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.
Note: Since this blog was published in July 2021, North Carolina Senate Bill 146 passed and was signed into law. You can find the enacted legislation here.
“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.
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.
Brushing Fido’s Teeth
Your furry friends need regular oral health care, just like you. Unfortunately, good information can be hard to find, care can be expensive, and too many people simply don’t know what they should be doing to keep their pets’ mouths happy and healthy.
Dr. Lenin Arturo Villamizar-Martinez, DVM, MS, PhD, Dipl. AVDC, is a board-certified dentist, head of the Dentistry and Oral Surgery Service of the Veterinary Teaching Hospital at the North Carolina State University College of Veterinary Medicine.
Dr. Villamizar-Martinez sat down with us at NCOHC to talk about animals, their mouths, and what best practices pet owners should be aware of.
What should people know about their pets and their mouths?
“The first thing that the owner needs to know is to brush their pets’ teeth daily,” said Dr. Villamizar-Martinez. “The teeth in dogs are equal to teeth in humans.”
He said that humans do tend to have more issues with cavities than their pets, but around 80 to 85 percent of dogs have periodontal (gum) disease. Regular brushing can help prevent gum disease and other issues that lead to expensive treatments down the road.
According to Dr. Villamizar-Martinez, choosing your pets’ toys wisely is another way to ensure that they maintain good oral health.
“There are a lot of products on the market for chewing,” he said. “Something that we recommend is to use any toy that you can make an indentation in with your fingernail. That toy will be soft enough to not cause a fracture on the teeth—that is a problem that we see a lot of.”
Softer toys will also rub your pets’ teeth when they are chewing, helping remove dental plaque. Harder toys like bones, on the other hand, can end up causing serious issues that lead to costly procedures.
“Research shows that these kinds of toys (bones and other hard toys) are related to complicating crown fractures, and at this point the only treatment that exists is to do root canal therapy or to extract the tooth,” said Dr. Villamizar-Martinez. “And that is expensive. When we are talking about root canal therapy, that ranges between $1,500 and $3,000. You can avoid that just by picking good toys for your dogs and cats.”
Before you jump up and search for new toothpaste or replacement toys online, Dr. Villamizar-Martinez said that there is a lot of inaccurate information on the internet. It can be hard to figure out what is actually good or bad for your pets online, and it is always better to ask for advice from your primary veterinarian.
He also recommends that pet owners visit the Veterinary Oral Health Council’s website. The VOHC reviews pet products and publishes lists of everything from pet toothpastes to toys, treats, and food that meet good oral health standards.
So, my dog is no longer a puppy (or my cat is no longer a kitten) and they aren’t used to having their teeth brushed. What do I do now?
“I’m living that experience right now,” said Dr. Villamizar-Martinez, talking about his newly adopted six-year-old dog, who never had his teeth brushed before.
He recommended to start by taking your pet in for a professional dental cleaning if possible.
“The first thing I did was put him under general anesthesia and did a professional dental cleaning,” said Dr. Villamizar-Martinez. “Then I said, ‘Now I need to start brushing her teeth !’”
He said the easiest way to start brushing a pet’s teeth is to use your finger first, mimicking the brushing motions you will eventually use a toothbrush for.
“After two or three weeks, your dog will know that it is normal and good, then you can move to a toothbrush,” said Dr. Villamizar-Martinez.
What do I do if I think my pet has an issue in their mouth?
“First, go to your primary veterinarian,” said Dr. Villamizar-Martinez.
General practice veterinarians can diagnose most oral disease, and they can run any blood tests or other diagnostics that may be necessary. If your pet has an issue, the veterinarian will be able to point you in the right direction for next steps.
Dr. Villamizar-Martinez said that many general practice veterinarians are trained to do professional dental cleanings and extractions if necessary. If your pet’s needs are more complex, your veterinarian should be able to recommend a veterinary dental specialist.
If you do find yourself taking your pet in for an oral procedure, Dr. Villamizar-Martinez said to make sure to only go to specialists who offer procedures under general anesthesia. A quick Google search will reveal many specialists who offer “anesthesia-free” procedures, but they are generally only cosmetic fixes that don’t fix the root of your pet’s disease. In many cases, Dr. Villamizar-Martinez said that these kinds of procedures can even make problems worse.
What about the cost of care?
Specialist veterinary procedures can be expensive, and unfortunately there aren’t many resources available for pet owners with financial constraints.
“Prevention is the most important thing at this point,” said Dr. Villamizar-Martinez. “That is the number one thing that is going to help.”
Dr. Villamizar-Martinez said that the NCSU College of Veterinary Medicine has been planning to start a program to offer veterinary solutions for shelter and rescue organizations that can’t afford to pay.
“We were thinking of adding some kind of pet dental care for shelters and rescue organizations who don’t have financial resources,” said Dr. Villamizar-Martinez. “Dr. Kelli Ferris, one of our faculty, directs our Mobile Veterinary Hospital. Veterinary students under Dr. Ferris’ supervision perform spay and neuter procedures. We were planning to incorporate dentistry, but the pandemic got in the way, at least for now.”
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.
School-Based Dental Programs
Oral health providers: Make sure to scroll to the bottom of this post to learn more about a school-based oral health grant opportunity from The Duke Endowment, the Blue Cross and Blue Shield of North Carolina Foundation, and the Blue Cross and Blue Shield of South Carolina Foundation
The COVID-19 pandemic has offered many lessons for public health, one of the greatest being the importance of “meeting people where they are.” Whether it be serving patients remotely via teledentistry or enabling dentists to deliver COVID-19 vaccinations, the oral health care community has shown resilience and innovation in expanding access to care during the pandemic.
Yet there are many more opportunities to increase access and equity in oral health care, both during and post-pandemic. One of these opportunities is expanding school-based dental programs.
In this post, we’ll take a look at school-based dental programs — what they are, why they’re needed, and how they can transform overall health in North Carolina by increasing access to oral health care for some of our state’s most vulnerable populations.
What Are School-Based Dental Programs?
School-based dental programs provide a range of oral health care services directly to students. While the extent of services offered varies, every school-based dental program brings care into the community, providing access to oral health care that many vulnerable populations may otherwise be denied.
Some school-based dental programs utilize fixed equipment in schools, while others rely on mobile clinics parked on school property. Services provided may include, but are not necessarily limited to:
- Oral screenings and risk assessments
- Fluoride varnish applications
- Dental sealant applications
- Oral prophylaxes
- Radiographs
- Oral hygiene instruction
- Nutrition and/or tobacco counseling
Above all, the configuration of school-based dental programs is flexible, and there are impactful ways to meet communities’ needs across all types of clinical models (more on this a little later).
In particular, school-based dental programs are uniquely positioned to address the social determinants of health, many of which present significant barriers to oral health care for school-aged children. The success of these programs in driving positive oral health outcomes is also well-documented, as we will explore further in this post.
“School-based health programs can level the playing field for children otherwise unable to access oral health care services,” says Dr. Zachary Brian, director of the North Carolina Oral Health Care Collaborative (NCOHC), a program of the Foundation for Health Leadership and Innovation (FHLI). “These programs offer an approach that can significantly increase access and equity for children across our state.”
The Need for School-Based Dental Programs
The need for improving access to oral health care for children in the United States is starkly evident, as is the opportunity for school-based dental programs to address disparities and barriers faced by at-risk populations.
Dental caries (cavities) is the most common chronic disease among U.S. children, according to the U.S. Department of Health and Human Services. According to the Centers for Disease Control and Prevention (CDC), roughly 52 percent of U.S. children have had a cavity in their baby teeth by the time they are eight years old.
In North Carolina, almost 50 percent of schoolchildren have tooth decay, according to the NC Department of Health and Human Services, Oral Health Section.
Disparities in oral health status between socioeconomic groups are also widespread. The CDC reports that low-income children are twice as likely to have cavities as higher-income children. In North Carolina, the picture is just as bleak. According to an analysis by NC Child, “children from poor, rural counties [in North Carolina] tend to have the highest rates of decay.”
“We have a high percentage of schools with students who get free and reduced lunches. We have some schools where 100 percent of our students receive that free lunch because of how many of them qualify under the federal poverty level,” said Dr. Elly Steel, dental clinical director at the Cabarrus Health Alliance, which has operated a school-based program since 1999. “With these children who aren’t getting access to care in other places, bringing the care to them at their schools is really helpful.”
Racial and ethnic disparities are extreme, as well. A study of more than 70,000 North Carolina kindergarteners found that “the prevalence of dental caries was 30.4% for White, 39.0% for Black, and 51.7% for Hispanic students.”
The Importance of Oral Health for Children
With an ever-increasing amount of evidence establishing a connection between oral health, overall health and wellbeing, the case for expanding access to oral health care for children is clear.
Oral health plays an important role, not only in children’s overall systemic health, but also in their well-being and social development. The CDC reports that, “on average, 34 million school hours are lost each year because of unplanned (emergency) dental care.”
The data in North Carolina is similarly damning, with an analysis finding that “children with poor oral health status were nearly 3 times more likely … than were their counterparts to miss school as a result of dental pain.” The study concluded that children with poor oral health status were also more likely to perform more poorly in school.
Oral health is also integrally connected with a child’s self-esteem and behavioral health: one recent study found that “various dental disorders … cause a profound impact on aesthetics and psychosocial behavior of adolescents, thus affecting their self-esteem.”
Social Determinants of Health
The social determinants of health are significant factors driving disparities in access and outcomes for North Carolina’s school-age children. Parents and caregivers often lack access to reliable transportation to take children to and from dental appointments. And even when transportation is available, however, it may be impossible to get time off work.
Location also plays a major role, with access to oral health care significantly more limited for those living in rural areas. In North Carolina, dental providers are highly concentrated in urban centers; 98+ of the state’s 100 counties are designated as Dental Health Professional Shortage Areas (dHPSAs) by the Health Resources and Services Administration (HRSA).
Why School-Based Dental Programs for North Carolina?
The need is apparent, and while efforts to improve and sustain surveillance and evaluation in oral health care have been undertaken in North Carolina, the state lacks an adequate system to provide direct preventive services and closed-loop referral for comprehensive oral health care for at-risk populations. School-based dental programs can fill critical gaps in that system by meeting people where they are and reducing barriers to care influenced by the social determinants of health.
Increasing Access, Improving Outcomes
More than 2,500 school-based health centers (SBHCs) are operating in the United States, with only an estimated 28 percent having an oral health care provider on site, according to a report in Health Affairs.
The research increasingly supports the effectiveness of these programs improving access and oral health status among U.S. children. A 2021 study published in the Journal of the American Dental Association (JADA) determined that bringing cavity-prevention programs directly into school settings reduced cavities by 50 percent, after only six visits.
“Our hygienist who works more directly in the mouth is seeing a huge improvement in many of the children that are returning for repeat visits,” said Rachel Stewart, a registered dental hygienist who works for the East Carolina University School of Dental Medicine on a school-based initiative in Bertie County, North Carolina. “Their oral hygiene is improving, they’re taking more pride in their teeth, and their teeth are looking cleaner and better.”
A 2016 study of school-based dental sealant programs also demonstrated similar effectiveness among schoolchildren in low socioeconomic areas.
School-based dental programs are cost-effective, too. A recent report concluded that “the cost to place sealants on a child in a SBSP [school-based sealant program] is approximately $100 compared with the lifetime cost to maintain a tooth that develops caries, which can exceed $2,000.”
Researchers have also estimated that implementing a national school-based caries prevention program “could reduce Medicaid spending on children’s oral health by as much as one-half.”
Dental Hygiene Workforce
North Carolina’s oral health care workforce is well-equipped to provide preventive services in school-based settings. Dental hygienists in North Carolina are highly trained, skilled, and engaged, and there is ample opportunity to leverage this expertise and experience in school-based dental programs.
Recent regulatory changes, including a change to Rule 21 NCAC 16W .0104, co-sponsored by NCOHC in 2020, aims to provide greater opportunity for dental hygienists to deliver preventive services in high-need settings such as school-based programs. These changes allow for dental hygienists to deliver preventive services in high-needs settings without a prior examination by a dentist, therefore amplifying service delivery and decreasing administrative burden. Other potential legislative changes, such as increasing the dentist to hygienist supervision ratio, could also prove similarly helpful.
The Next Step
Recently, The Duke Endowment has partnered with the Blue Cross Blue Shield of North Carolina Foundation and the Blue Cross Blue Shield of South Carolina Foundation to expand school-based dental programs across the Carolinas. Collectively investing more than $35 million, these groups are supporting dental safety-net health centers in implementing school-based dental programs in North Carolina and South Carolina.
“This initiative is a revolutionary opportunity to increase access and equity and improve oral health outcomes among schoolchildren in the Carolinas,” says Dr. Brian. “With the support of The Duke Endowment, the Blue Cross Blue Shield of North Carolina Foundation, and the Blue Cross Blue Shield of South Carolina Foundation, North and South Carolina can make significant strides in reducing barriers to oral health care and improving oral health outcomes for at-risk populations.”
Get Involved
If you are an oral health care provider or administrator interested in learning more about expanding your practice to serve your communities’ children in school-based settings, we invite you to join us for our second free online informational session on September 14th, 2021. We had a fantastic info session on July 27th, so make sure you don’t miss out!
In these sessions, in addition to learning about opportunities for community impact through school-based oral health programs, participants will have a chance to learn about the application process and the deadline for funding, as well as hear directly from current grantees about their experiences.
In addition, following the live, interactive learning sessions, participants interested in applying for the next cohort will have an opportunity to engage in 1:1 coaching where you’ll dive into your program ideas and innovative approaches to strengthen your application.
To reserve your spot in a virtual informational session, please click here to register.
Nearly a year ago, NCOHC launched a COVID-19 oral health access map. As dental offices transitioned to only offer emergency services — and while health professionals worked to figure out how to best ensure provider and patient safety — our staff wanted to make sure that those who needed care weren’t left without any idea where to go.
There were several reasons why NCOHC hoped to highlight facilities offering emergency care across North Carolina. First and foremost, tooth decay and gum disease aren’t going to wait for the pandemic to subside. And, as anyone who has ever suffered from a toothache knows, when you have an oral emergency, you want it taken care of fast.
We also know that so many people with dental emergencies seek care at their local hospitals, which often are not equipped to handle that type of care. Even in a non-pandemic world, it is important to divert these patients to facilities that can address their concerns, rather than offer temporary solutions. Especially during a pandemic, however, reducing demand on hospital staff wherever possible is absolutely critical.
Our staff decided that a centralized map would be helpful to anyone who needed care, but didn’t know where to go. We thought a map would be a good resource, but we certainly didn’t think that more than 31,000 people would have viewed it nearly one year later.
But it makes sense. There wasn’t any centralized resource to use to find a provider near you—especially if you need to find affordable options that accept Medicaid or offer care on sliding fee scales.
Now that most offices are open for routine care again, NCOHC has decided to make the Access Map a permanent resource, displaying useful information beyond operating status. If you navigate to the map, you can see hours of operation, service type (kids and adults), and more.
Additionally, in the coming months, NCOHC staff will be updating the map with more information, such as the availability of translation resources.
What do you want to see on the NCOHC Access Map? We are looking for feedback as we continue to develop this resource. Take a moment and fill out our survey with any suggestions you have.
Looking for other ways to get involved? Head over to NC4Change today!
Last year, soon after the COVID-19 pandemic reached the United States, those of us at NCOHC were working to devise plans in how we would work to contribute to the public health response. We came up with a couple of ideas, including the creation of our safety-net access map and the launch of the NCOHC Teledentistry Fund.
We partnered with the Blue Cross and Blue Shield of North Carolina Foundation (BCBSNC Foundation) to launch the Teledentistry Fund, awarding up to $60,000 in grants for safety-net dental providers geographically spread across NC. So far, the fund has allowed 14 safety-net clinics to purchase teledentistry software, enhancing their ability to provide a wide variety of services with their communities without risking the health of patients and providers alike.
A year later, and we have been blown away by the results.
We recently sat down (virtually) with just a sample of the oral health professionals who received Teledentistry Fund grants to hear about their experiences. Check out the video below to learn how the software helped them navigate the pandemic, and what kind of future they see for remote care technology in a post-pandemic world.
Tell us a little about your background, where you are from, and your educational path.
I am from the Washington, D.C. area originally. I moved to Raleigh in 2004 to pursue a degree in history from Peace College, an all-women’s college at the time. I knew that my life’s work would be realized by working with people from all different life experiences, cultures, and backgrounds. Both personally and professionally, my time at Peace College led me down a road through the higher education landscape, helping students navigate their experiences while advancing the mission of the university. This direction helped me see value in gaining my Master of Arts in Higher Education at Appalachian State University, and eventually I ended up at North Carolina State University. There I learned the value of large public land grant institutions and the value of partnership with statewide organizations to provide needed resources to the people of North Carolina. My eyes were opened to the idea of shifting to the nonprofit world, where making a difference and changing necessary landscapes is at the forefront of the work.
What professional accomplishment before coming to NCOHC are you most proud of?
Building many relationships with both internal colleagues and external partners. A recent partnership I am most proud of is the development and management of the Off Campus Consortium group at NC State. I managed relationships between private off-campus partners and the university to provide the most direct and trusting housing resources to students.
What originally drew you to working in the oral health space?
Making a difference in our society by creating change and helping to provide needed services to the residents of North Carolina.
What has been the most rewarding part of your work with NCOHC thus far?
Working with the staff and learning about all of the work the Oral Health Collaborative engages in to create systemic changes in our state.
What are the biggest challenges that you see facing access and equity in oral health care in North Carolina?
Barriers to access due to the social determinants of health.
What do you enjoy doing when not working?
I enjoy spending time getting my hands in the dirt and working to create useful and beautiful garden spaces for my family and friends to enjoy. When I’m not in the garden, I’m generally building useful furniture made out of scrap materials. My two dogs, Oliver and Sage, and my partner, are always along for wherever the adventure may take us. In the time of the pandemic, because travel was not an option, we have enjoyed watching traveling shows and dreaming about getting overseas when it is safe to do so again.
What do you want our membership to know about you?
That I am a passionate individual who loves people and working hard to make systems more efficient.
We’d like to start off this blog post with a quote from the Terry Pratchett novel, “Men at Arms.” The book is a fantasy novel, but the quote underscores an important reality of poverty, that is, it is expensive to be poor.
Pratchett’s fictional “boots theory of socioeconomic unfairness” is a reality for many across North Carolina, and across America, today.
For example, the average washing machine uses 19 gallons of water per load. Accounting for the average cost of municipal water and electricity, running your own washing machine costs a mere 30 cents per load. Nationwide, however, laundromat patrons pay approximately $2.00 per load.
It is over six times more expensive to have clean clothes in America if you’re too poor to buy a washing machine. And that doesn’t even take into account the luxury of an electric clothes dryer.
Saving money is a luxury tied in many ways to wealth. If you have a little extra cash at the end of the month, you can invest your hard-earned dollars in stocks, property, or other means that allow those dollars to grow. You can make decisions to spend money up front that allow you to save down the road. For example, you can decide to spend an extra few thousand dollars on a newer, more efficient vehicle, saving money on gas and repairs in the long-run.
If you have mouths to feed and rent to pay, and you’re living paycheck-to-paycheck, you generally will end up spending more on basic necessities than you would if you had more economic flexibility.
If you are poor in North Carolina, you are more likely to lack access to basic preventive care and oral health education as a child. As a result, you are more likely to experience tooth decay, both as a child and later as an adult.
Insurance aside, the average cost of one filling runs between $200 and $600.
For a root canal, average costs range from $700 for a front tooth up to $1,800 for a molar. Add the necessary crown following a root canal and you’re looking at an additional $300 – $3,000, depending on the crown’s material.
There are many options for low-cost dental care using sliding scales based on income, but at the end of the day, even one tooth with serious decay is much more expensive than an annual checkup and cleaning (especially with insurance, which generally covers the entire cost of routine preventive care).
Outside of the dental office, oral health takes an additional economic toll. How do you think a missing front tooth would impact your job prospects? Your confidence? Your ability to eat healthy foods?
North Carolinians visit emergency departments for oral care at twice the national rate. This particular statistic may be the most shocking, as the majority of hospitals are entirely unequipped to handle oral disease.
If you go to a hospital once you can’t handle the pain of your toothache any longer, you are likely to be prescribed an antibiotic and an opioid. Opioids are only a temporary fix for pain, and they bring with them a host of other potential problems. Antibiotics are not a solution for oral disease, either, but a temporary solution to potentially address the acute need. The pain and swelling may go away temporarily, but the root cause will still be in your mouth, potentially landing you back in the emergency department in a few months, with a new hospital bill.
In the same way that individuals with economic flexibility can spend dollars up front to reduce costs down the road, systems can operate in a similar fashion. In oral health, and in health care in general, dollars invested in preventive care—spent up front and before issues emerge—can not only lead to the best health outcomes, but they can also create more economically sustainable systems.
We need to structurally change the oral health care system in North Carolina, ensuring that every single child and adult has access to quality preventive care and oral health education. Beyond being the right thing to do, it is a fiscally responsible move that will save both individuals and our state government money in the long run.
Oral health care price estimates were gathered from newmouth.com
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On February 24, 2021, Senator Jim Perry and Representative Donny Lambeth filed legislation in the North Carolina House and Senate to formalize the practice of teledentistry and allow dental hygienists to administer local anesthesia.
For the purpose of this blog post, we will refer to the legislation as SB 146. The Senate and House bills were identical when filed, a common practice in the legislature.
SB 146 represents two important steps toward a future where all North Carolinians can access quality, affordable oral health care. Here’s what you need to know about the legislation and its path forward.
What’s in SB 146?
If passed into law, SB 146 would do two important things. First, it would formally define teledentistry in North Carolina’s Dental Practice Act, setting forth patient protections and allowing for patient evaluations to be conducted via remote modalities.
Prior to the COVID-19 pandemic, the NC Department of Health Benefits (Medicaid) reimbursed for synchronous teledental services, but not for asynchronous. However, as a part of their COVID-19 relief provisions, Medicaid added asynchronous reimbursement as a way for providers to further connect with the patients they serve. We believe this legislation will help signal to payers, both public and private alike, that teldentistry’s role in the future of oral health care delivery is both safe and effective.
Teledentistry has been, and will continue to be, an important tool in helping providers reach patients who wouldn’t traditionally have access to care. It can connect dental care teams in non-traditional dental settings, such as schools and long-term care facilities. Teledentistry can also expand service options in rural North Carolina — where providers are more scarce. All in all, teledentistry makes it more feasible for providers to improve access and equity in care.
Second, SB 146 would allow properly trained dental hygienists to administer local anesthesia. This clinical responsibility — which has already been authorized and delegated to hygienists in 44 other states and Washington D.C. — can help practices increase efficiency, reduce costs, and care for more patients.
North Carolina has historically been one of the more restrictive states in terms of the clinical procedures dental hygienists are permitted to perform. Fortunately, recent regulatory reforms such as the change to Rule 21 NCAC 16W .0104 have begun the process of updating the delegation of duties in the dental office. SB 146 represents an important next step, and we commend and thank Senator Perry, Representative Lambeth, and the stakeholders including the North Carolina Dental Society who worked to make this happen.
Where is the bill in its path toward becoming law?
As of March 17, both bills (SB 146 and corresponding HB 144) have moved through one committee in their respective chambers.
On the House side, HB 144 was referred to the committees on Health, Insurance, and Rules. This means that the Health Committee, Insurance Committee, and Rules Committee all must vote on the bill before it will be voted on by the entire House of Representatives.
On March 9, 2021, the Health Committee approved of the legislation with minor technical changes, passing it on to the Insurance Committee.
On the Senate side, SB 146 was referred to the committees on Health Care, Commerce and Insurance, and Rules. This means that the Health Care Committee, Commerce and Insurance, and Rules Committee all must vote on the bill before it will be voted on by the entire Senate.
As of March 17, 2021, the Health Care Committee approved of the legislation, inclusive of the minor technical changes that were first introduced to HB 144, and it now will move onto the Committee of Commerce and Insurance.
Whichever version of the legislation reaches a vote of its respective full chamber first will cross over for a vote in the alternate chamber. In other words, if the House bill is approved by the Insurance and Rules committees, and the full House of Representatives votes in favor of the bill, then the Senate will need to vote in favor, as well, or vice versa.
If both chambers vote “yes” on either version of the bill, then the legislation will be sent to Governor Cooper to be signed into law.
The steps between the proposal of legislation and the legislation becoming law can be complicated, but we will break down the process every step of the way. Stay up to date on the movement of SB 146 and HB 144 by signing up for NCOHC News today!
The American Dental Association Health Policy Institute (HPI) released a report earlier this year analyzing access for those with Medicaid/CHIP insurance across North Carolina. After taking a deep dive into the contents of the report, those of us at NCOHC kept reflecting on what access truly means, how our definitions of access can impact data collected, and how that data can in turn influence policy.
We recently published a summary of the main points in the HPI Report, which you can find here. As a brief recap, the report found that:
- Supply of “meaningful” providers —meaning providers who meet a benchmark of $10,000 in Medicaid claims each year — varies geographically for both children and adults.
- While overall utilization among children is above the national average — with 58.9 North Carolinian children seeing a dentist within the past year versus 51.7 percent nationwide — there are also areas where utilization falls below 25 percent.
- Dental care utilization among Medicaid-insured adults is low, at 18.7 percent statewide, versus 23.2 percent nationwide.
- Medicaid-insured individuals are less likely to secure appointments compared to their privately insured counterparts.
So, What’s Next?
The bottom line is that, as long as disparities exist in our oral health system, structural change will continue to be needed in order to bridge divides and increase equity in care.
At NCOHC, we believe that a future where those with Medicaid insurance or who lack coverage altogether can access care just as easily as their privately insured counterparts is not only achievable but absolutely necessary.
We believe that where you live, how much you earn, your race, ethnicity, or any of the other social determinants of health that have been shown to impact access to oral health care shouldn’t determine whether you can achieve optimal oral health. And we believe there are simple steps that North Carolina can take to structurally change inequities that exist along these lines.
Policy change will be an important piece of the puzzle as we work to change how care is provided and received. NCOHC released its first policy brief in 2020 outlining a variety of changes that are evidence-based and shown to successfully and equitably improve access to care.
At NCOHC, we are particularly interested in the potential that community-based models of care offer. One step in connecting community-based dental sites is through the promotion of remote care technology. This is especially critical to increasing access in rural North Carolina, and when coupled with enhancement strategies to more effectively utilize the dental hygiene workforce, leads to greater and more equitable access to critical oral health care services for all.
Keep your eyes on House Bill 144 and corresponding Senate Bill 146, which were recently filed in the North Carolina General Assembly. Along with defining teledentistry and authorizing patient evaluations to be conducted through remote technologies, the bill would allow dental hygienists to administer local anesthesia.
Stay up to date on the status of House Bill 144 and Senate Bill 146, as well as hear about additional oral health content by signing up for NCOHC News today!
Equity in Data
There is another conversation to be had — one about equity in data. It is easy to see data as a race-neutral, impartial juror in the realm of scientific discovery and analysis. But that’s not always the case.
Recently, data collection and equity have become prominent in the COVID-19 conversation. As states distribute vaccines, data collection is proving to be a critical step in equitable distribution planning. In fact, North Carolina is one of the more equitable states in vaccine distribution, thanks in large part to an early focus on data collection.
In future research pertaining to oral health care access, NCOHC hopes to see a greater stakeholder focus on the social determinants of health and their impact on health outcomes. For example, access to care was measured in the HPI report by a 15-minute travel time between patient and provider, but does 15 minutes mean access if a patient lacks transportation, childcare, or time off from work?
It is important to note that NC Medicaid offers transportation to appointments, an important step toward navigating transportation barriers.
Access can mean different things to different communities, and as oral health professionals seek to understand the landscape of access, and work to remove barriers to care, it will continue to be important to improve how we collect and analyze data.
For anyone interested in learning more, this Urban Institute webinar is a good resource on centering racial equity in data use. The Urban Institute also has a well-developed white paper titled, “Principles for Advancing Equitable Data Practice.”
