North Carolina Oral Health Collaborative

As of January 2022, the U.S. Health Resource and Services Administration has partially or fully designated all 100 North Carolina counties as Dental Health Professional Shortage Areas. This means many North Carolina residents still struggle to find oral health care today.

Medicaid Access in North Carolina

As we enter the summer of 2023, North Carolina is on the brink of finalizing a huge public health victory. The state legislature finally voted to expand Medicaid after more than a decade of hard work and advocacy from countless organizations and individuals across the state.

While the legislation has passed through both chambers of North Carolina’s legislature and was signed into law by Governor Roy Cooper, a provision prevents it from going into effect until all parties agree on and enact a state budget.

Medicaid Expansion became available for individual states to adopt after Congress and former President Barack Obama enacted the Affordable Care Act in 2010. Medicaid is health insurance program for low-income individuals jointly funded by states and the federal government. North Carolina was one of only nine states that had not yet expanded their Medicaid program. An estimated 600,000 North Carolinians will gain access to quality health care once the state legislation goes into effect.

The work toward equitable access to health care doesn’t end with Medicaid Expansion. For people with Medicaid insurance, the oral health crisis the entire state is experiencing could worsen in the short run. Only 35.1% of North Carolina dentists participate in Medicaid. This puts North Carolina 37th out of all 50 states in dentist participation in Medicaid. As more North Carolinians gain access to Medicaid insurance which includes oral health care coverage, our state must work to ensure an adequate supply of dental providers.

The bottom line: Dentist participation in Medicaid, and the many underlying factors that contribute to our current manpower shortage in our already oral health-compromised state, must be addressed. We believe North Carolina residents deserve to have access to oral care, and North Carolina must do better for its low-income and marginalized citizens.

Rural-Urban Divide

More than half of North Carolina’s counties have fewer than four dentists per 10,000 people, an access disparity that skews heavily toward rural parts of the state. In fact, five Eastern North Carolina counties have no practicing dentists.

This forces resident of these counties to travel long distances to receive oral care, making the likelihood of someone going to the dentist for a routine checkup dramatically decrease.

While a routine appointment in Charlotte – which is still inaccessible to many urban residents – could be as easy as a 15-minute trip up the road, a brief wait, and a 30-45-minute appointment, a dental visit in Tyrrell County could include an hour or more of travel time both ways.

For people with children and jobs that make it difficult to take time off, travel time alone can be a significant barrier. Add in access to transportation and consider more intensive oral health needs, such as fillings or root canals that could take several appointments to complete, and you can see how so many who may even have access on paper can’t visit a dentist simply because they live in a rural area.

Movement in the Right Direction

There are bright spots for the state of North Carolina in 2023. During the COVID-19 public health emergency, state level teledentistry policy changes made access to oral health services more accessible for many. People can do check-ups, ask questions, and have follow-up appointments remotely using online virtual technologies..

Teledentisty services lessen the burden of going to in-person appointments for care.

Teledentistry is especially beneficial for individuals who don’t have a dentist in their county, as they can still receive the basic care they deserve without making multiple trips to an office far away.

Spotlight: Bill Milner and Access Dental Care

Bill Milner is a dentist who deserves a spotlight for his work. Access to oral health care is one of North Carolina’s largest issues especially for institutionalized individuals and special needs patients. Milner and the organization he founded, Access Dental Care, are working to fix that. He recently received the 2023 ADA humanitarian award for his diligent work in oral health.

Access Dental Care is a non-profit mobile dentistry organization that Milner founded.

The organization works to bring oral health care to “residents of retirement homes, individuals with intellectual and developmental disabilities, and the community-at-large.”

People like Milner, and organizations like Access Dental Care, are doing all they can to provide N.C. residents with the oral health resources they deserve. While what they are doing is heroic, individual action alone can’t solve some of these system-level problems. There will continue to be a significant need for policy action. Our goal at NCOHC is to create a North Carolina where providers, community organizers, and advocates don’t have to be heroes because true access is the standard, not an anomaly.

Bright-spots, pressing issues, and goals moving forward for oral health in North Carolina were on full display during Oral Health Day on June 21, 2023. The theme for this year’s event was, “Challenges and Opportunities for the Dental Team.” Keynote speaker Kathy Colville and the other wonderful panelists brought expertise and ideas for how North Carolina can become a healthier, more equitable state.

If you missed Oral Health Day 2023 and want to watch the webinar, click here.

Teeth are important, but providers struggle to meet the need

“We have truly amazing and exceptional people holding up an inadequate system.”

This quote from Kathy Colville, president and CEO of the North Carolina Institute of Medicine, underscored an important point restated throughout Oral Health Day 2023.

Colville spoke at length about the necessity of a systems-level approach to improving oral health. She began with an analogy about movie tickets, comparing price increases to the cost of an education and health care reimbursement for providers.

Colville said that if she bought a movie ticket today in Burlington, “it will set me back about $11.50. In 2007, around 15 years ago, the average price of a movie ticket was $6.88.”

“Undergraduate in-state tuition for two semesters at UNC-Chapel Hill in 2022-23 was $7,518. In 2007, it was $3,455. That one has more than doubled,” Colville said. “Some of you already know why I’m talking about 2007. It’s because that was the year reimbursement rates to North Carolina’s oral health providers stopped increasing.”

“Keep your health, that’s number one. Teeth are important.”

Colville brought this quote up numerous times throughout her speech during Oral Health Day. The quote comes from her Aunt Anne, who she asked for advice on living a long, healthy life.

“The mouth communicates, eats, smiles, frowns, and makes silly faces,” said Colville.

“Our mouth and teeth allow us to show emotion, communicate our thoughts, and be human. With proper oral health, our mouth can do all of these things better.”

Kathy Colville’s Ideas for High Quality Oral Health Care

• Clinically Advanced
• Culturally-Attuned
• Accessible
• Integrated with Overall Health and Social Care
• Starts with “Oral Health Home” by Age 1
• Based in Trusting Relationships Aligned with Patient Values and Mutual Respect

Medicaid Expansion and Dental Reimbursement Rates

Medicaid was a heavily discussed topic during the panel and Q&A portions of Oral Health Day 2023.

“Medicaid reimbursement rates are frozen in time,” said Rhonda Stephens, Acting Section Chief and Dental Public Health Residency Director at the North Carolina Department of Health and Human Services, Oral Health Section. “The rates have barely increased since 2007 and have not increased with inflation.”

With low Medicaid reimbursement, there isn’t much of an incentive for private practices to accept Medicaid insurance. This means individuals on Medicaid have difficulty finding providers which leads to less frequent visits and sub-par oral health.

Medicaid Expansion is also a topic on the horizon for North Carolina oral health providers.

More than 600,000 North Carolina residents are set to gain access to oral health care through Medicaid Expansion. The impact that could have is huge for individuals as well as providers.

For individuals, they will have new opportunity to receive the care they deserve.

For providers, they will need to increase their capacity to be able to serve increased demand.

Improving North Carolina’s Dental Workforce

In order to effectively care for everyone who needs oral health services in North Carolina, the state needs an adequate workforce and infrastructure in place.

As Colville said during her keynote, our current system is inadequate, forcing exceptional people to move mountains to keep it running. Safety net providers make daily sacrifices and work long, grueling hours to care for those in need, creating a system fraught with high turnover rates and difficulty hiring staff.

The panelists brought up topics like flexible hours, more focus on work-life balance, “4/10” work schedules as ways to ensure the existing workforce is better supported. They also discussed the importance of exposing more high school and college students to the dental field and the opportunities within it to help support workforce growth.

Trust in Communities

This year’s Oral Health Day speakers brought up several points about building trust in communities, discussing how essential trust is to ensuring patients get the care they need.

From speaking intentionally and accounting for anxiety, fear, and shame to personalizing care and becoming part of your community, they offered many strategies to build trust with the people providers serve.

Teeth Are Important!

Teeth are important. North Carolina needs better infrastructure so exceptional people do not have to continue holding up an inadequate system. Looking forward, several opportunities are on the horizon as we look past Oral Health Day 2023.

First and foremost, NCIOM and NCOHC have partnered on the Oral Health Transformation Initiative, a multi-sector task force to evaluate, assess, and recommend potential options regarding oral health system transformation.

Since January, 2022, the Oral Health Transformation Task Force has brought together key oral and health care stakeholders, policymakers, academics, and other influencers in the collaborative design, development, and messaging of oral health care transformation opportunities in North Carolina.

In the coming months the task force will be releasing a final report with their findings and recommendations for North Carolina. To learn more about the task force, click here.

For years, Medicaid Expansion in North Carolina has been health advocates’ proverbial white whale. When it comes to policy changes that could dramatically improve access and equity in health care across the board, Medicaid Expansion would be a huge step in a positive direction.

North Carolina has unfortunately remained among the 11 states across the country that haven’t expanded Medicaid since its enabling federal legislation, the Affordable Care Act (ACA), was signed into law in 2010.

A Fresh Opportunity for Medicaid Expansion

As the 2023-2024 legislative session kicks off, members of the state House of Representatives are striking a new tune. On Feb. 8, 2023, Three Republican representatives and one Democrat filed House Bill 76, which will expand Medicaid in the state if passed into law.

A bipartisan group of 49 legislators had signed onto the bill as co-sponsors. On Feb 15, the bill passed its first two votes in the North Carolina House before passing its third and final vote on Feb 16. Now, the legislation is in the North Carolina Senate’s hands. If it passes through the upper chamber, it will head to Governor Roy Cooper’s desk to be signed into law.

North Carolina is one of 26 states (including Washington, D.C.) to offer extensive oral health benefits to both children and adults with Medicaid insurance. Because of this, anyone who gains coverage under Medicaid Expansion would gain oral health benefits.

What is the Coverage Gap?

The ACA enabled Americans to purchase health insurance through a government-managed marketplace, known as the “exchange.” To qualify for health insurance and tax credits through the exchange, individuals or families must earn enough income to be at or above the federal poverty level (FPL).

In North Carolina, Medicaid insurance only kicks in at or under 42 percent of the FPL, meaning anyone between 43 and 100 percent of the FPL have no options for health insurance. This is the coverage gap.

For example, a single parent with one child would need to earn $18,310 per year to qualify for tax credits and health insurance through the exchange. If they earn less than $18,310 but more than $7,240, however, no insurance options would be available.

Source: Care4Carolina

Medicaid Expansion was a provision of the ACA. Unlike the exchange, expansion was made voluntary on a state-by-state basis. States that choose to expand Medicaid fill in that gap, offering Medicaid services to anyone up to 100 percent of the FPL.

By The Numbers: Expansion’s Potential for North Carolina Health

More than 500,000 North Carolinians stand to gain health coverage if Medicaid Expansion is passed. Of those who would gain coverage, more than three quarters are employed and one in three are parents.

Financially, North Carolina stands to gain significantly if it closes the health care coverage gap. By expanding Medicaid, North Carolina could:

Create 37,200 jobs

Bring $4 billion in federal funding into the state every year

Save businesses $1,685 in lost productivity per employee per year

A Long Road Ahead for 2023 Medicaid Expansion

Senate Majority Leader Phil Berger has signaled that his chamber may not be as eager to take up the House’s version of Medicaid Expansion. There are several provisions that appeared alongside expansion in a Senate proposal during the 2021-2022 session that are not part of this year’s bill.

As House Bill 76 moves through the chambers, elected officials will have several chances to add or amend the legislation’s text. The NCOHC team is tracking this legislation and will post updates as it moves forward, so be sure to stay tuned for updates.

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.

Goodbye 2022, hello 2023! What a year…

From a loooooong midterm election season to the World Cup, inflation, the war in Ukraine, the continuation of the COVID-19 pandemic, and so much more, there has been a lot on our minds. So much so that it is difficult at times to remember the accomplishments we all certainly made throughout the year.

Here’s a snapshot of NCOHC’s 2022. Our coalition of oral health advocates accomplished a lot, but there is always more to do as we usher in 2023.

Oral Health Day 2022

We decided to go big for Oral Health Day 2022, tackling the topic, “Equity in Action,” to try and define how we can all work toward a more accessible oral health system.

Dr. Eleanor Fleming gave the keynote address, highlighting systemic factors that impact our teeth and the need for antiracist collaboration to overcome barriers to care.

Oral Health Day attendees heard from a lively panel featuring providers, payers, government, and community members discussing their personal experiences and paths forward toward an improved oral health system.

Oral Health Day 2022 was the first to span two days. On the second day, NCOHC invited all participants to a collaborative workshop where we worked together to identify actionable policy solutions to oral health inequities.

Altogether, we were beyond impressed with the engagement and collaboration we witnessed over the course of Oral Health Day 2022, and we are excited to see that groundwork come to fruition in the coming years!

Student Partnerships Galore

NCOHC was fortunate to work with so many incredible student interns this year. You’ve probably already seen some of their work, and you will continue to see their content published in 2023.

Amber Moholehski – Amber returned to NCOHC after a prior internship through Campbell University. This past spring and summer, she worked on analyzing the existing landscape for dental assisting education in North Carolina, identifying key needs and options for future policy advocacy.

Sydney Patterson – Sydney is a public health student at East Carolina University. She joined NCOHC this past summer to write blog posts about various oral public health topics.

Parth Patel and Nidhi Oruganti – Parth and Nidhi worked together this past summer to explore North Carolina’s Medicaid system and innovative ways to incentivize more private practice providers to participate. Both Parth and Nidhi are undergraduate students at UNC-Chapel Hill.

Bryan Francis – Bryan worked with us during her fall semester to expand upon Parth and Nidhi’s summer work. She focused on policy pathways to expand and enhance the existing dental safety net. Expect to see more from Bryan, Parth, and Nidhi’s work in 2023!

Campbell University 2022 Cohort – Every year NCOHC has the pleasure of working with a cohort of Campbell University public health students. This year, Austin Blake, Juniki Langle, Jordan Moseley, and Matthew Pacofsky worked with us to explore dentist-administered HPV vaccines.

COrHT Initiative

In 2022, NCOHC and the CareQuest Institute for Oral Health fully launched the Community Oral Health Transformation (COrHT) Initiative in North Carolina. With 14 clinics onboarded into the program, we are putting resources into communities across our state to explore a value-based model of care. We hope this initiative sets the stage for evidence-based policy reform to structurally improve access and equity in oral health care for everyone in North Carolina.

Oral Health Transformation Initiative

Beginning in January 2022, NCOHC launched another initiative in partnership with the North Carolina Institute of Medicine (NCIOM). The Oral Health Transformation Initiative is currently in its second phase, where a task force is engaging in a 12-month evaluation of oral health transformation models from across the United States.

You can expect this task force to wrap up its work in 2023, with a full report on its findings to follow.

Oral Surgery Mini-Residency

In a continued effort to better equip our existing oral health safety net providers to meet the comprehensive needs of the people they serve, NCOHC partnered with the Mountain Area Health Education Center (MAHEC) to launch a mini-residency program.

This program will “train up” existing safety net dental teams, equipping providers with the confidence to offer more complex surgeries themselves rather than referring patients to specialists. For uninsured people and those with Medicaid insurance, accessible specialist care can be incredibly difficult to find.

In 2023, the first mini-residency cohort will begin their studies at MAHEC’s western North Carolina (WNC) facilities.

Patient Advocate Pilot

NCOHC solidified the framework for its Patient Advocate Pilot Program, which will fully launch in 2023. Across WNC, four practices have worked with NCOHC to prepare contracts and set the groundwork to hire “patient advocates,” employees who will help people navigate the system and access the care they need.

Brush Book Bed

Wrapping up nearly two years of planning, NCOHC was able to launch a pilot Brush, Book, Bed program with five pediatric primary care practices in WNC. NCOHC and its partner organization, Reach out and Read, were able to provide thousands of books and oral health kits to these practices, which were trained to provide basic oral health education and fluoride varnishes to their early childhood patients.

The End of a Productive Legislative Biennium

2023 marks the beginning of a newly elected legislature in North Carolina. NCOHC is excited to build upon many legislative wins from the past two years, from Executive Order 193 authorizing dentists to join the COVID-19 vaccination effort to Session Law 2021-95 and the state budget’s extension of the North Carolina Medicaid for Pregnant Women (MPW) program.

In 2023, we look forward to working with legislative and advocacy partners to continue improving the oral health status of all in our state.

Looking Forward to 2023

As we reflect on 2022, we are humbled by the incredible partnerships and coalitions we have the opportunity to be a part of. Our goal is to create a North Carolina where everyone can access the care they deserve, and 2022 represented many steps in that direction.

There is still so much work to be done, but we are entering 2023 confident and energized for what is to come!

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.

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.

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.

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.

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.

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.

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.