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Recap: Oral Health Day 2020

2020 marks the fifth anniversary of Oral Health Day. Our annual advocacy event, which usually takes place in person at the North Carolina General Assembly, went digital this year due to the COVID-19 pandemic. We are pleased to say that our first online Oral Health Day was a success! Despite struggles with technology—and even a few “zoom bombers” in the beginning—we had a great turnout, and our panel of speakers were engaging and informative.

Here are some highlights from the event

Darlene Leysath, executive director of the Cornerstone CDC, a community-based organization in Warsaw, North Carolina, kicked off the event with a passionate speech about the importance of access to quality oral health care.

State Representative John Autry of Mecklenburg County joined to discuss his career providing oral health care in the U.S. Navy, the disparities in oral health he witnessed among incoming servicemen and women, and how oral health impacts his constituents.

Dr. Shaun Matthews, the UNC Adams School of Dentistry’s director of teledentistry, joined us for his last talk before leaving the state to take on a new role. Dr. Matthews discussed some of the intricacies of teledentistry before showing a video of a live teledentistry consultation. He ended his portion of the event with a call to action for advocacy to push for better oral health policy.

Dr. Andres Flores, East Carolina University’s division director of oral and maxillofacial pathology, spoke about ECU’s extensive network of Community Service Learning Centers and how they are using teledentistry to increase access to patient care.

Dr. William Donigan joined to share his perspective as the dental director for Kintegra Health, a Federally Qualified Health Center in Western North Carolina.

After Dr. Donigan, The North Carolina Dental Society Executive Director Dr. Alec Parker, State Representative David Lewis, and North Carolina State Board of Dental Examiners (NCSBDE) CEO Bobby White all spoke about the future of oral health from their unique perspectives.

Representative Lewis spoke about the role policymakers can play in advancing equity in oral health care. He spoke about the stigma that can come with poor oral health and the duty that elected officials have to promote policies that can help their constituents access optimal oral health care.

Dr. Parker spoke about dental community buy-in for teledentistry. He spoke about the history of telehealth, the beginnings of teledentistry technology, and how far the technology has come.

Mr. White discussed the role that the NCSBDE plays in the dental rule-making process. He spoke to the important role that advocacy organizations serve, because policy change through the legislative process is necessary to allow important rule changes to move forward.

At the end of Oral Health Day, NCOHC Director Dr. Zachary Brian discussed some of the details for Oral Health Day Part 2. Since we weren’t able to engage in advocacy at the North Carolina General Assembly this year, we have worked with Federally Qualified Health Centers across the state to organize tours for members of the community and elected officials later this fall.

As we get closer to the fall, we will announce additional details so you can join us at a community tour near you! To stay in the loop, sign up for our newsletter here.

NCOHC is a program of the Foundation for Health Leadership & Innovation.

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A Dental Provider on the COVID-19 Front Lines

“If I start at the beginning, I have to say that I was extremely overwhelmed with everything that was going on,” said Dr. Amanda Stroud, the dental director for AppHealthCare. “But if you’re in a pandemic situation, ‘No, I can’t do it,’ is not an option. Either I know how to do it already, I can figure it out, or you’re going to have to train me. Those are the three options.”

Picture of Dr. Amanda Stroud

When North Carolina began to shut down due to the COVID-19 pandemic, Dr. Stroud and her team had just started the spring session of their school-based oral health care program. Every year, AppHealthCare spends four months in schools—two in the fall and two in the spring—visiting every school in Ashe, Alleghany, and Watauga Counties.

“When we started to hear rumblings about schools closing, we had a paperwork day to figure out what we could do from the office instead,” said Dr. Stroud. “Then, I got a call from our health director, Jennifer Greene, asking me to join the COVID-19 team meeting.”

Dr. Stroud then joined the army of public health professionals across the country doing their best to prepare their communities and health care systems to withstand the COVID-19 pandemic.

Even with non-urgent dental work postponed, AppHealthCare has been able to keep its entire dental workforce employed, reassigning dentists, hygienists, and office staff to help triage patients, call in prescriptions, and reach out directly to at-risk communities.

“I think a lot of people launched into this not really knowing how to face a pandemic,” said Dr. Stroud. “We just had to realize that we do have some of the tools and we need to be resourceful to figure out the rest.”

For Dr. Stroud, a typical day for the first few weeks of COVID-19 was dominated by phone conferences and planning.

“When this thing first broke out, we had conferences with all three counties every day. That’s calls with incident management teams, community partners, all these groups,” said Dr. Stroud. “We’re looking at Armageddon-type things—I hate to say it that way—but it’s setting up plans for a temporary morgue, looking at what happens if the food chain supplying the hospital and prison goes away. What’s our backup plan, and what’s the backup to the backup plan?”

Now that those plans are in place, Dr. Stroud is working to reach out to vulnerable communities, making sure they have the resources and knowledge to stay as safe as possible.

Christmas tree farming is an important industry in Ashe, Alleghany, and Watauga Counties, with workers coming from across the U.S. and outside of the country for the growing season. It became essential that Dr. Stroud and her fellow health care workers assist growers and farmworkers in taking steps to reduce the risk of catching or spreading COVID-19.

“Fortunately, we have been able to get out a lot of information to the people coming in,” said Dr. Stroud. “We have been working with the North Carolina State University agriculture folks to get out resources in English and Spanish with handwashing information, making sure they’re staying six feet apart, and making sure they know what the signs and symptoms are.”

Migrant communities, who systemically lack access to health care resources, are at an especially high risk of both contracting COVID-19 and not being able to seek health care when they need it.

“We’re really trying to alleviate the fear that many have of seeking medical care,” said Dr. Stroud. “A lot of migrant workers are worried that they’ll be targeted. Trying to overcome that has been another thing we’re working on, just trying to ensure the migrant population that we are really here to help.”

Dr. Stroud said that farm owners have been receptive to working with the public health departments to improve farmworker safety.

“I think most of them realize how detrimental this could be, to their own health, the health of their families, and the health of their business and the people working for them,” said Dr. Stroud.

Sandra Rodriguez, the assistant director of Student Action with Farmworkers, said that farm owners do have a lot of stake in helping worker communities stay healthy and safe. But at the end of the day, putting safe practices in place is incredibly difficult, if not impossible.

“It’s just a very difficult growing season for the people in the field,” said Rodriguez.

In a normal season, migrant farmworkers face many barriers to accessing health care. In Rodriguez’s view, COVID-19 has compounded those barriers and shed light on other dangerous conditions that workers often face.

“These houses that migrant workers live in are usually in poor condition. They often consist of a large room with many beds, a small space to eat, and a small number of bathrooms,” said Rodriguez. “How do you actually quarantine in that kind of situation?”

Rodriguez said that while new housing obviously can’t go up overnight, it is time to start the process of addressing the migrant farmworker housing crisis.

“With the current living situation, the concern is that if just one worker gets the virus, it will spread very quickly to everyone else,” said Rodriguez.

“I don’t think we can eliminate interaction, but we have been working with the growers to keep groups together,” said Dr. Stroud. “So that’s keeping farmworker Pod A from Home A together, working together in the field and not interacting with farmworker Pod B, from Home B, trying to mitigate the spread that way.”

“I’m a dental provider. I have something to offer, but this whole thing has been a huge learning experience, too. Not just learning what the other departments do in their daily lives but learning how to drop everything and turn on a dime and say, ‘hey, I can help you with this,’” Dr. Stroud said.

Beyond extra human capacity for preparation and outreach, Dr. Stroud’s dental office has also been able to provide a lot of relief, especially in the very beginning of the pandemic response.

“Since we transitioned to telemedicine and closed our school program, we were able to shift supplies and be a backup source of PPE (personal protective equipment) for the other departments and agencies throughout the area,” said Dr. Stroud.

For Dr. Stroud, the bonds created between the different agencies who have come together to face the COVID-19 pandemic is one silver lining.

“It’s really important, especially for small counties, to realize that we can group together and lean on each other even more than we have in the past,” said Dr. Stroud. “I include dental under the umbrella of medical providers. I think we were already moving toward more integration, but I hope that with this we realize that there is even less of a separation than before.”

Beyond the strain of re-working an entire medical system to meet the immediate challenge, the well-being of those providing care is also an important topic of concern. Faced with more exposure to COVID-19, many health care providers are finding themselves forced to isolate from loved ones because they are at greater risk of exposure to the virus.

“I miss seeing my family,” said Dr. Stroud. “My parents live just 35 minutes from here, and I haven’t seen them in a few months now. We also had a death in the family. My husband’s grandmother passed away during all this on the opposite side of the state, and I didn’t go to the funeral.”

From us at NCOHC, thank you to all of those like Dr. Amanda Stroud and Sandra Rodriguez who are working hard to meet vulnerable communities’ needs during this time.

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!

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Maintaining Mental Health During a Pandemic

“This pandemic is a perfect storm,” said Dr. Lisa Tyndall, an integration specialist with the Center of Excellence for Integrated Care, a program of the Foundation for Health Leadership & Innovation (FHLI).

As North Carolinians navigate COVID-19 and its various impacts, NCOHC decided to sit down with our partner program at FHLI to discuss how the pandemic poses significant mental health concerns, for patients and providers alike.

Tyndall, a licensed marriage and family therapist, said that the wide range of impacts caused by COVID-19 — from financial stress to anxiety and isolation — are serious stressors that negatively impact mental health.

“The fact that we can’t be with each other absolutely negatively impacts the coping mechanisms most people use of reaching out and spending time with friends and loved ones,” said Tyndall. “We are wired to connect, and right now we are limited in those personal, face-to-face relationships.”

For the provider community specifically, Tyndall worries that we tend to forget that they are humans, too.

“I think that we forget that the frontline providers are facing a lot of the same uncertainty that the rest of us are,” said Tyndall. “Especially for those providers who live alone or are caregivers in their personal lives. If a provider doesn’t have a support system, or if their support system is already stretched thin, it is an especially difficult time. There’s a physical as well as an emotional toll to the stress, and it builds up. Providers manage the stress of patient caregiving every day, and then still go home to manage their own households, potentially adding an additional layer of stress.”

“As doctors, we are trained to be the rock,” said Dr. Zachary Brian, NCOHC’s director. “We’re trained to be the provider, there to serve the community, sometimes at the expense of our own physical and mental health.”

Both Tyndall and Brian described a juggling act for providers, balancing service to their communities, personal and family safety, as well as financial well-being.

“It can feel as though you are navigating a sea of conflicting resources, literature, and research to determine the safest way to move forward with your practice,” said Brian. “Given that this is a novel virus, it is not uncommon to see this type of response. The issue arises in that there’s no one clear authority to look to for guidance, which makes informed decisions on behalf of your patients and staff ever more challenging.”

As health experts learned more about the novel COVID-19 virus in recent months, guidance from the American Dental Association, the Centers for Disease Control and Prevention, and other state and national regulatory bodies were released, but were not always in exact agreement with one another.

“The resources for providers that we have seen, although very helpful, have not necessarily always been in parallel,” said Brian. “This has created a surge in confusion.”

What can you do about the uncertainty?

Dr. Brian says, “While the provider community as a whole may be very isolated during this time, forced to make decisions with so many unknowns, there is support within your regional communities. Don’t be afraid to reach out to your colleagues. People need to be very open and transparent, so we don’t have to navigate this crisis in a vacuum.”

Dr. Tyndall says, “We have to lift ourselves up and we have to lift each other up. We don’t have to talk about it all the time, but we also should give a voice to it and not minimize the stress. It is important to have outlets to express uncertainties, fears, and concerns.”

Dr. Tyndall also shared a couple of resources for providers who need help managing their own mental health needs during this time.

The Hope for NC Helpline is a free helpline for people who need assistance coping and maintaining resilience during COVID-19. The number for the 24-hour helpline is 855-587-3463.

For first responders, the University of Minnesota, the Minnesota Department of Health, and the University of Minnesota College of Education and Human Development have released a First Responder Toolkit to help those deployed in emergency response maintain their own physical, emotional, and social well-being. The app can be accessed here (note: a login is required).

Financial uncertainty is another stressor impacting many oral health care providers. This is especially salient in the private sector, where most dental practices are small businesses. On top of figuring out how to keep everyone safe and healthy, while still providing necessary care to the community, providers must also navigate out how to stay above water financially.

“Even though it seems like practices would be bustling during a health crisis, we also know that there is a side where providers aren’t seeing as many patients,” said Tyndall. “So that financial stress — especially for smaller practices, rural practices — is very real.”

Brian said that the oral health profession is on the low patient volume side of the equation. Largely due to the use of aerosolizing instruments, dentists, and hygienists in particular, are near the top of the list of most at-risk professions for COVID-19 transmission. In response to the elevated risk, most dental offices have only seen patients for urgent needs during the pandemic.

Brian said that in the oral health care space, safety net practices are facing profound and lasting financial impacts, as well. Practices that see patients regardless of their ability to pay, and who offer care on a sliding fee scale, have very thin to nonexistent margins to begin with. Nearly completely cutting off their revenue stream can be catastrophic.

What can you do to navigate financial uncertainty during COVID-19?

Dr. Brian points to the ADA’s resources for providers, especially the following the guidances:

Return to Work Toolkit

Financial Assistance for Dental Practices from Third Party Payers

COVID-19 Coding and Billing Interim Guidance: Virtual Visits

COVID-19 Coding and Billing Interim Guidance: PPE

Financial Obligations to Staff during COVID-19

Additionally, the North Carolina Division Health Benefits has issued temporary modifications for telehealth billing, and NCOHC has launched a teledentistry fund with support from the Blue Cross and Blue Shield of North Carolina Foundation.

If your practice is a safety net provider in need of teledentistry software, please reach out to ncohcinfo@foundationhli.org for information on how to apply for funding through the NCOHC Teledentistry Fund.

Please note: The aforementioned guidance documents are only to serve as a resource, and are not necessarily founded in scientific evidence, or endorsed by NCOHC.

According to Brian, it is important for providers to be aware of oral signs and symptoms that can alert them to potential mental health needs of their patients.

“You have parafunctional habits such as clenching and grinding that can develop as a result of stress, and from this you can see detrimental effects on teeth and other oral structures, such as extensive attrition and fractured teeth,” said Brian. “I saw that a lot with my patients when they were going through stressful events in their lives. They would come in with three or four fractures in their teeth, sometimes where the fractures extended past the gumline requiring surgical interventions.”

Brian also said that dietary changes due to stress and anxiety can negatively impact oral health. Increased sugary food and carbohydrate intake, as well as alcohol consumption, can both increase risk of tooth decay and gum disease.

“One thing that we’re not talking about enough is that we’re only seeing emergency patients right now,” said Brian. “There are people who are delaying appointments or not seeking care, and by the time they come in, what could have been a simple filling previously has now advanced to the point where it requires a root canal or an extraction. This is also particularly important for routine oral and pharyngeal cancer screenings.”

How can an oral health provider look out for mental health strains in patients?

Dr. Brian says, “Look for attrition patterns from clenching and grinding, fractured teeth, and TMJ pain.”

“As an oral health professional, having a relationship with someone in the mental health space is vitally important, also. You need to have a sounding board to discuss mental health concerns of your patients, and a trusted referral source to help route that patient to proper care.”

“It is crucially important that you have deeper conversations with your patients. Make sure that you take a whole-person care approach by including the mental health of your patients into the patient experience.”

Both Tyndall and Brian agreed that taking time to reflect and take care of yourself is incredibly important for providers during this pandemic. Taking steps to interact with family, friends, and colleagues is an important way to cope with the isolation and stress we all are experiencing.

“Dig deep into your resource and faith buckets, and be kind to yourselves,” said Tyndall. “Take time to make sure that you’re taking care of yourself, too.”

“This too shall pass,” said Brian. “Dentistry remains a profession that allows us to impact our patients in direct ways, see immediate results, and change lives. That doesn’t change with the pandemic.”

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Meet the Staff: Kelsey Ross Dew and Brady Blackburn

This past November, the North Carolina Oral Health Collaborative welcomed two new staff members. Kelsey Ross Dew is NCOHC’s new program coordinator, and Brady Blackburn is the Collaborative’s content marketing specialist. As they pass the half-year mark, they sat down to answer a few questions about who they are and why they decided to join NCOHC.

Kelsey Ross Dew

Tell us a little about your background, where you are from, and your educational path.

I am from Severna Park, a town in Maryland situated right between Annapolis and Baltimore. Visiting family in North Carolina regularly, I became very familiar with the Wilmington area and was drawn to the university there.

I attended UNC-Wilmington, originally planning to go into nursing. I was exposed to so many fields and areas of study but just couldn’t choose. After looking at the courses closely, I decided on community health education for my undergraduate degree. That program at the time was transitioning to become the Public Health Program.

After graduating, East Carolina University offered a Master’s in Public Health program, so I decided to move from Wilmington to Greenville to pursue my MPH.

While working on my MPH, I worked as a research assistant for a childhood obesity prevention program. I was trained in research management, program management, evaluation and community engagement. I worked with that program for 2 years during my MPH and 2 years after graduating. Open to new opportunities at the time, I began to search for something different to focus on that would have a public health impact.

What professional accomplishment before coming to NCOHC are you most proud of?

I am most professionally proud of my master’s degree because it gave me time to build my skill set and learn.

What originally drew you to working in the oral health space?

I saw the job posting for the program coordinator for NCOHC and started thinking about working in the oral health space. It quickly made me realize that I had not been exposed to the importance of oral health and public health dentistry previously. I wanted to transition to something different that would benefit the health of the whole person. Oral health seemed like an area that needed strong advocates and I wanted to be a part of that.

What has been the most rewarding part of your work with NCOHC thus far?

The most rewarding part of my work so far has been the different opportunities to be involved in policy change and engage with community. Policy changes have a large impact on increasing access and are a sustainable solution. In addition, I really think working directly with community and engaging them in the policymaking process can be helpful. It is rewarding to work towards solutions.

What are the biggest challenges that you see facing access and equity in oral health care in North Carolina?

I feel that there are systemic barriers to change through restrictive policy that limit access and equity in oral health care in this state. There are numerous policy solutions available that are evidence-based and would increase access and address oral health among the most vulnerable populations.

What do you enjoy doing when not working?

I enjoy spending time with my husband and dogs, whether that be at home or out around Raleigh. We enjoy games, sports, and traveling (when safe!). I like cooking as well!

What do you want our membership to know about you?

I want our membership to know that I am so grateful to be a part of this work and team. It takes a lot of committed individuals to make lasting changes. I also think prevention is key and we should focus efforts on increasing preventative solutions.

Brady Blackburn

Tell us a little about your background, where you are from, and your educational path.

I have lived in North Carolina for my entire life. I grew up in Asheville and went to college at UNC-Chapel Hill, where I was in the second graduating class of a dual-degree program that paired an undergraduate degree in environmental studies with a graduate degree in mass communication.

I worked in climate change communication for The Nature Conservancy during graduate school before moving back to Western North Carolina to run a 2018 state legislative campaign in Haywood, Jackson, and Swain Counties. We won the campaign, and I joined Joe Sam Queen as his legislative assistant for the first half of the 2019-2020 legislative session.

I have always been drawn to the nonprofit world, so after a while in the legislature, I began to turn my eyes toward new opportunities.

What professional accomplishment before coming to NCOHC are you most proud of?

Managing Joe Sam Queen’s legislative campaign was one of the more difficult things I have done. I am incredibly proud of our victory. In the seven-month stint between my graduation and the 2018 election, I grew in ways that I didn’t know were possible and I learned a lot from my first-hand experience with Representative Queen’s constituents in Haywood, Jackson, and Swain Counties.

What originally drew you to working in the oral health space?

In high school, I found myself on the wrong end of a golf club and lost my two front teeth. I would say that’s when I first became passionate about oral health care, and when I first understood how expensive more serious procedures can be.

Years later, in the North Carolina Legislature, our top priority was expanding access to affordable health care for underserved North Carolinians. I didn’t have a lot of experience in health and health policy going in, but I quickly learned just how stark the disparities our state are, and how vital policy is when it comes to increasing equity and access.

What has been the most rewarding part of your work with NCOHC thus far?

I’ve had several opportunities to interview people across North Carolina who work in oral health care or who have been impacted by a lack of access to that care. Hearing their stories has been incredibly moving, and it has really helped me understand the importance of the work we do.

What are the biggest challenges that you see facing access and equity in oral health care in North Carolina?

I think that there is a world in which oral health care is affordable for everyone. Preventive care is so much less expensive than restorative care, but unfortunately so many don’t have access or don’t know where to go before costly treatment is necessary. Creating an education infrastructure and building a system where care is accessible, no matter who you are or where in the state you live, seems to me to be the biggest step we could take towards achieving oral health care equity.

What do you enjoy doing when not working?

When I’m outside the office I love gardening, woodworking, and taking my dog on adventures. We love to go backpacking or just generally get outdoors.

What do you want our membership to know about you?

I want the membership to know that my (virtual) door is always open! I think that collaboration and storytelling are key to good communication, and there are so many amazing stories to tell about the people working hard to improve North Carolinians’ oral health.

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Recap: Oral Health Day Webinar

Oral Health Day 2020 is going digital! At NCOHC’s Oral Health Day Webinar on April 29, we announced plans to shift our signature advocacy event to an online format to ensure participant safety given COVID-19. Oral Health Day will now be a two-part event, and we’re bringing part two out of Raleigh and into communities across the state.

The theme for Oral Health Day 2020 will still be teledentistry, with a special focus on its use as a tool to mitigate access gaps in North Carolina. Our main event will still occur on June 3rd.

Part One: Virtual Oral Health Day

Instead of meeting in person, we will convene virtually to learn about teledentistry and its role in equitable oral health care. Speakers will discuss the state of oral health in North Carolina and the shortage areas we must address. They will also demystify teledentistry and describe how it can be used as a tool to bridge our state’s access gaps. Finally, our director will outline policy priorities to increase providers’ ability to incorporate teledentistry into their practices.

Virtual Oral Health Day Featured Speakers

Dr. Bill Donigan, Kintegra Health

Dr. Shaun Matthews, UNC Adams School of Dentistry

Dr. Andres Flores, ECU School of Dental Medicine

Darlene Leysath, The Cornerstone CDC

Bobby White, North Carolina Board of Dental Examiners

TBD, North Carolina Dental Society

TBD, North Carolina Legislature

Part Two: Community Tours

Since we will not be able to visit legislators at the North Carolina General Assembly this year, we have adapted our plan to include community tours of safety net dental clinics later this fall.

We will bring legislators and community members together for tours of Kintegra Health in the west, Green County Health Care in the east, and Piedmont Health in central North Carolina. Each visit will include a tour of the dental clinic, a teledentistry demonstration, and a town hall-style discussion with policymakers.

To Watch the Webinar

For more information, you can watch the full webinar here. If you have further questions, please email us at NCOHCinfo@foundationhli.org.

Click the timestamps below to jump to a specific part of the webinar.

00:00 Who We Are (Purpose, mission, vision, and strategic pillars of focus)

03:46 Our Team

07:56 About Oral Health Day

10:02 Policy and Advocacy (Why is policy advocacy important, how is policymaking accomplished, and overview of North Carolina’s rulemaking process)

14:50 Change to Rule 16W

17:33 Oral Health Day 2020

18:40 Why Teledentistry?

28:28 New Plans for Oral Health Day 2020

36:45 Recap

38:33 Q&A

Oral Health Day 2020 Webinar

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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!

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Social Determinants of Health – Structural and Governmental Influences

The heart of oral health equity is a blend of improving actual health care delivery, modifying public policy, and influencing structural change. Approximately 80 percent of a person’s health is the result of factors outside the doctor’s office, so it is necessary to account for all three. Each plays an important role in addressing systemic barriers to oral health care access.

We recently published an introduction to social determinants of health—the environmental conditions that impact a person’s health—outlining several categories of systemic barriers that prevent people from achieving optimal oral health.

Graphic depicting five social determinants of health: physical environment, structural & governmental influences, education, food, and economic stability

From the physical distance between a patient and provider to the policy that governs dental practice, this week we’re diving into structural and governmental influences to see how they impact oral health outcomes.

Where can I go to access oral health care?

Depending on where you live, this can be a difficult question to answer. North Carolina ranks 37th in dentists per capita, with just 49 practicing dentists for every 100,000 residents.

To put that in context, if all North Carolinians were to receive standard cleanings and check-ups every six months, every single practicing dentist in the state would need to field 4,080 appointments every year. And that doesn’t even account for emergency visits, restorations, and other care beyond regular preventive appointments.

Graph comparing nationwide average patient volume of 3,505 per year to the needed patient volume of 4,080 per year to actually meet demand in North Carolina

Most of North Carolina’s practicing dentists are consolidated in just one fifth of the state’s 100 counties, compounding this shortage in rural communities. Seventy-four, predominately rural, counties are designated dental Health Provider Shortage Areas (HPSAs).

For many in North Carolina, the answer to, “Where can I go to access oral health care?” includes additional childcare, time off from work or school, and long drives (if they have access to a vehicle).

How do I pay for oral health care?

Even if every person in North Carolina could afford to see a dentist, it is clear from the statistics above that there isn’t the infrastructure in place to meet that demand. Everyone can’t afford to see a dentist, though. Oral health care is prohibitively expensive for many, especially those without insurance.

Many private practice dentists in North Carolina don’t accept Medicaid. However, for the uninsured and those on Medicaid, there is a great network of public health providers across the state. These clinics accept Medicaid and offer care on a sliding fee scale for those without insurance or who can’t afford to pay. Specifically, Federally Qualified Health Centers, local health departments, free and charitable clinics, among other entities across the state, offer these care options for those who lack access.

Unfortunately, the existing network of public health providers still doesn’t meet demand. Many patients simply aren’t familiar with what options are available in their communities, and those with urgent oral health needs often seek care in a hospital’s emergency department.

Emergency department physicians are not dental health professionals, so patients won’t get the needed treatments such as root canals, extractions or fillings when they go in for toothaches. Generally, an emergency department patient will receive a prescription for an antibiotic and an opiate, which will just calm the pain until the meds run out.

North Carolinians visit emergency departments at twice the national rate, and operating room costs for dental procedures exceed $40 million annually.

Increasing Visibility of Safety-Net Access Options During COVID-19

To help reduce emergency department demand for urgent oral health concerns during COVID-19, NCOHC has published an interactive map of oral health care safety nets across the state. The map is meant to serve as a tool to divert patients with urgent needs from emergency departments to nearby local health departments, Federally Qualified Health Centers, free and charitable clinics, and other safety nets.

The Collaborative is currently outlining strategies to re-purpose this map and develop additional tools that will help those with oral health needs find affordable care providers after the COVID-19 pandemic.

Picture of NCOHC's statewide provider access map

So, how do we change North Carolina’s oral health care structure to better meet the needs of those in our state?

The answer to this question in many ways lies in public policy. North Carolina is one of the four most restrictive states when it comes to allowing dental hygienists to practice to the full extent of their education and licensure.

While we have a serious, and growing shortage of dentists, we simultaneously have a growing surplus of dental hygienists. Unfortunately, state law only allows a dentist to supervise two hygienists at a time, preventing the growing workforce from having the opportunity to expand access to care, especially in remote areas where the dentist shortages are the most severe.

Earlier this year, NCOHC and the North Carolina Dental Society co-sponsored a change to Rule 16W.0104 of the Dental Practice Act. This change allows public health dental hygienists in Dental Health Provider Shortage Areas (HPSAs) to practice in community-based settings such as schools and long-term care facilities based on a written standing order from the supervising dentist, in lieu of a physically present dentist on site.

In one of our recent interviews, dental hygienist, educator, and advocate Crystal Adams said that if she could change anything in North Carolina’s regulatory framework, allowing dentists to supervise more than two hygienists would be at the top of her list.

There are many other policy proposals that could also increase access, like introducing postpartum Medicaid dental coverage, or modernizing the Dental Practice Act to allow providers to bill for telehealth care delivery.

Stay tuned as we break down other social determinants of health and the work being done to address them in the coming weeks.

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FHLI’s New Office Mates

The North Carolina Oral Health Collaborative’s parent organization, the Foundation for Health Leadership & Innovation, moved to remote work back in March. Social distancing can be a difficult transition, so we decided to check in on our co-workers, and their new office mates, to see how they’re doing.

Ava O., Foundation for Health Leadership & Innovation

Picture of dog Ava with her head on a pillow

Ava is tired after a very long day helping her mom at the office. She waits patiently but is delighted about the work-from-home situation. She has put in a formal request for more belly rub breaks during the workday.

Ava S., NCCARE360

Picture of dog Ava asleep on a couch

Ava is frustrated that her office isn’t warmer, but she has found that sleeping on the job is a solution she can work with.

Blu, North Carolina Oral Health Collaborative

Picture of dog, Blu, with a bow tie in front of a laptop

Blu has really stepped up to the plate since FHLI moved to remote work. He retains some sense of normalcy by dressing up for Zoom calls, and he loves screening emails in his outdoor office. He’s very glad to have so much company during the day.

Diesel, Center of Excellence for Integrated Care

Picture of dog Diesel sleeping on a carpet.

Diesel is an older fellow. He just turned 11 in January. He’s grateful that his workmates moved their office to the first floor, so he doesn’t have to navigate the stairs.

Edie and Pearl, Practice Sights

Picture of cats Edie and Pearl sitting in front of laptops.

Edie (left) doesn’t take “no” for an answer. She will grind her office’s work to a halt and refuse to move until she gets her pets. Pearl (right) is the more intellectual of the two. You can often find her searching for deeper meaning in her computer’s screen saver.

Freya Jane, M.E.O.W., Center of Excellence for Integrated Care

Picture of cat Freya Jane standing menacingly in front of a computer

Freya Jane, M.E.O.W., supervises and reviews all of her human’s reports before they can be submitted. She is the boss of her virtual office, and she is known for ruling with an iron fist.

Frida Pawlo, Rural Forward NC

Picture of cat Frida Pawlo stretching on her human's bed

Frida Pawlo has finally accepted that her coworker is not leaving the house any time soon—on the condition that she gets the bed during daytime hours.

Ila and Abbey, North Carolina Oral Health Collaborative

Picture of dogs Ila and Abbey sleeping next to each other

Ila and Abbey enjoy sleeping on the job most of the day. They have been referred to HR to work on their productivity, as well as their video chat etiquette.

Lydia, Center of Excellence for Integrated Care

Picture of dog Lydia asleep on her back

Lydia is busy adapting to her new shared workspace—humans can be so disruptive when they’re home all day—so she sent in a picture from her younger years.

Peanut, Rural Forward NC

Two picture of a dog, Peanut, at a desk in front of a computer and sleeping outside

Peanut is busy adapting to her new work environment. She misses getting out in the community and meeting her partners where they are.

Since moving to remote work, Peanut has been caught sleeping on the job a few times. We understand how tempting the sun can be, but we’ve had to refer her to HR to develop a pupformance improvement plan.

Pepper and Marley, Center of Excellence for Integrated Care

Picture of two dogs, Marley and Pepper, snuggling each other on a bed

Pepper and Marley have finally grown to accept that there will be no dog park adventures in the future, but they find consolation in the fact that their owners are home. All. The. Time. They sleep on the job, yell during calls and video meetings, and have a bizarre fascination with all squirrels and birds that quite frankly is becoming a little entertaining to the rest of us. TBD on how their performance evaluations will be next month…

Phoebe, Rural Forward NC

Picture of dog Phoebe sitting in a field

Phoebe, aka Feebs, Feebo, or Sneako, works at the Graham-based FHLI satellite office. Phoebe has quickly demonstrated her effectiveness as a footwarmer, and she has a knack for team-based work, playing a critical role in her office’s fetch and lap-sitting duties.

Phoebe’s performance in the last month has been spectacular, and her supervisor has recommended her for a promotion.

Sheldon Lee Schribman, B.S., M.S., M.A., Ph.D., Sc.D., FHLI Communications

Picture of dog wrapped in curtains he tore down

Dr. Sheldon Lee Schribman, B.S., M.S., M.A., Ph. D., Sc. D, is by far the best educated member of the FHLI team. He has been social distancing since before it was cool. Dr. Schribman does not appreciate being around anyone other than his mom, so this remote work situation is really working out well for him. He spends his days eating his weight in treats and “greeting” the UPS guy at the front window.

Now, if only those pesky drapes would get out of his way…

 

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!

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Dental Hygienists Week – An Interview with CVCC’s Crystal Adams

Picture of Crystal Adams, Department Heat at Catawba Valley Community College, with quote pulled from text

Last week was National Dental Hygienists Week, so we sat down (virtually) with Crystal Adams, a dental hygienist and dental hygiene program director at Catawba Valley Community College (CVCC), for a conversation about her career path and the importance of hygienists in the dental home.

Adams is a passionate advocate for oral health care with an inspiring drive to improve the lives of those who traditionally cannot access care. She has important insight into the role that hygienists play in the dental home, and she has worked in several capacities to modernize North Carolina’s regulatory framework.

In our interview, we discussed Adams’ path to becoming a dental hygienist, the important services that hygienists provide, and changes that could be made to better allow hygienists to serve their communities.

When did you decide that you wanted to be a dental hygienist?

When I graduated high school, I knew I eventually wanted to be a dental hygienist, but first I went the dental assisting route. I graduated from Wilkes Community College with my dental assisting diploma and then I worked for four years in a private practice as a dental assistant.

I had the urge to continue my education, though, and the dentist I worked for allowed me to leave work early to take prerequisite courses at CVCC to prepare for the dental hygiene program. I attended the Dental Hygiene Program at Central Piedmont Community College (CPCC) in Charlotte — I commuted from Alexander County to Charlotte for two years — and graduated in 2001. From there I went back, as a dental hygienist, to the practice I had worked at before my education at CPCC.

What are the education requirements to become a dental hygienist?

A dental hygienist has to take prerequisite courses — they have about a year and a half of prerequisites that they have to take, in addition to the two-year dental hygiene curriculum. Most programs like for students to take those prerequisites prior to starting the dental hygiene curriculum because it is so demanding. It’s a lot of work.

So, it’s a year and a half of prerequisites and then two years of curriculum. It’s very close to being a bachelor’s degree. I think that’s something that is important for people to understand. It’s more than just a two-year program. It’s really closer to three and a half with the prerequisites.

Why did you want to pursue dental hygiene for your career?

I didn’t have dental care when I was young. My parents didn’t have that oral health literacy. So, this was an area where I knew that I could help, especially in my community. There are a lot of people in my community that don’t understand oral health care.

In your view, what is a dental hygienist? What role do they serve in the dental office, and how has that allowed you to serve your community and improve patients’ understanding of oral health care?

I believe a dental hygienist is an educator. We can clean someone’s teeth, but the biggest part of our job is making sure that patients understand what to do at home. We make sure they’re taking care of their needs so that whenever they come in we can focus on preventing things from happening instead of treating something that has already gone wrong. So, I feel like we are prevention specialists, and our number one role is education.

So, education was a big part of your role in private practice. Now you are full-time at Catawba Valley Community College. Is the role of educator what led you to the community college setting?

Once I started practicing as a dental hygienist, I still had that drive to help even more. I started working part time at Catawba Valley Community College and I just loved sharing my knowledge and skills, and I loved seeing the students grow.

Once I started teaching, I decided to continue my education and get my bachelor’s degree and master’s degree. I was able to get a full-time teaching position at CVCC, and eventually I became the director of the program, which has allowed me to serve in several capacities at the state level, as well as serving as the president of the North Carolina Dental Hygienists Association.

Something that we have been putting a lot of thought into at NCOHC is the disparity between dentists and hygienists in terms of volume. There is a growing shortage of dentists as they are aging out and retiring faster than our universities are graduating new dentists. Simultaneously we have a growing surplus of hygienists. How is this impacting the hygienist workforce?

I think this is a big problem, and I think the most important thing here is that hygienists aren’t able to use the skillset in North Carolina that they are taught to use. They could be serving local communities where there aren’t many dentists, and we could be providing care to individuals who don’t normally get care.

I think if we could go to more of a general supervision model and actually use the skills we are taught, then we would be able to serve more of the underserved communities in our state that don’t get care.

The recent change to Rule 16W seems to be a step in that direction, to allow dental hygienists to go into underserved areas and provide care with a written standing order from a dentist, without the dentist being physically present. Could you speak briefly from the hygienist’s perspective about what the rule change means for oral health care in North Carolina?

I think it is a really positive direction for our state. The rule change allows hygienists to get more involved in school settings, nursing homes, and long-term care settings where we can actually use our skills to the full extent of our training. It gives us the ability to serve communities when dentists are not as available to be physically present, and I think it is a step toward allowing us to be the professionals we are intended to be.

Are there other skills that hygienists are taught in school that you are not allowed to practice under North Carolina’s regulatory framework?

Yes. So, that’s a bit of a tricky question because we are taught the theory of local anesthesia, but since it is not a delegable duty in North Carolina, we don’t teach the skill portion. But we are taught local anesthesia.

Hygienists in other states can administer local anesthesia. If North Carolina began to allow this here, what change would need to happen on the education level? Would beginning to teach the skill portion be a big change?

We already incorporate pretty much all of the education into the dental hygiene program because our students have to test on the national level. Anesthesia is included in that testing because so many states do allow hygienists to administer local anesthesia.

The extra step of teaching the skill portion would not be difficult to incorporate into our programs at all, because the foundation is already there.

If you could snap your fingers and change anything in North Carolina’s regulatory framework, what would it be?

If I could change anything, I would allow hygienists to administer local anesthesia. Additionally, I would expand the change that has already been made to rule 16W for indirect supervision to allow hygienists to use their skills when the dentist is not on the premises in more settings.

I think those changes would allow us to actually perform what we are taught in school and to be the professionals we are meant to be. So, local anesthesia and relaxation on supervision to allow us to treat more people when the dentist is unavailable.

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!

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Education Oral Cancer Public Health

Should I Be Worried About Vaping?

With youth-oriented advertising depicting e-cigarettes as not only a cigarette alternative, but a clean, fun, and popular choice to make, an increasing number of teens and young adults are picking up the habit, often without having ever smoked cigarettes in the first place.

Graphic depicting the potential risks of e-cigarettes, including gum disease, tooth decay, and oral cancer

The quick adoption of e-cigarettes among young users is especially alarming because experts still don’t know what long-term health outcomes may result. Because of that, no one can say for sure what will happen to young people who habitually smoke e-cigarettes, even though initial research suggests that many negative health impacts are possible.

April is Oral Cancer Awareness Month, so we’re taking a look at e-cigarettes and what existing research suggests about their impact on the mouths and throats of users.

Here are some of the health outcomes discovered so far.

Gum Inflammation

A study in Oncotarget, a peer-reviewed oncology and cancer research journal, found that flavored e-cigarettes induce gum inflammation. The study found that e-cigarette use causes a form of DNA damage that re-enforces chronic inflammation, an important contributor to the spread of oral disease.

Bone Loss, Oral Disease, and Tooth Decay

Several studies (cited below) have found connections between e-cigarette use and bone loss, oral disease, and tooth decay.

One study of 18,289 participants found that those with no history of gum disease who used e-cigarettes regularly for one year had increased odds of being diagnosed with gum disease.

Another study of 456,343 adults found an independent association—meaning the association persisted even when other risk factors were controlled—between e-cigarette use and the likelihood of having at least one permanent tooth removed because of tooth decay.

Sources

Oral Cancer

A study in the International Journal of Molecular Science compared e-cigarettes and traditional cigarettes, focusing on their impacts on the mouth at a cellular level. Broadly, this study found similarities between cigarettes and e-cigarettes when it comes to the cellular damage that has the potential to lead to oral cancer.

Additionally, other studies cited below found potent carcinogens and carcinogenic trace metals in e-cigarette vapor and the saliva of e-cigarette users.

Sources

What does all this mean?

What do we know E-cigarettes have been associated with poor oral health outcomes, from tooth decay and gum disease, to a potentially increased risk of oral cancer.

What don’t we know Without further research, oral health care experts cannot say how often poor outcomes will happen, how often an individual must use an e-cigarette to be impacted by negative health outcomes, or how severe the impacts could be.

Long-term studies must be conducted in order to obtain more representative data.

However, what we do know is important: The risk is present, and e-cigarette users must ask themselves,
“Is it worth the risk?”

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!

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Oral Cancer Awareness

Every year, an average of 53,000 Americans are diagnosed with some form of oral cancer, killing one person every hour.

When detected in its early stages, oral cancer is highly treatable and, in many cases, curable. Unfortunately, oral cancer often goes undiagnosed until late in development, significantly elevating its death rate.

Here are a few steps you can take to make sure you aren’t increasing your chances of developing a form of oral cancer.

Choose a lip balm with sunscreen, and use it whenever you are outside

Lip balm isn’t just for chapped lips. We should shield our lips from the sun just like we protect the rest of our skin, as overexposure increases the chance of oral cancer of the lip. Many brands offer lip balm with SPF that you could add to your sunny day routine.

Eat your fruits and vegetables

It may seem like an urban myth that parents tell their children to make them finish their dinner, but low intake of fruits, vegetables, vitamin C, and fiber has been associated with increased cancer risk. Inversely, high consumption has been shown to cut the risk of oral cancer in half.

Avoid tobacco, and use alcohol in moderation

While not as significant as the link between cigarettes and lung cancer, smoking tobacco products has been linked to oral cancer. Additionally, heavy consumption of alcohol—which is generally defined as more than three drinks per day—increases the risk of oral cancer.

According to the Oral Cancer Foundation, cell wall dehydration from alcohol makes it easier for carcinogens from tobacco smoke to penetrate oral tissue cells. When alcohol and tobacco are combined, which is often the case for people who refer to themselves as “social smokers,” the risk of oral cancer skyrockets to more than 15 times that for non-users of the two substances.

Don’t use smokeless tobacco products either

Smokeless tobacco products like chewing tobacco are a major risk factor for oral cancer. Additionally, new research is highlighting risks associated with vape and e-cigarette products. More research still needs to be done in this area, but initial studies suggest that e-cigarette use increases risk of gum disease, tooth decay, and oral cancer.

Get an HPV Vaccine

Human Papillomavirus (HPV) has been linked to an increased risk of developing oral cancer. Because the sexually transmitted virus goes largely undetected in most carriers, getting an HPV vaccine is a good practice to both avoid the virus and reduce the risk of HPV’s impact on the oral cavity. For further guidance on HPV vaccination, please discuss with your primary care or dental provider.

HPV is the leading cause of the oropharyngeal cancers of the tonsils and base of the tongue. While there are nearly 200 strains of HPV, strain 16 is of concern as it relates to your oral cavity. Please review the Oral Cancer Foundation’s website to learn more.

Visit your dentist

The Oral Cancer Foundation suggests that patients receive an oral cancer screening annually, especially if they fit any of the common risk factors for the disease.

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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!