Author: NC Oral Health Collaborative

“Historic and systemic structural racism are inherent parts of the United States,” said Jen Zuckerman, director of strategic initiatives at the Duke World Food Policy Center. “This means every single system that exists within the United States is rooted, designed, and based in racism, and has been built on the system of oppression. Nobody alive today is to blame for the unfairness of our history, but we each hold a responsibility to create a better future.”

Continuing NCOHC’s series on the social determinants of health and how they impact equity in oral health, we spoke with Zuckerman to discuss how the Duke World Food Policy Center approaches inequities in food systems and the policy work that can make a lasting impact.

 

Click here for more on equity in oral health.

 

Access to food is an important social determinant of health, and healthy food options can significantly impact oral health. Unlike other posts in this series that directly break down relationships between the social determinants and oral health, this post will focus on food systems, underscoring how Zuckerman and the Duke World Food Policy Center are addressing inequities, while drawing parallels to oral health systems.

 

 

The Center for Assessment and Policy Development defines racial equity as “the condition that would be achieved if one’s racial identity no longer predicted, in a statistical sense, how one fares.”

Racial inequity plagues food production, distribution, financing, ownership, and access in the U.S., so much so that Zuckerman said there is no true working example of an equitable food system. To understand the fundamental role that racism plays in creating systems of inequity, the World Food Policy Center looks toward ownership structures.

“An equitable food community is one where there is an equitable distribution of ownership as it relates to the ability to grow food, distribute food, and provide retail,” Zukerman said. “An equitable food community would also have equitable access to capital.”

 

 

The ability — or lack thereof — to build generational wealth has been fundamental in creating inequities. According to the Duke World Food Policy Center, barriers to building generational wealth should also be front and center in policy work to address and reverse inequities.

“When we think about food, or when we think about anything in the United States, history has demonstrated that the white community has continually gotten investment through policies, programs, and initiatives,” said Zuckerman. “And communities of color have continually gotten programs and services, which do not build wealth.”

While programs and services for those who lack access are incredibly valuable, it is simultaneously important to take conversations of equity a step further to encompass the financial, policy, and power structures at play.

 

 

Zuckerman pointed to housing as an example of racist policies that have created lasting impacts on generational wealth. White veterans returning from World War II were able to buy homes through the GI bill, while returning Black veterans were disproportionately blocked from homeownership due to redlining and other policies rooted in racism.

“Broadly speaking, instead of home loans, Black veterans got public housing from government support,” said Zuckerman. While policies like redlining are illegal today, “think about the wealth built over generations of homeownership versus the wealth you cannot build by living in public housing.”

 

 

Racist policies, no matter when they were enacted or ended, have contributed to an historic disparity in wealth between white and BIPOC communities. Because of this, a lack of direct racism is not enough to reverse past racism. Whether we are aware of it or not, there are still people, policies, and structures in place today that have disproportionate negative impacts on communities of color.

So, how do we actually change racist systems and create equitable structures?

According to Zuckerman, ownership, which refers to both wealth creation and agenda setting, is a central piece of the puzzle.

“There need to be changes in financing and philanthropic investments,” Zuckerman said. “More philanthropic dollars need to be invested in BIPOC-led organizations, and those community organizations need to be able to set the agenda for what they would like their community to have.”

In oral health, significant focus is given to providing low-cost oral health services to those who have historically lacked access. While these programs and services are incredibly important, and this post is not in any way meant to downplay the hard work that so many people do to extend access, oral health champions can learn a lot from the Duke World Food Policy Center’s perspective.

As oral health policy champions, how can we help create more equitable structures that include a diverse workforce more representative of the population as a whole? Where is wealth being built in the dental industry, and how can we work to increase access to and equity in that side of the equation?

“Technology has really changed the field of dentistry since March,” said Dr. Katrina Mattison-Chalwe, Piedmont Health’s dental director, referring to the need for dramatic shifts in how providers approach patient care to adapt to the COVID-19 pandemic.

As COVID-19 closed economies across North Carolina and the U.S., health departments and the American Dental Association recommended that dental providers reduce services to only treat patients with emergent needs. As a result, many practices and clinics began to re-think how they could use teledentistry to maintain patient care.

“When we were all confined to our homes and only able to come out for essential needs, teledentistry came into play,” said Dr. Mattison-Chalwe. “It has opened up our ability to treat patients—we are now able to talk with someone face-to-face without actually being face-to-face.”

 

While a full slate of dental services cannot be provided remotely—your dentist can’t reach through the computer screen to perform a filling—many diagnostic, education, and consultation services can be performed remotely, connecting patients to a provider for these essential services.

“Teledentistry has enhanced our abilities tremendously,” said Melvin Williamson, a dental assistant at Piedmont Health. “We are able to reach out to our community, especially the younger kids, who need help really bad right now.”

Remote care technology is also helping providers reduce the amount of time a patient needs to be in the office to receive care.

“Teledentistry has allowed us to triage our patients better,” said Dr. Lauren Harrison, a general dentist at Piedmont Health. “It has allowed us to screen our patients without exposing ourselves to anything that’s not necessary, and we’ve also been able to reserve more clinic time for patients who really need that time.”

Traditionally, dental care can require several appointments from start to finish, beginning with an examination, where a dentist and staff would assess the patient, develop a treatment plan, and schedule a follow-up appointment to deliver the care needed. With teledentistry, providers have been able to perform the initial examination remotely, minimizing the time a patient would need to be physically present in clinic.

Earlier this year, NCOHC launched a teledentistry fund with support from the Blue Cross and Blue Shield of North Carolina Foundation. The fund has helped award 20+ grants, including one for Piedmont Health, to purchase annual teledentistry subscriptions. These subscriptions will help health centers and other clinical facilities provide remote patient care both during and after the COVID-19 pandemic.

“We were not prepared for COVID-19. No one was. As a result of that, we didn’t have extra funds to be able to purchase teledentistry licensing for all our providers,” said Dr. Mattison-Chalwe. “The (NCOHC) Teledentistry Fund helped us purchase licenses for all 12 of our providers, so we are able to be on the teledentistry platform while we were all in quarantine, and we are still able to use it now.”

The North Carolina Oral Health Collaborative (NCOHC) recently released its first policy brief. The document outlines changes to North Carolina’s regulatory framework that, if enacted, could significantly increase access and equity in oral health care.

Read the policy brief here.

In the coming weeks, NCOHC will publish a series of deep dives into each section of the policy brief to explain the details of each proposal and how each could improve care for underserved North Carolinians.

North Carolina’s oral health workforce faces a growing imbalance that unnecessarily restricts access to care. The dental hygienist workforce is growing, and North Carolina’s dental hygiene programs remain competitive and full. Unfortunately, the population of practicing dentists is shrinking as dentists age out and retire faster than new ones graduate and enter the workforce.

This is a serious concern, as many of the access gaps in North Carolina are driven by a lack of dentists in rural and already underserved areas. In a recent post, NCOHC found that every practicing dentist in North Carolina would need to see 4,080 patients every year just to provide all residents with standard cleanings and checkups, not including follow-up appointments or visits for fillings and other advanced procedures.

With these trends in mind, it is important that North Carolina leaders take steps to allow the oral health workforce to provide care more efficiently. The proposals in the Workforce Utilization section of our policy brief address five policy changes* that can help:

1. Revise the two hygienist per dentist supervision ratio
2. Revise supervision definitions, primarily looking at revision of “direct supervision”
3. Expand delegated duties for hygienists
4. Eliminate restrictions on hygienists’ delivery of local anesthesia
5. Recognize and credential Expanded Function Dental Assistants (EFDAs)

*It is important to note that these proposals do not necessarily reflect NCOHC’s current policy priorities. Rather, they are evidence-based steps that, if implemented, would increase access and equity in oral health care for North Carolinians across the state.

Supervision Requirements

North Carolina is considered one of the more restrictive states for dental hygiene scope of practice parameters. The North Carolina Dental Hygiene Act restricts dentists in private practice from employing more than two dental hygienists at the same time, and it also requires direct supervision—the most stringent form of supervision in a dental office—for most tasks that hygienists are effectively trained to perform.

Easing restrictions to these supervision requirements could significantly increase care provided, especially in community-based settings like school-based clinics and long-term care facilities, where dentists may not always be available on site.

Source: North Carolina General Statutes Chapter 16

Fortunately, easing direct supervision requirements, and expanding the number of hygienists a dentist can supervise, are not new or unique approaches to expanding access and equity in care delivery. Many states across the country have taken these steps, and often these changes were enacted several years ago.

Earlier this year, North Carolina took one important step toward a more equitable oral health landscape by allowing public health hygienists to work outside of direct supervision and rather based on a written standing order from the supervising dentist. The 16W rule change was important, but it only applies in limited settings. Allowing the rest of the dental hygiene workforce to practice in similar settings by written standing order instead of with a dentist physically present on site could significantly increase how many North Carolinians receive basic screening and preventive dental services.

Revision of Delegated Duties

North Carolina’s regulatory framework prevents hygienists from performing several clinical services in which they are required to be learn in their dental hygiene programs. With a few updates to include duties commonly delegated to hygienists in other states across the country, hygienists could significantly improve care access to the underserved, especially in settings outside the traditional dental office.

Source: oralhealthworkforce.org

The NCOHC policy brief’s proposals for additional duties for hygienists includes interim therapeutic restorations (ITR), which refers to a restoration placed on a tooth to prevent the progression of a cavity. ITR’s should be done only in specific cases, when the cavity or decay in question hasn’t progressed too far. You can further read about ITR’s in the American Academy of Pediatric Dentistry’s Policy Statement on their use.

ITR is proven to reduce levels of cavity-causing bacteria and is used mostly when treating children and infants, especially when full restorative care is unavailable, unaffordable, or needs to be deferred.

Source: ADHA

When restorations or other surgical procedures are necessary, dental hygienists could improve efficiency in the dental office by administering local anesthesia, which they are provided the didactic training for in their dental hygiene programs but prevented from performing under North Carolina law.

Along with hygienists, dental assistants play important roles in the dental office, and they, too, could increase dental office efficiency if allowed to perform expanded functions. Many states credential Expanded Function Dental Assistants (EFDAs). This workforce receives additional training to perform certain restorative procedures, such as the direct placement and modification of restorative filling material.

Source: AAPD

Stay tuned as we break down the rest of NCOHC’s policy brief. To receive updates in your inbox, sign up for NCOHC news 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!

As some states reopen, others pause reopening, and more consider shutting down again, figuring out what is and isn’t safe to do can feel like a nationwide game of “red light, green light.” In a recent Kaiser Family Foundation poll, 52 percent of adults reported that they or a family member had skipped a medical appointment because of COVID-19. Sadly, the most common appointment skipped was for dental care.

In North Carolina, many dental offices are still closed, and others are only open for emergency services or are limiting services as they reopen. If your dental office is open for full services, you still might choose to stay home if a family member is immunocompromised, or if you are concerned about North Carolina’s rising case count, which is regularly topping 1,000 new confirmed cases daily.

Regardless of the reason, if you or a loved one are staying home and have missed an appointment—or even if you have seen a dentist or will see one soon—here are some steps we all can take for better oral care at home.

Use Fluoride Toothpaste AND Mouth Rinse

While brushing your teeth alone is important, fluoride actually strengthens your enamel and in some cases can reverse early signs of tooth decay. Fluoride toothpaste can be used at all ages, but it is important to use the right amount.

Mind Your Peas and Q’s

Fluoride toothpaste can be used as soon as a child’s primary teeth have started erupting from the gums. Before age three, just use a smear of toothpaste, no more than the size of a grain o rice. Start using a “pea at three”—a pea-sized amount of fluoride toothpaste for children and adults ages 3 and up.

Source: American Dental Association

Remember that less is more. You really don’t need the long squirt of toothpaste covering the entire brush you may see on commercials.

Know the Basics of Good Brushing

The saying doesn’t go “close only counts in horseshoes and brushing your teeth.” Brush for two minutes to ensure that you hit every single tooth, even those back molars. Two minutes may feel like a long time, but it is necessary to properly brush all sides of all your teeth.

While brushing, makes you are you are using circular motions. Brushing with a sawing motion can actually harm your teeth by increasing abrasive removal of your enamel and potentially damaging your gums. You should only apply mild pressure to your brush, about the same amount of pressure you would use to write with a pencil. It might feel like you aren’t cleaning hard enough if you use less pressure, but that’s just another reason why the full two minutes is so important!

Last, but not least, don’t forget about your tongue. Bacteria and other germs can build up on your tongue and can contribute to tooth decay, gum disease, and bad breath. Brushing your tongue is an important part of maintaining good oral health.

Change your Brush Regularly

When your brush becomes frayed, its time to replace it.

Most dentists recommend changing your brush every three months or when the bristles become worn down.

Floss Daily

Brushing thoroughly can clean three sides of your teeth, but brushing alone can’t remove plaque or bacteria in between your teeth. Adding floss to your routine is an extra layer of protection from cavities, tooth decay, and gum disease.

Check your Mouth Regularly for Signs of Oral Cancer

Oropharyngeal cancers kill one person every hour in the U.S. Fortunately, early detection significantly increases survivability. Self-exams for oral cancer warning signs are quick and easy, and they are an important component of a healthy oral routine.

Check out our recent graphic about oral cancer and HPV for self-exam guidelines.

Click here for a full PDF to access any hyperlinks above.

Know How Your Food Affects Your Teeth

What we eat can seriously impact our oral health, even with good brushing habits.

To learn more and get involved, be sure to sign up for NCOHC news.

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!

Where you live can have significant impacts on your oral health.

NCOHC recently dove deep into the first of a series of factors that impact health, known as “social determinants of health.” You can catch up and learn how government structures impact our oral health here.

A US National Resource Council and US Institute of Medicine report highlights three important physical environmental factors that impact health: proximity to toxic substances, like air pollution; access to resources, like grocery stores and health care practices; and community design, or the built environment.

All of these factors can have negative oral health consequences, from cavities and gum disease to tooth loss and oral cancer.

Can Pollution Really Impact Oral Health?

A study in the Journal of Clinical Pediatric Dentistry found that hard dental tissue could be an environmental indicator—your teeth can say a lot about the world around you. Children in this study living in high-pollution areas had higher cavity rates and even had significant levels of toxic compounds in their tooth tissues.

Similarly, a study in the British Medical Journal found an association between air pollution and mouth cancer.

These studies were conducted in the Eastern European country of Georgia and Taiwan, respectively. Georgia and other USSR countries endured significant environmental degradation during the Soviet era, and Taiwan is known to have particularly significant periods of air pollution.

While more research is necessary to explore links between pollution and oral health, one thing can be said for North Carolinians: if you live in a high-pollution area—such as in the vicinity of one of the 3,300 hog waste lagoons in the state—you are more likely to be Black and poor, two well-documented determinants of oral health.

Access to Resources and the Built Environment

In North Carolina, where you live can significantly impact your access to resources necessary to live a healthy life. For example, rural North Carolinians are more likely to live in food deserts. Poor nutrition and high intake of fast food and other high-sugar, high-carb foods significantly increases the risk of tooth decay and gum disease.

Additionally, 75 of North Carolina’s 100 counties are designated dental health provider shortage areas (dHPSAs). So, rural North Carolinians are more likely to face long drives—and in turn, longer periods of time off from work, childcare costs, and transportation costs—just to get to see a dentist.

To compound the effects of limited resources in rural areas, especially for low-income residents, other aspects of our built environment such as public transportation can further limit access to oral health care. In a city, you’re more likely to be able to hop on a bus if you need to see a dentist and don’t own a car. For much of rural North Carolina, however, that is simply not an option.

This isn’t to say that the only shortages in optimal oral health care occur in rural areas. There are plenty of urban food deserts, and oral health disparities between affluent and low-income individuals exist everywhere.

As we navigate oral health care systems and work to build an equitable future, where all North Carolinians have access to quality care, we have to think outside of the dental office. Join NCOHC in its work toward structural changes that expand oral health care access for underserved populations across our state.

To learn more and get involved, be sure to sign up for NCOHC news.

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!

Janet Reaves was a tireless advocate for North Carolinians, working statewide to improve the health of those with chronic disease. Janet excelled at creating partnerships and helped champion innovative quality improvement initiatives that put North Carolina at the forefront in of chronic disease management.

In her memory, and to highlight the connection between oral and systemic health, the North Carolina Oral Health Collaborative sponsored the first Janet Reaves Community Achievement Award this year.

The award was initially supposed to be presented during lunch at the North Carolina Community Health Center Association’s Clinical Conference on Quality and Chronic Disease in April, but the conference was cancelled due to COVID-19.

Instead, we met virtually with this year’s awardee, Dr. Rob Doherty, chief dental officer at Greene County Health Care Inc., to discuss his lifetime of service and what the award means to him.

Dr. Doherty is an innovator in the field of community-based dentistry. Throughout his career, he has worked hard to increase access to quality oral health care for underserved communities. From spearheading new approaches to school-based dentistry to pushing the envelope to offer more services from a public health setting, Dr. Doherty has shown that hard work, dedication, and collaboration can achieve incredible results.

Watch the full interview with Dr. Doherty or use the table of contents below to skip to specific topics of interest to you.

 

Table of Contents

0:15 – About the Janet Reaves Community Achivement Award

1:10 – About Dr. Rob Doherty

5:32 – Opening the Janet Reaves Award

8:31 – Choosing dentistry and public health

11:00 –Coming to North Carolina for farm worker dentistry

12:10 – Back to school

12:40 – Impacting the community in Greene County

13:25 – Innovating the workplace: adding orthodontics to a public health clinic

17:25 – Three requests: open the doors, offer comprehensive dentistry (18:35), and create a teaching environment (20:24)

21:39 – Bringing residents to Greene County

22:34 – Local health department roles in oral health care

24:25 – Collaborating with community

27:22 – Keeping the flame lit: mentorship and sustaining safety-net dentistry

31:44 – Innovating the workplace: school-based care

33:43 – Working on a shared vision: restorative dentistry in a mobile clinic

37:33 – Advice to dentists in public health

Remote graduation has been a melancholy reality for the class of 2020. It’s nearly impossible to replace the feeling of joining your classmates to celebrate years of hard work and dedication. And, for many, graduation will be the last time that they see one another.

We spoke with recent graduates of the East Carolina University School of Dental Medicine and the University of North Carolina Adams School of Dentistry to learn what finishing school and graduating remotely was like for them.

Both UNC and ECU’s dental schools released students a day early for spring break, which quickly extended into an indefinite cancellation of classes and clinical work.

“I was on a rotation at one of our community service learning centers in Sylva, North Carolina,” said ECU graduate Dr. Jiwon Lim. “That week of spring break felt normal, then they started telling us every two weeks that we were out of clinic for another two weeks. It stretched into April and that’s when I realized that this is pretty serious.”

At UNC, students similarly eased into the realization that they might miss the entirety of their final semester of school.

“We got the Friday before spring break off and were under the impression that maybe we’d get an extra week and then we would be back,” said UNC graduate Dr. Brittany Klein. “Then it became increasingly apparent that we wouldn’t be going back at all.”

Educators at all levels, from daycare to doctoral programs, scrambled to develop remote course plans as schools cancelled in-person classes. For dental schools, especially when it came to students in their final semesters, there was no replacing the value of in-person learning.

“We were at a time in our education where everything was done in person, and there is simply no substitute for that. You can’t do it virtually,” said ECU graduate Dr. Dakota Peachee.

Lim explained that ECU eases into the clinical setting. In the second half of the second year, students begin performing basic procedures, like cleanings and treatment planning. Then, in the third year, students are in the clinical setting for three days a week. In the fourth year, students spend five days a week in clinical settings, with little to no traditional lecture-style coursework.

The timeline for UNC dental students is very similar.

“A lot of our work in the fourth year is finishing up those complex cases for people who have been with you for years,” said UNC graduate Dr. Anne Dorsey. “So, you’ve gotten them through the control phase, taking care of their cavities and oral hygiene. And you’ve gotten them to a place where you are actually replacing teeth so they can feel comfortable with their smile.”

For the students we spoke to, missing the final months of patient treatment was the hardest part of finishing school remotely.

“We have been with many of our patients for a long time, working through complex treatment plans that we should have wrapped up this semester,” said Klein. “Not getting to finish their treatment or say goodbye — and on top of that, not being able to provide a firm timeline on when their care will be complete — has been really tough.”

Dorsey said that the students are doing their best to keep in contact with patients to help them from a distance, but she is worried that delays in treatment plans will mean many will have to start over.

“A lot of my patients were coming in once a month, and some were even coming in once a week or every other week if I could get them in,” said Dorsey. “So those will probably have to start from the beginning, going back through having their teeth cleaned, repairing new cavities, and starting a new treatment plan. It will be pretty devastating.”

Looking forward, the dental graduates see both good and bad for the future of the dental profession. The pandemic has not impacted job prospects for dentists, and if anything, opportunities may be around every corner in the post-pandemic world.

Dorsey said that in one of her remote lectures, her professor brought in a few experts to talk about dentistry and COVID-19. One of the experts said that as many as one in five dental offices might not reopen, largely due to older dentists retiring rather than attempting to weather the pandemic and post-pandemic landscape. (In a follow-up, we learned that the expert referenced data for Minnesota, New York, New Jersey, and the UK, but the professor felt comfortable saying that many offices in NC will not re-open as a result of the pandemic.)

Peachee said that he expects the post-pandemic dental profession will change in many ways, especially when it comes to the awareness of patient, provider, and office hygiene. He also expressed concern for the patient load building up while offices are closed.

“I do expect that, during this time while restrictions are in place, there’s a demand that’s silently growing,” said Peachee. “Once some of these restrictions are lifted, or once it grows too big, I think the demand is going to be out there and dentists are going to be more busy than they’ve ever been.”

In a follow-up article later this summer, we will explore how these two potential trends—dental provider retirement and a potential dental patient backlog—will impact oral health outcomes, especially for the underserved.

Where are these students headed now?

Dr. Brittany Klein is starting an oral medicine residency at Brigham and Women’s Hospital in Boston.

“Going from hunkering down in an apartment to taking the public transit to a hospital every day is a bit nerve-wracking, but I’m excited to get back to work, and I’m excited to be helpful,” said Klein. “There hasn’t been much that any of us students could do to directly help with the pandemic, so I’m looking forward to seeing patients again and helping where I can.”

Dr. Jiwon Lim is starting a one-year dental residency in Ann Arbor this summer.

“I think we’re going to push back the start date for orientation, and they have cancelled a lot of the meetings,” said Lim. “But as far as the start dates for the actual residency, nothing has changed for me.”

Dr. Dakota Peachee is joining Smith Family and Cosmetic Dentistry in Sneads Ferry, North Carolina.

“Before COVID was really on everyone’s radar, I had already locked down a deal and signed a contract,” said Peachee. “I can’t wait to get that underway.”

Dr. Anne Dorsey is sticking around for a radiology residency at UNC.

“There will be very little change for me, so I feel very lucky,” said Dorsey. “Radiology is not an in-person specialty—you don’t have to see a patient to do an exam on a radiograph or an image.That’s one of the only dental specialties that can say that.”