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Thank you, Dr. Zachary Brian!

After four years as the director of NCOHC, Dr. Zachary Brian has taken the next step in his career.

Dr. Brian will join UNC-Chapel Hill with a dual appointment with the Adams School of Dentistry and the Gillings School of Global Public Health. While his time with NCOHC has come to an end, it is clear that his impact on oral health in North Carolina is far from over!

Since he joined FHLI in 2018, Dr. Brian has led the NCOHC team along with countless partners and advocates to policy victories that are actively transforming access to care in North Carolina. His leadership was fundamental in achieving regulatory rule changes allowing more children to receive preventive oral health care and passing landmark oral health legislation, making North Carolina’s dental landscape more equitable and accessible.

From key pandemic provisions allowing dentists to administer COVID-19 vaccines to recent expansion of North Carolina’s Medicaid for Pregnant Women program, the entire NCOHC team is incredibly proud of what our broad coalition has been able to accomplish during Dr. Brian’s tenure.

Dr. Brian’s impact certainly won’t end with his departure. This past year, NCOHC was able to launch several programs and initiatives that also promise to positively transform oral health access and equity. The COrHT Initiative, the Oral Health Transformation Initiative, Brush Book Bed, and the Patient Advocate Pilot Program are all ongoing projects exploring new and innovative ways to get care to those who need it most.

The NCOHC team is certainly sad to see Dr. Brian go, but we are also well-equipped to continue our important work as we head into the new year. Dr. Steve Cline, who has served on NCOHC’s advisory team and FHLI’s board, has stepped in as interim vice president of oral health. Crystal Adams, formerly our associate director, has received a well-deserved promotion to director of NCOHC.

We are incredibly proud of Dr. Brian. From the entire NCOHC team, thank you for your tireless work to improve oral health access and equity in North Carolina!

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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The Political Determinants of Oral Health

Daniel E. Dawes began his 2020 book, “The Political Determinants of Health,” with a story about a farmer looking for land to plant an orchard. He finds a plot of land split into three sections: one with rocky soil, one with poor soil, and one with rich soil.

In the story, the farmer planted fruit trees in all three sections of his newly acquired land. As you can probably guess, the trees in the rich soil grew fast and strong, producing abundant fruit while the trees in the other two sections struggled, withered, and died off.

While the trees’ outcomes could be attributed to their respective soil conditions, location wasn’t the only factor at play. The farmer paid extra attention to the best-performing trees; the ones planted in the fertile soil. Because the trees in the other sections didn’t grow as fast or as strong, he paid less attention to them and provided them with less care.

Dawes’ lesson from this story is that people’s health outcomes are often based on limited choices and opportunities. Each tree planted had the same innate function: to grow and bear fruit. The trees that died didn’t decide they wanted to be unhealthy. Rather, they succumbed to a lack of resources in their immediate surroundings.

In this story, the farmer is a stand-in for the role of a government. From there, Dawes expands into a new framework for understanding health outcomes, equity, and the inequities that plague health care in America.

What are the “Political Determinants of Health”?

The political determinants of health are an attempt to explain the various ways that politics – voting, government, and policy – create the social drivers of health and impact actual health outcomes, access to care, and more.

Dawes is a public health policy expert, educator, researcher, and executive director of the Satcher Health Leadership Institute at the Morehouse School of Medicine. His “Allegory of the Orchard” is the foundation for his political determinants of health model.

The political determinants of health can be broken into three categories: voting, government, and policy. According to the Satcher Institute, “The political determinants of health create the social drivers — including poor environmental conditions, inadequate transportation, unsafe neighborhoods, and lack of healthy food options — that affect all other dynamics of health.”

Image source: Daniel E. Dawes (2020), The Political Determinants of Health, John Hopkins University Press

An Argument for Multiple Approaches

Advocacy groups and health care organizations that seek to resolve existing inequities often fall into one of two buckets: those that seek to impact policy and other structural forces; and those that seek to directly allocate resources to those in need.

The political determinants of health illustrate the important fact that little can be done to permanently resolve inequities if overarching structures are not changed. However, that doesn’t mean organizations seeking structural policy change have the only “right” answers. Systems change takes a long time, and people experiencing health inequities need help now.

Resource Allocation

That’s where resource allocation comes in. Providing low-cost health care, transportation services, free equipment, and other means of direct aid are equally necessary, even if they don’t address the root causes of inequity.

As health advocates work to create more equitable systems, organizations can work together to find a balance, meeting immediate needs on one hand while influencing policy and creating structural change on the other.

Addressing the Political Determinants of Oral Health

As NCOHC and our partners work to build a more equitable oral health system, policy will continue to play a leading role. Understanding the interaction between the political determinants of health and the social drivers of health also underscores the need for a diverse coalition of advocates working toward these structural changes.

Policy changes that range from specific, targeted reforms allowing hygienists to fill all the roles they are trained for to broader updates to the Medicaid structure are necessary to increase access to care across the state. However, reforming the Dental Practice Act isn’t the only thing that can be done to impact oral health. Affordable housing, fair wages, and healthy food advocacy will also impact oral health, and vice versa.

The bottom line is that everyone, everywhere has a role to play in creating better systems, and all those roles, no matter how niche, fit into a network of advocacy that must work together if we are to succeed in creating a better future for all North Carolinians.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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Medicare Dental Services are Poised to Expand

A recent announcement from the Centers for Medicare and Medicaid Services (CMS) signals a possible expansion of dental services available for Medicare beneficiaries.

Proposed changes to the procedures covered under Medicare would be a significant step in the right direction. NCOHC commends CMS for this historic move toward a more equitable oral health care system for older adults, and look forward to further expansion of services to ensure comprehensive oral health care for a population that is sadly often left out of the conversation

Specific details are still somewhat uncertain, but any changes to Medicare’s dental coverage would be limited to its current framework in which dental services are tied to other medical procedures.

Background: Medicare and Dental Coverage — Reinforcing a Historic Divide in Care

Medicare is currently only allowed to reimburse for limited dental procedures deemed necessary to treat a covered medical condition. For example, an infected tooth removal may be covered if the patient is about to begin radiation treatment for certain cancers.

The structure as it currently exists ignores several factors, including the fact that oral disease can significantly impact a person’s quality of life, regardless of other medical conditions. It also ignores the oral-systemic connection and the many diseases and health conditions that can result from poor oral health.

Nearly a year ago, NCOHC Director Dr. Zachary Brian published his thoughts on the need for a Medicare Dental Benefit.

In Brian’s words, “Dental coverage under Medicare is sorely needed, but to make Medicare dental benefits anything but universal diminishes the message that public health-minded dentists have fought so hard to advance: that oral health is overall health.”

Any changes to Medicare’s dental coverage outside of the current framework tying oral health care to other medical procedures would need to happen through legislation. Earlier in 2022, Congress appeared on the brink of passing a Medicare dental benefit. The change, championed by Senator Bernie Sanders (I-VT), nearly made it into the Inflation Reduction Act. The provision didn’t make it into the bill, but momentum appears to be building behind a more comprehensive dental benefit.

What Could Change with Dental Benefits Under Medicare, and When?

The proposed changes to Medicare coverage put forward by CMS could take effect as early as January 2023. The changes would include an expansion of covered dental services associated with the success of other covered medical procedures – they wouldn’t include any standalone dental services.

While this expansion is necessary, NCOHC also looks forward to more movement in support of adding a full dental benefit for Medicare participants. The timeline of this type of action is much more uncertain and will depend in no small part on the outcome of the 2022 midterm elections.

A Call to Action

Older adults are too often left out of the conversation when it comes to oral health care, especially preventive oral health care. Our current structures reinforce a mindset that certain oral health outcomes are inevitable.

The reality, however, is that most oral disease is entirely preventable, even for older adults. That means that tooth loss and the need for dentures, for example, are not simply foregone conclusions associated with age. With proper care, anyone can live a full life with their natural teeth.

An expansion of Medicare services to include a dental benefit is a necessary step as we work toward a more equitable future. This change requires legislation at the national level, and it is on all of us to help advocate for this change.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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The Curb-Cut Effect in Oral Health

There are stories about “midnight raids” in the 1960s depicting disability rights advocates in Berkeley, CA, smashing and re-paving curbs so they would slope down to meet the street at intersections, allowing people in wheelchairs to cross.

These stories aren’t entirely accurate — although some “midnight raids” certainly did happen. What is true is that activism in the 1960s did result in a revolution in accessible infrastructure design, beginning with “curb cuts.”

In 2018, the podcast 99% Invisible covered the history of curb cuts, outlining the story of disability rights activist Ed Roberts, who contracted polio at 14 years old and ended up paralyzed below the neck.

Roberts joined a group of student activists at UC Berkeley called the “Rolling Quads,” who led the charge to get curb cuts installed across the city. While those curb cuts weren’t all installed during so-called midnight raids, they did result from grassroots advocacy targeting the Berkeley City Council.

Fast forward to today and curb cuts are nearly ubiquitous across the US, in part thanks to the Americans with Disabilities Act, another outstanding demonstration of the power of policy advocacy.

“The Curb-Cut Effect”

The “curb-cut effect” is now a term used to refer to the many ways addressing one group’s unique needs can benefit everyone. Research has shown that curb cuts positively impact nearly everyone, from mothers with strollers to elderly pedestrians, travelers with suitcases in tow, and more.

There are many examples of curb-cut effects in everyday life. Outlined by the 99% Invisible podcast, captions meant for the hard of hearing help everyone trying to watch a ball game in a noisy bar. Entering a building with your hands full is much easier with automatic door buttons installed for wheelchair users.

The hosts even noted that the football huddle was actually invented when Gallaudet University, a school for the deaf and hard of hearing, played other deaf football teams and wanted to hide their signs from being seen.

The Curb-Cut Effect in Oral Health Policy

In oral health, NCOHC believes the curb-cut effect is present across policy proposals to increase access and equity in care. As the saying goes, “A rising tide lifts all boats.”

Example: Emergency Department Diversion

North Carolinians visit emergency departments (EDs) for dental-related needs at twice the national rate, a trend that accounts for an annual $2 billion in health care bills across the United States.

The cost of care at an emergency department is very high. On top of that, most EDs are not equipped to resolve oral disease — they can only mitigate it. This means that if you visit an ED with a toothache, you are likely to receive an opioid and an antibiotic, resolving pain and swelling temporarily. Until you receive a root canal or other surgical treatment, however, that pain and swelling will return, landing you right back in an ED.

So, for the population making ED visits, the benefits of diversion to an oral health provider are clear: the cost would be lower, and oral disease could actually be resolved, removing the need for repeat visits (and bills).

What about the curb-cut effect in this situation? For one, diversion programs could reduce the demand for ED services, reducing wait times for everyone else who needs emergency care.

Additionally, a large portion of the population visiting EDs for oral health care do not have insurance or the income to pay expensive out-of-pocket bills. Because of this, there is significant opportunity to reduce uncompensated care costs through policies and programs that would divert care to oral health providers.

There are a variety of ways that uncompensated care costs are covered, including billions in public funds. For example, the federal government paid around $21.7 billion to cover uncompensated care costs in 2017. Reducing uncompensated ED oral health care costs could certainly impact the amount of tax dollars doled out each year for these services.

The Need for Equity

As policies are enacted to address specific population needs, equity must always be considered. Looking back at historic policies, even when curb-cut effects happen, inequities persist.

Take the GI Bill as an example. The legislation that provides a range of benefits for those who served in the U.S. military has positive impacts reaching far beyond its target population. In the years after World War II, the GI Bill was partially responsible for an economic boom for contractors as the demand for housing increased alongside a rise in homeownership.

Unfortunately, red lining policies prevented Black veterans and their families from benefitting from the bill, cutting an entire population out of the positive impacts in a way that persists today.

For oral health providers and advocates, two things are important to remember: 1) specific, targeted legislation can have far-reaching benefits, and 2) steps must be taken to ensure that inequities are addressed whenever policy is enacted.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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What We Know About Monkeypox from an Oral Health Perspective

As the monkeypox outbreak continues to spread, we sat down to explore what oral health connections exist, what is currently being researched, and what you should know about monkeypox with relation to oral health

What is Monkeypox?

Monkeypox is a viral disease with symptoms similar to, but much milder than, smallpox. It is rarely fatal, and is primarily spread by close personal contact, often skin-to-skin.

Monkeypox was first discovered in 1958 in monkeys being kept for research. The first human case was recorded in 1970.

Common symptoms of monkeypox include fever, fatigue, and flu-like symptoms. The disease also presents with a rash on the skin reminiscent of smallpox. While it should be taken seriously, it is much less deadly. In fact, of the 14,000 cases worldwide as of July 20, 2022, only five deaths had been reported.

Oral Symptoms of Monkeypox

Overall, oral manifestations of monkeypox appear to be relatively rare. A recent report in the Journal of Oral and Maxillofacial Surgery did outline two cases of oral lesions associated with monkeypox.

In both cases, the oral lesions appeared before the skin rash. In the first case, oral lesions were the first symptom.

The Centers for Disease Control and Prevention (CDC) is urging providers to be on the lookout for symptoms that could be associated with monkeypox, including oral manifestations. Although oral symptoms seem to be relatively uncommon as of August 2022, providers with patients presenting oral lesions might consider monkeypox among potential causes.

What Else Should Oral Health Providers Know?

The CDC has published guidance for providers treating patients with monkeypox. The organization outlines considerations for infection control and provider safety, including PPE, waste management, and other precautions to prevent transmission.

Learning from the Past

Many are discussing the similarities between the current monkeypox outbreak and HIV. For many providers, it is easy to look back on the early 1980s with regret for how the community responded to the emerging HIV epidemic. Too many patients with HIV were met with fear and shame, unable to receive the care they needed, including oral health care.

We recently sat down with Dr. Lewis Lampiris, who was a practicing dentist in the 1980s as the HIV epidemic emerged. His story offers insight into the important role oral health providers need to play when a new disease emerges, and we believe it can offer guidance as we navigate the monkeypox outbreak.

“As a dentist I feel responsible for taking care of everybody who walks through that door, regardless of who they are, what they look like, what kind of condition they are in,” said Lampiris. “It’s an obligation to take care of people. That comes part and parcel with your degree as a dentist, as a physician.”

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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How to Keep Your Gums Healthy, and Why It Matters

Teeth aren’t the only things in your mouth that need to be cared for. From your gums to your tongue, molars to canines, everything in your mouth needs proper care to stay healthy. In this blog post, we’ll take a look at what you can do to care for your gums — and why it’s so important.

How to Care for Your Gums

When it comes to gum health, you fortunately don’t have to learn a bunch of new rules. The basics are pretty much the same:

  1. Brush twice per day with fluoride toothpaste
  2. Floss consistently
  3. Visit the dentist regularly for a routine checkup

While the routines are the same, there are a few tips and tricks you can learn to take better care of your gums.

But First, Why Does Gum Health Matter?

Your gums and underlying bone play an important role in your mouth: they keep your teeth in place. If they aren’t healthy, that job can be a harder one to do. Poor gum health can lead to disease that can affect other parts of your body. In fact, gum disease has been linked to heart disease, diabetes, and even dementia, among other conditions.

The bottom line: healthy gums reduce risk of oral infections, tooth loss, and cavities along with heart disease, diabetes, and other negative health impacts associated with the oral-systemic connection.

There are two main types of gum disease:

  • Gingivitis — Gingivitis is a rather mild gum infection with symptoms like swelling and bleeding. It can typically be treated easily, just by following the three steps above (brush, floss, visit the dentist).
  • Periodontitis — Periodontitis, on the other hand, is the more serious gum disease that comes about when gingivitis is left untreated. Its symptoms include the same swelling and bleeding caused by gingivitis, along with tooth sensitivity, pain while chewing, receding gums, and bone loss that can lead to loose teeth or tooth loss.

Treatment for Gingivitis and Periodontitis

With periodontitis, the infection impacts your gum tissue as well as the bones that hold your teeth in place. These cases can sometimes be treated non-surgically if they aren’t too far advanced.

Gingivitis or periodontitis can usually be treated without surgery. Advanced cases of periodontitis may require more invasive care, however, potentially including surgery. Depending on the severity, the disease may require a variety of different surgeries, bone grafts, and other methods of regenerating lost tissue.

Habits for Good Gum Health

  • Brushing — To avoid gum disease, make sure to brush all sides of your teeth in a circular motion. Be gentle along your gumline, but make sure that you brush where your gums meet your teeth. Bacteria can easily build up along the gum line, which is a recipe for gum disease and tooth decay if left unattended.
  • Flossing — When you floss between your teeth, don’t just go straight in and out. Move the floss back and forth as you ease in. This helps make sure you are dislodging any food residue or bacteria that has built up between your teeth, and it will help clean and strengthen your gums.
  • Fluoride — Finally, consider adding a fluoride mouthwash to your oral health care routine. Mouthwash isn’t a replacement for brushing and flossing, but it can help add an extra layer of cleaning and protection.

Other Factors Impacting Gum Health: Food & Drink

A well-balanced diet can help strengthen your gums. Nutrients like vitamin C, vitamin D, omega-3 fatty acids, various B vitamins, and zinc have all been linked to gum health. Vitamin C, for example, plays a major role in collagen production, an important component of gum tissue. Vitamin C deficiency can result in bleeding or inflamed gums.

Smoking and drinking are also important considerations when it comes to gum health. The best recommendation is always to quit smoking altogether — both for cancer prevention and overall oral health management — and limit alcohol consumption. If you do smoke and/or drink, however, staying hydrated is a good way to mitigate some of the negative effects.

Drinking water won’t prevent the oral and pharyngeal cancers that smoking causes, but it will help with dry mouth that can result from tobacco or alcohol consumption. Click here for more about the ways that dry mouth can lead to tooth decay and gum disease.

All in all, gum disease and the habits that help prevent it follow the same narrative of most oral disease. While it is entirely preventable, if left unattended, gum disease can get seriously out of hand, leading to poorer overall health and more invasive, expensive treatments. Good personal habits go a long way, but they must be paired with affordable, accessible, preventive care.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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An All-Too-Common Story of Need, Scarcity, and Oral Disease

She vividly remembers waking up with a swollen jaw, tooth pain that wouldn’t go away, and a sinking feeling as she realized what it meant.

Melinda Johnson of Hayesville, North Carolina, whose name has been changed to respect her privacy, does not have insurance of any kind, including dental insurance. Her children are currently on Medicaid.

Johnson usually begins panicking when she thinks about dental care. She knows that she does not have enough money to afford it, as she is already living paycheck to paycheck just to account for basic needs.

She said she usually must resort to the emergency room for dental care, where she is typically not treated kindly. In past experiences, staff thought she was seeking opioids instead of care for dental pain, so she always told them she’s not an addict so they would give her a fair chance.

Johnson says that there is an income-based dental clinic in Hayesville, but it doesn’t offer the kind of care that she needs, like multiple extractions, fillings, and implants. Most importantly, she needs multiple teeth removed so that decay doesn’t spread.

Searching for Care

Johnson vividly remembers a recent experience waking up with a swollen jaw and excruciating tooth pain that continuously got worse. Since she had no financial means to get the tooth pulled, she went to the emergency room and was prescribed an antibiotic for the infection and Toradol for pain.

After she finished the antibiotic, the pain subsided but swelling persisted. Her next step was to go see a regular doctor, who gave her higher dose shots of antibiotics. She has now finished those antibiotics, as well, but still does not have enough money to have the tooth fully treated.

Today, Johnson is still trying to find a dentist in her price range. She is looking for a dentist out-of-state while waiting on her paycheck.

Fear, Anxiety, and Shame

This experience has made Johnson feel self-conscious and embarrassed. Her feelings about it are so strong that she can’t speak about it without crying.

She admits that drugs, which are a huge issue in rural North Carolina, are a factor contributing to her dental issues. According to the Western North Carolina Health Network, 50.5 percent of adults in Clay County, where Hayesville is located, have been negatively affected by substance use.

According to Johnson, pregnancy was also very hard on her teeth. Hormone changes and morning sickness that result from pregnancy, for example, can negatively impact oral health. She recounts that she did not have a single cavity until her first child, and then after her second and third children it was as if her teeth were just breaking off one by one.

Impossible Choices

Johnson said that she doesn’t understand why dental care is so expensive and inaccessible. She said that she is trying to get her life back together and doesn’t want to have to beg for money “because of her poor choices.” She isn’t looking for a “free ride” by any means; she just doesn’t want to have to choose between “feeding her family and getting a tooth pulled.”

For Johnson and too many others in North Carolina and across the United States, this story is a daily reality. Oral health issues that for many are nothing more than a minor annoyance (perhaps an extra dental appointment and a filling away from a full resolution) disrupt the daily lives of those who can’t afford the care they deserve, deteriorating and developing into major health concerns.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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An Oral (Health) History of the HIV Epidemic

“It just kept happening, over and over and over again. Patients of record, patients I’d known for years. Either they come in complaining about something or I see something. All of the classic oral manifestations of HIV disease, there they were.”

Dr. Lewis Lampiris is a retired dentist and educator. Over the course of his career, he:

  • Served as a dentist in the U.S. Army
  • Owned and operated a private practice
  • Served as the president of the Association of State and Territorial Dental Directors
  • Served as the director of the American Dental Association’s Council on Access, Prevention, and Interprofessional Relations
  • Served as the chief of the Illinois Department of Public Health Division of Oral Health
  • Retired as associate dean for community engagement and outreach at the UNC Adams School of Dentistry.

Lampiris is also a gay man, and he was early in his career practicing dentistry in downtown Chicago when the HIV epidemic hit. Here, in his own words, is Lampiris’ story about the years that followed:

“People like to go to providers who look like them or sound like them or understand who they are. So, I as a gay man ended up having quite a few LGBTQ patients in my practice, mostly other gay men.”

 

June 1981: The U.S. Centers for Disease Control and Prevention (CDC) published an article outlining five cases of a rare lung infection in young gay men, the first cases of what would become known as AIDS.

On the same day, a New York dermatologist reported multiple cases of Kaposi’s sarcoma, a rare form of cancer. These cases would later be linked to AIDS.

It wouldn’t be until 1984, three years later, that scientists would discover the cause of AIDS: a virus that would be named HIV.

 
 

“Anyway, around 1985 I got a call from a physician who was a patient of mine. He was a resident at Northwestern. He comes into my office, and I had never seen it before. I had only read about it. He had a Kaposi’s sarcoma lesion, no question about it.”

That man was Lampiris’ first HIV-positive patient. His case and its oral manifestations would play a large role in re-orienting Lampiris’ career toward providing care for HIV-positive individuals and educating other dental professionals to do the same.

“I felt an obligation to take care of my patients and there was so much hysteria about HIV at that time, both in the general public as well as among the dental community. I was one of the few dentists in Chicago who would get referrals for patients with HIV from the Chicago Dental Society. There were only three of us in the beginning.”

 
 

1985: More people were diagnosed with AIDS than in all earlier years of the epidemic combined, according to the CDC.

In 1985, 51 percent of adults and 59 percent of children with AIDS died from the disease.

 
 

“And as a dentist I feel responsible for taking care of everybody who walks through that door, regardless of who they are, what they look like, what kind of condition they are in. It’s an obligation to take care of people. That comes part and parcel with your degree as a dentist, as a physician.”

Lampiris saw a moral imperative when it came to providing care for HIV-positive individuals. But in many ways, his work was also driven by societal disregard for the wellbeing of LGBTQ people. He went on to discuss just how alone his community was as this new disease spread.

“In my opinion, and I think there’s a lot of evidence to support it, we really were undesirables. We were a stigmatized population. Reagan was president during that whole period of time, and he wouldn’t mention the word ‘AIDS.’ We had to take care of ourselves.”

“I remember marching in gay pride parades giving out brochures about oral sex and HIV disease transmission. Somebody had to talk about it. So, we had to educate folks, and we had to do it ourselves.”

 
 

March 12, 1987: Gay rights activist and playwright Larry Kramer founded ACT UP (the AIDS Coalition to Unleash Power) in New York City.

 
 

“I was a member of Act Up. Dr. Fauci was the director of the National Institute of Allergy and Infectious Diseases at that time. We were demonstrating. We were in front of him arguing about clinical trials – that they needed to be opened up right away.”

Lampiris paused here to mention the similarities and differences he sees between the HIV epidemic and COVID-19. Where trials were fast-tracked and the full weight of the scientific community was thrown behind finding vaccines for COVID-19, activists had to fight to secure federal funding and research for HIV treatment.

“Then after my own personal tragedy, where my own husband, my partner, died of AIDS in 1991, I needed to change my direction. Shortly thereafter I ended up selling my practice and going to get my master’s in public health degree from the University of Illinois in Chicago.”

 
 

1992: AIDS became the #1 cause of death for men in the U.S. ages 25 – 44.

1994: AIDS became the leading cause of death for all Americans ages 25 – 44.


Image taken from the movie Philadelphia (1993), the first major Hollywood film about AIDS.

 
 

“I ended up becoming the dental director for the Midwest AIDS Training and Education Center while I was in school, because they were affiliated with the university. I traveled around Wisconsin, Illinois, Indiana, Iowa, Michigan, giving talks about the oral manifestations of HIV disease, managing HIV disease in your practice.”

On his new trajectory, Lampiris set out to educate his peers in the dental community, preparing others to understand the oral manifestations of HIV and treat their patients accordingly. It wasn’t easy, however. HIV/AIDS would continue to be stigmatized for some time – the disease still results in discrimination today – and many members of the dental community would prove reluctant to provide care to HIV-positive people.

“There was a lot of hostility that came at me. I had a lot of teaching to do. But people showed up because they knew they needed to understand. There were dentists out there who were also treating HIV-positive patients in their practices, and they had no community – they had no place to go to learn. They would come to my lectures, so we said, ‘OK let’s set up a study group, so if you have something you see in your practice, we can all learn from each other.’”

 
 

1996: The U.S. Food and Drug Administration (FDA) approved the first HIV home testing kit.

1996: Scientists discovered a combination of HIV medicines that effectively suppress the virus’ spread.

1996: The first decline in AIDS diagnoses since the beginning of the epidemic is recorded.

 
 

Fast forward to today and HIV is a much more manageable disease. Most HIV-positive people in parts of the world with access to health care services can live full, vibrant lives. Parallel to advances in HIV treatment, Lampiris also saw positive changes in dentistry driven in part by the HIV epidemic.

“Absolutely HIV had something to do with universal precautions or standard precautions. Masking was not a standard protocol when I trained as a dentist. The CDC came out with precautions for infection control in the dental practice and they were adopted by the American Dental Association. That became the standard of care, and that emerged from the epidemic.”

 
 

2017: The CDC reported that U.S. HIV-related deaths fell by half between 2010 and 2017, largely due to early testing and diagnosis.

2022: Researchers announced that a woman’s HIV had been cured thanks to a new treatment approach. This new treatment is the first with potential for more widespread use.

 
 

“Going back to that first patient with Kaposi’s sarcoma, he was a patient of record. I’m responsible for taking care of everybody who walks through that door. The idea in terms of one of the basic ethical principles in our code of ethics is, ‘Justice, to treat everybody fairly.’ So that’s what I said back then but I’ll say it again. That translates to what we’re dealing with here in North Carolina with Medicaid patients, with the IDD community. There are similarities in treating folks that don’t fit into the mold.”

Just before this story was published, two new cases of individuals potentially cured of HIV were announced at the 2022 International AIDS Conference in Montreal. One case is of an 88-year-old man who was first diagnosed with HIV in 1988. After a stem cell transplant, he has been apparently cured of both HIV and leukemia.

In the other case, a woman who received an immune-boosting regimen in 2006 has been in what researchers characterize as “viral remission” ever since. In this case, the woman still harbors the HIV virus, but her immune system has been able to control its replication.

Researchers emphasized that both of these cases are not options for widespread treatment of HIV. Stem cell transplants are highly toxic and potentially fatal, and as such are typically not used unless a patient is facing a fatal and otherwise untreatable cancer. The immune system-boosting approach has not been widely researched, so much more needs to be done before it would be considered to be a replicable cure.

 

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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The Medicaid Access Gap for Children in North Carolina

It’s no secret that there is an oral health care access gap for North Carolinians with Medicaid insurance. It’s practically a rule of thumb that if you are born poor, you will have less access to health care services (medical and dental), and in turn will likely end up with greater incidence of dental disease.

There are many reasons why this is true. From the food on your table (click here to learn more about how where you live can impact access to healthy food) to the transportation you can access, the distance between your home and the nearest oral health care facility, and more, social determinants of health can significantly impact access to care.

In fact, an estimated 80 percent of a person’s health is the result of factors outside of a medical office.

That isn’t to say that the oral health care system itself is an insignificant factor. For a variety of reasons, there simply are not enough providers who accept Medicaid insurance, which creates large areas where adults and children alike cannot access the care they need and deserve.

North Carolina Medicaid Oral Health “Secret Shopper” Survey

The NCOHC team recently conducted an internal secret shopper survey in Western North Carolina, a region with significant oral health care access issues for Medicaid-insured individuals. Over the course of several weeks, NCOHC staff contacted oral health care providers listed on the website Insure Kids Now to inquire about an appointment for a seven-year-old child with Medicaid insurance.

Of 119 WNC locations, 50 were listed as accepting children with Medicaid insurance. Fifty-seven were listed as not accepting Medicaid, and 12 did not indicate whether or not they accept Medicaid. Upon calling each location, NCOHC found that only 35 locations were currently accepting Medicaid-insured children. A total of 70 did not accept Medicaid, and NCOHC staff were unable to reach the remaining 14 locations. Three counties were found to not have a single Medicaid-accepting oral health care provider.

Note: The NCOHC survey was conducted to serve as a preliminary look at the oral health care landscape in Western North Carolina, an area with significant access concerns. And while it was not conducted as a comprehensive research project, NCOHC’s findings do reflect some of the access gaps identified in the recent American Dental Association Health Policy Institute’s report on Medicaid access in North Carolina. Particularly, maps in the report of meaningful pediatric Medicaid dental office locations starkly visualize the relative scarcity of providers in the western part of the state compared to North Carolina’s urban centers.

Increasing Medicaid Acceptance by Oral Health Providers in North Carolina: What Can We Do?

It’s important to ask why these access gaps occur. Even when there are dental providers in an area, why do so many not accept Medicaid insurance?

Addressing Payment Disparities

Medicaid reimbursement rates for oral health care tend to be lower than the rates private insurers pay, often falling below the actual cost of performing some procedures. For many private practices, this can pose a significant financial issue.

Possible paths forward include increasing reimbursement rates to a level where Medicaid is on par with private insurers and simplifying the filing and appeals processes.

Strengthening the Oral Health Care Safety-Net

Another option is to patch up the holes in our “safety-net” facilities. Across North Carolina, Federally Qualified Health Centers (FQHCs), local health departments, and other safety-net facilities care for large numbers of our state’s residents who have Medicaid insurance or are uninsured or underinsured.

FQHCs, for example, receive federal funding that helps reduce the financial gap between Medicaid reimbursement rates and private insurance rates (as well as the gap between patients with insurance and those who can’t pay at all). Despite this support, many FQHCs still struggle to cover their costs. Additional funding will be needed to ensure the sustainability of these organizations’ efforts.

Similarly, local health departments and other safety-net facilities often receive funding from the government, charitable organizations, and private donors that help them see any patient, regardless of their ability to pay.

Systems-Level Reform to Address Medicaid Oral Health Care Access in North Carolina

To solve the Medicaid access gap issue, we must ask the right questions — and address the systemic challenges driving these disparities. For example:

  • What policies or other initiatives could strengthen the safety-net environment, allowing facilities like FQHCs to expand into regions that are underserved?
  • Can we achieve policy reform to increase reimbursement rates?
  • If so, how long will that take, and what can we do to help those in need in the meantime?

The solution to North Carolina’s Medicaid oral health care access issues will likely require organizing to build support for changes to the Medicaid system while also driving policy change to better support the safety net. No less important, however, and as NCOHC always emphasizes, we are far more likely to solve the problem through collaboration.

Doing nothing simply isn’t an option.

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.

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Oral Health Day 2022: Equity in Action Recap

This year’s Oral Health Day was a tremendous success!

Oral Health Day 2022 centered the work necessary to create a truly equitable oral health system. Following the theme “Equity in Action,” speakers discussed disparities and the actionable steps we can all take to improve oral health for everyone, from pursuing racial equity to increasing access for individuals with disabilities, and more.

If you missed the event and want to enjoy the full experience, you can find the event recording here.

Dr. Eleanor Fleming’s Keynote Address

Dr. Eleanor Fleming kicked off the first day with rousing remarks on race and racism in oral health, highlighting systemic factors that impact our teeth and the need for antiracist collaboration to overcome barriers to care. Dr. Fleming currently serves as assistant dean of equity, diversity, and inclusion at the University of Maryland School of Dentistry and is a nationwide leader in this work.

 

Fleming discussed the social determinants of health and the many ways that the world around us can impact our health. Most of her remarks, however, centered around antiracism, tying the need for antiracist effort to the ultimate goal of equity in oral health care.

Fleming identified ways that racism goes beyond hurting individual people or groups to “actually sap the strength of the whole society.” She said that we all have skin in the game when it comes to actively challenging racism at the personal, structural, and systemic levels.

 

Panel Discussion

After Fleming’s keynote address, Dr. Lewis Lampiris, associate adjunct professor at the University of North Carolina Adams School of Dentistry, moderated a lively panel discussion that included representatives from community, insurance, philanthropy, academia, and more.

Marie Helms, a mother of two, kicked off the panel talking about her experience finding oral health care for her daughter, who was diagnosed with spastic quadriplegic cerebral palsy at 6 months old.

 

Panelist Rachel Radford followed with examples of hardships her family has experienced finding oral health care for her two children, both of whom have autism.

 

Radford also talked about her own experience with oral health care. She didn’t see a dentist until she was 22 years old and was made fun of by her first provider for being nervous. She talked about the way this made her feel and how dental anxiety stemming from that incident made it difficult to continue seeking oral health care.

Continuing the conversation, Dr. Amadeo Valdez gave perspectives on equity issues from his roles as an oral health care provider and dental residency program director. Valdez works for the Mountain Area Health Education Center, the AHEC program serving Western North Carolina.

 

Lampiris asked Curt Ladig, president and CEO of Delta Dental of North Carolina, how private insurers can contribute to equity in oral health care. Ladig explained that his core beliefs center around access for everyone, something he brings to his work as he guides the direction of the insurance company.

 

Yazmin García Rico, director of Hispanic/Latinx policy and strategy at the North Carolina Department of Health and Human Services, joined the panel discussion to speak from her perspective within government. She talked about the need for a more robust workforce spanning the entire state.

 

García Rico also talked about diversity among providers as an important priority and mentioned language access as a major need in oral health spaces.

Finally, Dr. Susan Mims spoke from her perspective both as a pediatrician and as the current president and CEO of the Dogwood Health Trust. Dogwood Health Trust funds programs to improve the health and wellbeing of Western North Carolinians, including the Patient Advocate Pilot, an NCOHC-led initiative advancing care coordination and case management for vulnerable populations.

Mims spoke about the opportunities that philanthropic organizations have to advance equity in oral health, especially when it comes to pushing boundaries and trying new things. She also told personal stories from her time as a health care provider, witnessing the toll that poverty takes on people’s health.

 

Many panelists examined a specific and pressing policy need in North Carolina: Medicaid Expansion.

Radford’s final remarks during the discussion took a personal note. She enrolled in Medicaid coverage during the COVID-19 pandemic, but she and many others stand to lose that coverage unless Medicaid Expansion is passed.

 

Day Two: Equity in Action

This year’s Oral Health Day was the first to span two days. On the second day, participants from across the United States reconvened to participate in a collaborative workshop, identifying policy solutions to the inequities discussed the day before.

Prior to the workshop portion, NCOHC Director Dr. Zachary Brian kicked off the day with a data-based overview of disparities faced in North Carolina. With that background in mind, attendees split into four groups to discuss current realities and actionable solutions.

The NCOHC team was blown away by the level of engagement during the solutions workshop, and we are hard at work developing a comprehensive “Equity Action Framework” to share publicly. The framework will outline achievable, collaborative solutions to the problems facing communities across North Carolina, and will guide NCOHC’s work heading into 2023.

If you would like a copy of the report, make sure to sign up to receive NCOHC emails here.

You can find the full event recording below:

 

NCOHC, a program of the Foundation for Health Leadership & Innovation, works to advance systems-level changes, improving the overall health and well-being of all North Carolinians by increasing access and equity in care. To stay up-to-date and get involved, join us today as a North Carolinian for Change.