Author: NC Oral Health Collaborative

What does “access” really mean?

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:

1. 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.
2. 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.
3. Dental care utilization among Medicaid-insured adults is low, at 18.7 percent statewide, versus 23.2 percent nationwide.
4. 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.”

Haven’t had time to read the new HPI Report analyzing access for children and adults with Medicaid/CHIP insurance in North Carolina yet? We’ve got you covered.

Earlier this year, the American Dental Association Health Policy Institute, in collaboration with the North Carolina Dental Society and the North Carolina Department of Health and Human Services, published an analysis of access to oral health care for North Carolinians with Medicaid/CHIP Insurance.

To provide context as we continue to break down the report and discuss next steps to create a more equitable, accessible North Carolina, we put together a brief summary of the report’s highlights.

Key findings from HPI’s analysis include:

1. 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.
2. 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.
3. Dental care utilization among Medicaid-insured adults is low, at 18.7 percent statewide, versus 23.2 percent nationwide.
4. Medicaid-insured individuals are less likely to secure appointments compared to their privately insured counterparts.

Dr. Mark Casey, dental officer for the North Carolina Division of Health Benefits (NC Medicaid), penned an introduction to the report, tracing a history of innovation from the groundbreaking 1998 North Carolina Institute of Medicine “Task Force on Dental Access,” to a landmark lawsuit requiring NC Medicaid to raise reimbursement rates, and to the creation of “Into the Mouths of Babes”.

“NC Medicaid and its partner, the North Carolina Dental Society, agree that there is much work left to do to fulfill the promise of better oral health for the disadvantaged in our state,” wrote Casey. “However, it is also important to take note of the progress that has been made over the last 20 years from a time when the vast majority of publicly insured children were not receiving an annual dental visit.”

Casey also recently sat down with NCOHC for an interview about the HPI Report and his takeaways, which you can read here.

The HPI Report authors found that 90 percent of Medicaid-insured children live within 15 minutes of a participating dentist. It is important to note that this figure includes the entire pool of participating providers, not just “meaningful providers.”

When you filter for meaningful providers and break the data down geographically, access gaps begin to emerge.

The HPI Report authors outlined two important factors that contribute to North Carolina’s access gaps: the supply of dentists and the demand for dental services.

In the images above, red areas signify more than 2,000 Medicaid/CHIP-insured patients per meaningful provider. The grey areas, which are especially significant in the western and eastern parts of the state, lack a Medicaid office altogether.

When comparing supply versus demand, a clearer picture emerges, highlighting Northeastern and Western North Carolina as the two regions with the most pressing access disparities.

Looking forward, there are both good and bad signs for North Carolina…and there is a lot of work that can be done to increase access and equity in care.

On average, Medicaid/CHIP-insured patients have a more difficult time securing appointments compared to their privately insured counterparts. What work can be done to end this disparity?

HPI projected a net increase in practicing dentists in North Carolina in the coming years. Can North Carolina provide adequate incentives to encourage new providers to practice in underserved, rural areas?

Be sure to stay tuned for NCOHC’s perspective on the findings in the HPI Report and the collaborative’s suggestions for next steps to increase access and equity in oral health care! We will publish a full analysis soon. In the meantime, here are a few of our immediate takeaways:

1. In rural NC, innovative approaches to practicing dentistry — such as teledentistry and school-based care— can significantly improve access to those with Medicaid/CHIP insurance.
2. We need North Carolina stakeholders to work together and find innovative ways to incentivize newly graduated dentists to serve patients in underserved regions.
3. We are excited to work with stakeholders, both in private practice and public health, to find ways to increase the number of dentists serving Medicaid/CHIP patients, and similarly, to increase the number of patients participating dentists serve each year.

What changes do you think will help North Carolinians? Get involved by heading over to NC4Change and signing up for a focus group today!

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. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

At the beginning of the new year, the American Dental Association Health Policy Institute released a new statewide report on oral health access for North Carolinians with Medicaid dental coverage.

As those of us at NCOHC read through the report, we saw both encouraging signs and cause for concern. For more perspective, we spoke to Dr. Mark Casey, dental officer for the North Carolina Division of Health Benefits (NC Medicaid).

Our conversation with Casey covered two important points. First, how are we measuring access to providers, and how could that measurement be improved? Second, what strategies can be implemented to increase use of benefits to ensure that more North Carolinians are accessing oral health care?

What is a “meaningful provider,” and how can the metric be improved to better measure access?

From the report: Out of 2,295 pediatric providers who accept Medicaid/CHIP insurance, HPI found 1,522 to be meaningful providers. For adults, 988 of the 2,160 Medicaid/CHIP providers were found to be meaningful providers.

The HPI report measured Medicaid participation with a “meaningful provider” benchmark of $10,000. This means that a provider who accepts Medicaid/CHIP insurance is considered a meaningful provider if they file $10,000 or more in claims with NC Medicaid each year.

This kind of benchmark offers important insight, filtering out providers who may only see a handful of cases each year, and revealing a map that better shows where access points truly exist.

But while $10,000 has been a standard benchmark, Casey thinks that the number should be higher, given changes over time in reimbursement rates and baseline cost of care.

“It really doesn’t take much in the way of claims activity to hit the $10k threshold these days,” said Casey. “The fact that this level of participation has not changed for 20 years ignores the inflationary pressures on costs to provide treatment and increases in reimbursement rates for providers.”

Casey said that he would like the reimbursement threshold to be $25,000 or $50,000.

He also mentioned that some organizations opt instead to measure meaningful providers by the number of Medicaid or CHIP patients treated in a year, a benchmark that would not be subject to change due to inflation or changes in reimbursement rates.

How do we increase the percentage of Medicaid-enrolled children and adults who use their benefits and see a dentist each year?

From the report: HPI found that 90 percent of Medicaid/CHIP-insured patients live within 15 minutes of a participating dentist, but only one-fifth of Medicaid-enrolled children and one-fifth of Medicaid-enrolled adults live in areas with an enrollee-to-meaningful provider ratio that is less 500-to-1.

To increase participation among this population, Casey discussed a two-fold approach.

First, he said that he believes more coordinated, innovative education initiatives between interested stakeholders would help encourage parents to take their children in for routine care.

Second, Casey said that a closer look at the population of participating dentists is important as well.

“I think we have a large number of providers who are on the low end of the Medicaid spectrum of participation,” said Casey. “I really do think that if the professional membership groups encouraged providers to participate—take 5-10 families as new patients for the year—we would see a spike in participation.”

According to Casey, both increasing the number of patients that enrolled providers see, and encouraging non-participating providers to begin seeing Medicaid patients, is critical to increasing access to care.

An innovative addition: hospital dental clinics

Casey discussed increasing the number of hospital dental clinics in North Carolina as an addition to the oral health care landscape that could increase access to important services, especially for some of the most underserved populations.

“With hospital dental clinics, my main goal is to provide a safe place for dental treatment for patients who have co-morbidities,” said Casey. “My thinking is not just diversion of dental emergencies from the ER, but also as our population ages, there are going to be a lot more elderly folks with chronic medical conditions that put them at risk for problems during a dental office visit.”

Casey also mentioned that hospital dental clinics could offer better options for dental patients with intellectual and developmental disabilities, a population that remains underserved in much of North Carolina.

Stay tuned for more analysis of the HPI report and NCOHC’s thoughts on the approaches needed to create a North Carolina where everyone has access to quality, affordable oral health 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. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

In the early 1990s, cervical cancer was the most common cancer among women. Today, it has dropped to fourth place, thanks in large part to successful screening programs and human papillomavirus (HPV) vaccination.

Dr. Jennifer S. Smith, a vaccine epidemiologist and professor in the Department of Epidemiology at the UNC Gillings School of Global Public Health, has worked on cervical cancer prevention for most of her career. She said that scientific advancement, especially in the realm of HPV vaccine development, has played a critical role in preventing the cancer and saving lives.

“When I first started working on cervical cancer, we didn’t have the vaccines yet,” said Smith. “At that time, we weren’t even 100 percent clear that HPV caused cervical cancer, but scientific colleagues were able to determine it through a number of really important studies around the world.”

Fast forward to 2020, HPV vaccines are now available and have the potential to prevent nearly 90 percent of cervical cancer.

HPV vaccination is recommended for universal use between 11 and 14 years of age in the United States.

NCOHC has focused on the HPV vaccine as an important preventive measure against oropharyngeal and head and neck cancer, but the vaccine can prevent a host of other cancers, too. For more on HPV and oropharyngeal or head and neck cancer, you can download NCOHC’s fact sheets for patients and providers here, and read more about dentist-administered vaccines here.

So, how do you go from a possible relationship between a cancer and a virus to a lifesaving vaccine?

According to Smith, epidemiological research, the study of causes and distribution of diseases, is a critical part of the process. With HPV, one of the first steps toward an effective vaccine was the discovery of its relationship to cervical cancer.

HPV is the most common sexually transmitted infection (STI), with about 43 million infections in 2018, according to the CDC. HPV infection is very common and is often harmless. In many cases, people who contracted HPV don’t even know they had it.

“As an epidemiologist I want to understand disease natural history,” said Smith. “All of that plays right into understanding, for example in the case of HPV, the specific individual infection types that cause invasive cancers. All of that epidemiology data goes right into the development of the vaccines.”

After decades of research, strong links have been discovered between HPV and cervical cancer, anal cancer, cancer of the penis, vagina, and vulva, and oral cancers. In total, 21,100 women and 14,700 men will be diagnosed each year with an HPV-related cancer, according to the CDC.

“The current generation of HPV vaccines are estimated to prevent about 90 percent of invasive cervical cancer cases, so it is a really good example of how understanding the virus and how it causes cancer informs vaccine development in order to prevent death,” said Smith. “That is ultimately what we’re after—we vaccinate to save lives.”

The work doesn’t stop with a successful vaccine

Vaccine uptake—actually getting people to take the vaccine once it has been developed, tested, and approved for use—is the next step. Smith has been involved on this front as well, working to figure out how to get accurate information to parents as they consider whether or not to vaccinate their children.

Smith helped start Cervical Cancer Free America, a network of coalitions with the goal of eliminating cervical cancer through vaccination, screening, and education.

“We started Cervical Cancer Free America working in a number of states to try and build coalitions to address cervical cancer prevention,” said Smith. “I think it is absolutely critical to think on a state-by-state level. It is critical to have local tailoring of messaging and local commitment.”

Smith referred to Dr. Noel Brewer, another UNC Gillings School of Global Public Health professor who studies health behaviors around cancer prevention and vaccination. Brewer’s work includes teaching health care providers how to communicate more effectively with patients about vaccines.

“I think the very clear message is that the biggest persuader, or the biggest factor that might influence a parent’s decision to vaccinate their child, is their trusted clinical provider,” said Smith.

Providers often giving HPV vaccines are pediatricians, who may not be as familiar with invasive cancer outcomes as gynecologic oncologists, for example, who are the health care professionals taking care of cervical cancer patients.

Understanding the HPV vaccine in terms of a disease endpoint, such as cervical cancer, is vital in accurately communicating with patients and their parents.

“The question I have is, we know that HPV causes cervical cancer. We know it causes other cancers. It causes anal cancer and oral cancer in both men and women. It also causes penile cancer in men and vaginal and vulvar cancer in women. And we don’t have many good ways of screening for a number of these cancers,” said Smith. “Why wouldn’t you vaccinate your child if you knew you could prevent a virus that can cause all of these cancers?”

For parents considering vaccinating their children, the best time to vaccinate for HPV is between 11 and 14 years old. For more information on the HPV vaccine, visit Cervical Cancer Free America.

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. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

If it isn’t clear by now, COVID-19 is not just another flu.

In November, the New York Times published an article with the alarming headline, “Their Teeth Fell Out. Was It Another COVID-19 Consequence?” The article followed the story of one COVID-19 “long-hauler,” the term given to those who experience a wide range of symptoms long after they initially contracted the virus, ranging in from common symptoms like coughing to more unexpected manifestations like early symptoms of Parkinson’s Disease.

Before we go further, we’re going to stop right here and clarify that most of the information in this post is anecdotal. So, it wouldn’t be correct to say with certainty that “COVID-19 causes Parkinson’s Disease.” Doctors and patients are continuously discovering new symptoms and manifestations of COVID-19, and it will take some time for researchers to study the disease and find out why certain people’s bodies react the way they do.

But it’s worth talking about the more unexpected side effects experienced by long-haulers, if for no other reason than to reaffirm just how important it is to take steps to ensure that you are protecting yourself and those you love from the virus.

Are there direct connections between COVID-19 and oral issues?

The person interviewed by the New York Times — who noticed a loose tooth while chewing a breath mint only to have the tooth fall out the next day without pain or blood — had a history of smoking. When she visited her dentist, he discovered that she had bone loss in her jaw from when she used to smoke, which likely contributed to the loss of her tooth. But why hadn’t her tooth fallen out until it did? Or, what caused it to fall out when it did? Another long-hauler mentioned in the article, a 12-year-old with healthy teeth, also suffered tooth loss. (At 12, he had no history of smoking.)

One possible explanation is that COVID-19 in some way, shape, or form, could exacerbate pre-existing oral conditions. If that is the case, there is still significant cause for concern, as nearly half of the adult population in the United States has some form of periodontal disease.

Researchers are focusing more and more on the impacts that COVID-19 has on blood vessels, which also could help explain oral manifestations and other seemingly unrelated symptoms. We know that blood vessels are the conduit for many diseases with oral manifestations like heart disease and diabetes. Tie in COVID-19 symptoms like blood clots, bleeding of brain vessels, and rashes, and the possibility of oral implications makes a bit more sense.

A clearer picture: indirect consequences of COVID-19

Beyond the possibility of scary side effects of COVID-19, there are a couple indirect oral manifestations of simply existing during a pandemic that are worth talking about.

For example, take this New York Times interview with a Manhattan dentist who has seen a massive increase in cracked teeth among his patients since the onset of the pandemic. As more people are working from home, crouching over laptops on couches and kitchen chairs, or working in stressful situations, clenching jaws and cracking teeth are becoming important concerns.

Similarly, early in the pandemic, most dental offices cancelled all routine care, only offering emergency services. While this move was necessary to ensure patient and provider safety as proper protocols were created and put in place, it did cut off an important aspect of preventive care for many. Even as dental offices for the most part have reopened, without doubt there will be some portion of the population too nervous to schedule their next cleaning or dental exam.

The bottom line

At the end of the day, there are more unknowns than knowns when it comes to the oral consequences of the COVID-19 pandemic. There are more unknowns than knowns when it comes to the consequences in general, from our heads to our toes. At NCOHC, we are certain about three things:

• First, schedule your next regular dentist appointment if you can, and if you are uncomfortable, have a conversation with your dentist about their safety protocols.
• Second, brush up on your oral health education, and make sure you and your family are taking the steps you can at home to keep your mouths healthy and happy.
• Third, there are people who can’t afford to see a dentist, and there are people who have not received proper oral health education. Advocacy for policy change is one of the most impactful things we can do to structurally change the oral health landscape, increasing access and equity in care.

If you want to get involved and build a better oral health ecosystem in North Carolina, join us today!

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. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

Have you heard of fluoride varnish? This preventive treatment helps strengthen and protect teeth, reducing risk of tooth decay. Next time your child is at the dentist, or even at your pediatrician, you may want to ask about a fluoride varnish.

We know that fluoride is good for teeth, and we can get it in many ways. From fluoride toothpastes and mouth rinses (which you should use daily), to drinking water, regular fluoride intake is an important component of good oral health habits.

Fun fact: Fluoride is even present naturally in many foods and drinks, like bananas, avocados, coffee, wine, shrimp, and more.

So, what is a fluoride varnish?

Simply put, fluoride varnish is a more concentrated form of fluoride, painted onto the top and sides of a patient’s teeth. The varnish itself is not a permanent layer—it stays on a patient’s teeth for several hours, allowing the fluoride to seep into the enamel and strengthen the teeth. To visualize the process, it may help to understand how fluoride works in the first place.

The outer coating of your teeth, the enamel, is the hardest substance in your body, even stronger than your bones. But that protective layer gets weakened and eaten away when we consume foods and beverages high in sugars and carbohydrates, leading to tooth decay and cavities.

When fluoride is introduced, through toothpastes, mouth rinses, drinking water, varnish, or other sources, it actually works to “remineralize” your enamel. Additionally, before tooth decay even occurs, fluoride acts to further strengthen enamel, adding additional protection down the road.

To sum it all up, a fluoride varnish is a great way to add a serious layer of protection to your teeth, which can help you avoid costly dental procedures in the future.

Who can get a fluoride varnish?

Fluoride varnishes are mainly used for children, but the truth is that anyone at risk of tooth decay could benefit from the preventive treatment. However, most insurers, including Medicaid, only cover fluoride varnish for children. In North Carolina, in response to the COVID-19 pandemic, children on Medicaid can receive a fluoride varnish a maximum of once every three month period.

Given topical fluoride varnish’s important protective benefits, it will be important that Medicaid permanently adopt policies to reimburse fluoride placement for all age groups, even after the pandemic.

If you are an adult and are interested in a fluoride varnish, have a conversation with your dentist—they can likely help you find out if your insurance will help pay for it.

A similar treatment: dental sealants

Similar to a fluoride varnish, dental sealants create a protective layer to ward off tooth decay.. Unlike a varnish, sealants are actually semi-permanent (they do wear off eventually), sealing off grooves in your teeth and providing a protective layer against foods and drinks that can cause decay.

While fluoride varnish must be applied several times each year to be effective, sealants on children’s teeth are effective up to nine years, though they should be checked by a dentist regularly as they can wear away.

The bottom line

At the end of the day, dental sealants and fluoride varnish are two effective preventive treatments that are powerful tools to prevent tooth decay and costly dental treatments necessary to repair damaged teeth.

Unfortunately, we don’t live in a world where everyone who could benefit from preventive treatments can access them. If you have access to a dentist, they can work with you to identify the mix of preventive measures that best fits your needs. And if you don’t have a dentist, check NCOHC’s access map here to find an affordable access to dental services near you!

NCOHC is working to build a more perfect oral health ecosystem, one where all people, no matter where they live, how much they earn, what language they speak, or what their life circumstances are, can access the care they deserve. You can take action and join the movement today by visiting NC4Change.

In North Carolina, nearly 90 percent of the population is serviced by fluoridated water. This is not the case in Western North Carolina, where rates are estimated to be much lower. Limited access to fluoride means detrimental consequences for many people in the western region of the state, where people are more likely to suffer from tooth decay and other oral health complications. Without sufficient fluoride access, people are more vulnerable to these conditions.

Along with the lack of regular access to fluoridated water, there are other drivers that lead to the negative oral health conditions that are so prevalent in WNC. Consuming large amounts of sugar can be a major component for accelerating tooth decay. The acids in sugar damage the enamel on the outer layer of the teeth, leaving them more vulnerable to bacteria, which leads to cavities and gum disease.

Fluoride, however, plays a significant role in overall oral health outcomes in a given area. Fortunately, even in places like WNC where access to fluoridated tap water is not as widespread, there are other means of accessing the preventive mineral.

Regular brushing is important to keep bacteria under control. There are many fluoridated options for toothpaste, which are more effective in protecting teeth than non-fluoridated options.

For children in North Carolina, physicians in primary care medical offices can apply fluoride varnish that sticks to hard-to-reach areas of the teeth. Dentists can also paint on sealants for patients to help shield teeth from bacteria and prevent cavities. Fortunately, the public health division in North Carolina has also trained dental hygienists to be able to provide some of these preventive services.

Click here to see how Kintegra Health is improving WNC children’s oral health with its Dental Access Program, sending hygienists into schools to provide preventive care, including dental sealants.

We recently spoke in a virtual interview with University of North Carolina Distinguished Professor Gary Slade about the consequences of inadequate access to fluoride. Dr. Slade, who has worked in the Division of Pediatric and Public Health at the Adams School of Dentistry since 1994, works largely on epidemiological research that focuses on oral health and dental diseases in populations.

Dr. Slade explained that data show that children with access to fluoridated water have 30 percent fewer cavities in their baby teeth. As adolescents, they have 12 percent fewer cavities. Fluoride provides clear preventive oral health benefits, which makes the low rates of fluoridated water in WNC especially alarming.

“Because fluoridation rates in Western North Carolina do not count well water or sources that are not from tap water, the numbers we have from data with regard to tooth decay and other oral health conditions are probably worse than they appear,” Dr. Slade said.

As is the case with many small towns in Western NC, cost plays an important role when it comes to providing fluoride for communities. After being accustomed to living without fluoridated water, introducing it is not always seen as a priority. Engineering obstacles in some of these rural areas may also be a deal-breaker for many.

So, what is being done to enact change?

The first and most important step is advocacy. Whether it be a dentist, engineer, public health agency, or parent who speaks up first, change must begin at a local level. Dr. Slade explained that change is not guaranteed to happen just because it seems like the right thing to do. An effort like increasing access to fluoridated water begins with someone championing the cause.

Dr. Slade also spoke about important research he will be conducting in 2021 in Kinston, North Carolina, on the preventive effects of fluoridated bottled water. It is estimated that 115 million Americans do not have access to fluoride in their drinking water at home. That is roughly one-third of the American population, a number that Dr. Slade says will not significantly change in the near future.

Kinston resides in Lenoir County, located in eastern North Carolina. Dr. Slade described it as a prime example of a city that will not likely introduce fluoride into the public water system anytime soon.

Traditionally, dentists and oral health professionals have discouraged people from drinking bottled water due to the lack of fluoride, since most companies do not include it. However, with the rise in popularity of bottled water, Dr. Slade is taking a different approach. Rather than encouraging people to avoid bottled water, the upward trend in popularity would suggest that promoting the inclusion of fluoride in bottled water may be the best approach to improving access to better oral health.

There are many reasons why fluoride access is limited in some parts of the country, but one of them may be the criticism it receives. Dr. Slade suggested that some skepticism may be due to the fact that there has not been a randomized controlled trial of fluoridated water. His study in Kinston will be the first.

The study will include 200 participants, divided into two groups. One group will be given fluoridated bottled water, and the other will be given unfluoridated bottled water. After a period of three and a half years, each participant will receive a dental examination. Because of the true randomized design, no participant or researcher will know who had fluoridated water and who had unfluoridated water until the study is complete.

Dr. Slade expects the resulting data to speak for itself.

Today, it has become increasingly more difficult to implement public fluoridated water systems. There is a significant amount of advocacy from individuals and interest groups on both sides of the issue.

Dr. Slade said that with lower levels of health literacy, it is also more likely that misinformation will stick in people’s minds. Changing that starts with advocacy and education in schools at an early age. There are a lot of questions that surround the topic of fluoride in the United States, but more importantly, there are a lot of answers. Fluoridated water as we know today, provides the easiest and most efficient form of preventive care for lifelong oral health benefits.

Want to get involved and elevate your voice? From fluoridated water and teledentistry to the rising cost of health care, NC4Change is a platform for a diverse, inclusive group of oral health practitioners, public health professionals, community members, and other stakeholders who share a common goal: increasing equity and access in oral health care.

Head over to the brand new NC4Change page today and sign up for a focus group, give us feedback on our policy brief, and more!

What a year…

Needless to say, 2020 has been a year for the history books. At NCOHC, we are so incredibly thankful for the front-line health care workers and essential workers who put their lives on the line day in and day out to keep communities healthy and safe. And our hearts go out to all who have lost loved ones and friends.

Despite its challenges, this year has also been a testament to the power of diverse coalitions oriented toward positive change. Here’s a brief recap of what was accomplished to improve oral health in North Carolina in 2020.

Rule 16W Change

NCOHC kicked off 2020 with a bang.

The North Carolina Rules Review Commission gave its final approval to a rule change that we co-sponsored with the North Carolina Dental Society. The change to Rule 16W eased restrictions on dental hygienists, increasing access to preventive oral health care in high-need settings, moving us one step closer toward a more equitable landscape.

You can read about the rule change and the incredible coalition that worked for decades to make it happen here.

COVID-19 & Access Map

…and yet, the 2020 we anticipated shifted dramatically in early March. As heroic health care workers across the globe turned on a dime to fight the COVID-19 pandemic, and our community partners adjusted their workplans for maximum support, NCOHC adjusted our services in support of NC’s our most vulnerable communities.

NCOHC quickly published and continues to maintain a COVID-19 information page. This page includes our interactive COVID-19 Access Resource Map, which connects at-risk communities with safety-net dental providers across the state. As of December, nearly 30,000 people have engaged with the map.

Read more about the access map here.

The NCOHC Teledentistry Fund

In the initial months of the COVID-19 pandemic, most dental offices closed for routine services, only seeing emergency patients. As offices began to grapple with reopening, we partnered with the Blue Cross and Blue Shield of North Carolina Foundation to launch an NCOHC Teledentistry Fund.

With $60,000 to purchase teledentistry software subscriptions, NCOHC has provided more than 15 safety-net clinics with an innovative tool to help maintain patient care while prioritizing patient and provider safety.

NC Medicaid Teledentistry Billing Changes

Prior to the pandemic, NCOHC intended to focus on teledentistry policy in 2020. While teledentistry has incredible potential in a pandemic-free world, COVID-19 made its application even more relevant.

In response to the pandemic, NC Medicaid modified its billing policies to temporarily allow providers to be reimbursed for services provided across asynchronous, synchronous and telephonic teledentistry modalities. You can read about the billing code updates here. NCOHC was thrilled when NC Medicaid announced its temporary teledentistry provisions and, as we move forward, we are hopeful that these payment changes will be made permanent.

Even in a post-pandemic world, teledentistry will play a critical role in increasing access and equity in oral health care.

Oral Health Day(s)

Despite having to cancel the in-person portion of our annual advocacy event, Oral Health Day, we were still able to host not one but two successful virtual events this year! Oral Health Day Parts 1 and 2 focused on teledentistry and its potential in North Carolina, convening 230+ participants. Catch up on the events and hear from our star-studded lineup of special guests here.

What’s Next?

In 2020, NCOHC and the communities we serve had many successes, but there is much to do as we dive into 2021. As we look forward to the New Year, we are ready to hit the ground running, and we need your help!

While 2020 was fruitful for our coalition’s expansion in size and diversity, we always have additional room for all who are interested in working together to create a more equitable oral health landscape. We believe access to quality, affordable oral health care shouldn’t be a privilege or luxury, but a right.

Will you join us in the movement?

To kick off 2021, we’re excited to announce our new online platform to provide a more efficient and effective way to join the movement — North Carolinians for Change! Please join us over at oralhealthnc.org/nc4change/

Last week we had the opportunity to take an in-depth look at teledentistry at Oral Health Day Part 2. Three North Carolina dental directors and a panel of national experts took questions and presented to a crowd so large that we had to upgrade our Zoom subscription mid-event!

The dental directors at Kintegra Health, Piedmont Health, and Greene County Health Care (GCHC) kicked off the day, talking about the many ways their Federally Qualified Health Centers (FQHCs) use teledentistry to improve patient care. All three directors took questions from the audience.

“Know where you’re going and have a roadmap,” said Dr. Mattison-Chalwe, answering a question about the planning process to successfully begin using teledentistry technology in a practice.

The dental directors answered questions and discussed everything from the planning process, to tips and tricks, to getting diagnostic-quality patient information, and the ways that new technology has increased clinic efficiency.

“We got a lot closer to medical,” said Dr. Doherty, referring to the relationship GCHC’s dental facility was able to make with their medical counterparts as they implemented teledentistry protocols. “It is very easy for a provider to give us a call — a medical provider, and we just jump right in on the call and get those patients seen very quickly.”

 

Watch Drs. Donigan, Mattison-Chalwe, and Doherty in three live teledentistry demonstrations.

 

After the dental directors spoke, three nationally recognized teledentistry experts took the virtual stage. Dr. Paul Glassman, the “father of teledentistry” and professor and associate dean for research and community engagement at California Northstate University College of Dental Medicine, spoke about the process of actually “doing teledentistry,” and the future of remote care.

“This is really based on calibration and communication,” said Dr. Glassman. “It’s based on the idea that you’re going to trust the hygienist who is in the community.”

Dr. Scott Howell, assistant professor and director of teledentistry at the A.T. Still University Arizona School of Dentistry & Oral Health, walked the audience through several examples of the various ways he uses teledentistry in his clinical practice.

Dr. Howell mirrored Dr. Glassman, saying that collaboration and communication is key to successfully using teledentistry technology.

“The field team must be calibrated,” said Dr. Howell. “There has got to be trust. Trust between dentist and hygienist; the dentist has to trust the technology. And as I tell my students, this is not something that you develop overnight. It is something that takes time to develop.”

Brant Herman, CEO of MouthWatch — a provider of teledentistry software and equipment — spoke about the actual technology necessary to practice via teledentistry. He also covered common misconceptions about what it takes to incorporate remote care in a clinical setting.

One of the bigger misunderstandings highlighted by Herman is the idea that there is only one way to do teledentistry.

“It’s really just the tool. You’re just using the technology as the tool,” said Herman. “You’re facilitating the other approaches to care coordination, care delivery, through this technology. It can be all of these different services that really just use teledentistry as the backbone to connect patients, providers, and care.”

MouthWatch, LLC, was generous enough to donate four intraoral cameras for the event, which NCOHC raffled off live.

NCOHC has worked collaboratively alongside diverse stakeholders in jointly drafting teledentistry legislation, which is slated to be introduced during the 2021-2022 legislative session. This bill will work to improve providers’ ability to incorporate teledentistry technology in their practices, and will ensure that quality oral health services, aided by teledentistry, are delivered equitably throughout North Carolina.

Stay tuned as we move forward. We encourage and welcome all voices at the table, so please consider signing up to receive our newsletter, and help us create a more equitable oral health landscape in our state.

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. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

From the highest peaks east of the Mississippi to the unique sounds of bluegrass music, Western North Carolina is a one-of-a-kid region. But like many rural areas across North Carolina and the United States, the communities that make up WNC face pressing challenges when it comes to oral health.

 

Across the western region, children on Medicaid receive less preventive oral health care than their peers across the state. In Regions 1 and 2, as reported by the North Carolina Department of Health and Human Services Oral Health Section, only 43 and 42 percent (respectively) of children ages 1-2 receive any preventive oral health care.

We could rattle off statistics and conclude that there simply aren’t enough dentists in WNC, but the problems faced are not so simple. While the workforce numbers and the distribution of providers across our state are an important issue, there are several layers of barriers preventing many in WNC from accessing the care they need.

When looking at third grade students, the data suggests that initiatives to reach children outside of the traditional dental home are at least partially responsible for a higher-than-average rate of dental sealants among third graders. Across Regions 1 and 2, nearly 49 percent of third graders surveyed in the 2017-18 school year had received dental sealants, compared to a statewide average of 45.9 percent.

Even with the rate of sealants in Regions 1 and 2, however, only 41.8 percent of surveyed students had no tooth decay, compared to the statewide average of 54.5 percent.

So what do all these numbers mean?

There are unique issues that vary across WNC, and each individual community faces its own challenges. For example, if you look at Region 1, only 13 percent of the population is serviced by fluoridated water. For comparison, nearly 90 percent of North Carolinians have access to fluoridated water.

So, whether the problem be access to providers, adequate oral health education, access to basic preventive measures like fluoride, or any number of other issues, significant effort is needed to improve children’s oral health in WNC.

In 2017, the Duke Endowment, Mission Children’s Hospital, and the WNC Health Network partnered to conduct an oral health needs assessment and further explore the specific issues facing WNC communities. From there, stakeholders identified strategic focus areas and formed the WNC Children’s Oral Health Initiative.

Earlier this year, NCOHC absorbed the WNC Children’s Oral Health Initiative, now called the WNC Steering Committee, to help specifically tailor efforts to increase equity and access in the region.

Meet the steering committee and further explore the barriers to access in WNC here.

As we continue our work, keep an eye out for breakdowns of the issues that WNC communities face, and the innovative approaches leaders in dentistry are taking to tackle them.

Get started by exploring how Kintegra Health is pushing forward, even during the COVID-19 pandemic, with a plan to use teledentistry and school-based care to provide preventive services to more than 6,000 elementary school students in the counties west of Charlotte this year alone.

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. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!