and most of these dentists are practicing in a fifth of the state,” said Vidrine. “Even with great programs through UNC and ECU that are very targeted at getting better access to rural communities, they are not going to graduate enough dentists to meet the need. Plus, we have a rapidly retiring population of currently practicing dentists.”
With the growing shortage of dentists, hygienists are necessary to fill the gaps in high-need settings.
“There are more dental hygiene programs than dental schools in the state, and they stay full and are very competitive,” Vidrine said. “We don’t have a similar shortage of hygienists in North Carolina.”
Along with waiving the prior exam in high-need areas, the rule change also allows dentists to supervise more than two dental hygienists who are practicing in high-need settings and have been duly trained as public health hygienists. Given the surplus of dental hygienists in the state, there is potential to access a much larger workforce focused on early preventive interventions.
“A dental hygienist’s role is to serve as the prevention arm,” said Vidrine. “Dentists spend a lot more time in school on treatment and interventions and less time on prevention, which is really the function of hygienists.”
The Takeaway: This Change Has Been a Long Time Coming, and We Will Keep the Momentum Moving Forward
“Advocates have pushed for similar rule changes for over 20 years, dating back to a 1999 North Carolina Institute of Medicine task force report on dental care access,” said Vidrine. “That happened before my time in oral health, but NC Child has been involved since 2015 when we started to look at policy options in collaboration with NCOHC.”
Years of effort, with the involvement of many different groups, has finally paid off. The final rule change was co-sponsored by NCOHC and the North Carolina Dental Society, the two organization’s first partnership of this magnitude.
Looking forward, the partnerships and collaboration that made this rule change a success will lay the groundwork for future efforts. Vidrine hopes that this is the first of many updates to North Carolina’s regulatory framework to further increase access and equity in oral health care.
“I think that there is an opportunity to look at things that complement this existing school-based prevention system, such as teledentistry,” Vidrine said. “And then there is a lot we can do with perinatal oral health, especially given some of the new research identifying risks for a pregnant mom with poor oral health.”
