NCOHC hosted Oral Health Day 2021 on July 21st, featuring a speaker lineup with nationwide recognition, including a keynote address from the United States Assistant Surgeon General. If you missed the event, you can watch it in full here.
RADM Timothy L. Ricks, DMD, MPH, FICD, Assistant Surgeon General and Chief Dental Officer of the United States Public Health Service (USPHS), gave the keynote address at this year’s event.
RADM Ricks started with an overview of the many roles the USPHS plays in advancing health and safety across the nation and abroad. He spoke about the different branches of the federal government where dentists serve, including the Department of Justice, the Department of Homeland Security, and the Department of Health and Human Services.
RADM Ricks went on to discuss the federal government’s COVID-19 response and how dentists have joined the effort to vaccinate the American public against the virus. He also discussed the impact that COVID-19 has had on dental care for the uninsured.
RADM Ricks gave the Oral Health Day audience an overview of equity and what it means in the dental world. Be sure to check out the 19-minute mark of the Oral Health Day recording for his breakdown of oral health disparities across the lifespan by race/ethnicity and income.
Dr. Martin, Chair of the Department of Stomatology and Director of the Division of Population Oral Health at the Medical University of South Carolina (MUSC), spoke at Oral Health Day about the innovative ways MUSC is approaching community-based care.
Dr. Martin gave an overview of children’s oral health efforts in rural South Carolina, including how MUSC has engaged in partnerships to develop school-based oral health programs. She also discussed engaging school nurses as local champions to improve oral health services before discussing policy priorities, and the importance of advocacy and influence to improve oral health care.
Dr. Donigan and Ms. Boughman wrapped up the event, speaking about the success that Kintegra Health, a clinic in Gaston County, North Carolina, has experienced since they began employing patient navigators.
Dr. Donigan discussed patient navigators, giving the audience an overview of Kintegra Health’s patient flow before and after hiring a navigator toward the end of 2016. At their Statesville location, 47 new patients crossed over from Kintegra’s pediatric medical facility to its dental facility in 2016. After bringing on a patient navigator, they had 50 new patients in one month alone! Between 2012 and 2016, 4,584 new patients visited Kintegra’s Statesville dental facility.
Boughman, who Dr. Donigan considers to be “the original CDHC in North Carolina,” followed up with a brief talk about some of the specific experiences she has had working with children through Kintegra Health’s school-based program.
Dr. Kelly Bailey is a student at UNC-Chapel Hill pursuing a Master of Public Health degree. She has a unique perspective on the intersection between the environment and health, and this summer she worked with NCOHC to develop educational resources for dental professionals on issues related to PFAS contamination and cannabis legalization.
Can you tell me a bit about your career/education path prior to pursuing your current degree?
I graduated from the University of Florida with a bachelors degree in Microbiology and then went on to complete professional training at the University of Maryland School of Dentistry. I was incredibly fortunate to receive a scholarship through the U.S. Navy Health Professions Scholarship Program (HPSP). After graduating from dental school, I went on to serve in the military for eight years.
Where are you in school, what are you studying, and why did you choose that program?
I am currently entering my second year in the Master of Public Health (MPH) program at UNC Gillings School of Global Public Health, with a concentration in Environmental Health Solutions (EHS).
I chose the EHS concentration based on my interest in environmental justice, which is entangled in many of the “wicked issues” of our time, including oral health inequities. The environment and humanity are interdependent, and I think we are becoming increasingly aware of our connectedness to the natural world and to each other on a global level. We are all impacted by the environments in which we live, work, learn, and play, and I believe that a shift toward whole-person healthcare must incorporate environmental determinants of health to comprehensively address these pressing public health issues.
Where did you first hear about the North Carolina Oral Health Collaborative, and why did you want to pursue an internship with NCOHC?
During a dental health policy and management course, I had the pleasure of hearing Dr. Zachary Brian speak on barriers to dental care access in NC. It didn’t take much research on NCOHC afterwards to realize that their team is a small but mighty coalition of innovators and change-makers! NCOHC has been a leader in the advocacy space, fighting systemic barriers to dental care access through policy reform and education, and their group has catalyzed some really impactful changes in NC. Who wouldn’t want to be a part of that movement!?
What about public health dentistry is intriguing to you?
The dental public health (DPH) community is fundamental to leading the dental profession outside of its traditional silo and into integrated healthcare. From utilizing teledentistry services, to administering vaccines, to playing a role in natural disaster response, I think the profession’s scope of practice will continue to evolve in ways that foster multidisciplinary collaboration and improve the wellbeing of all North Carolinians. It’s an exciting time to be in DPH!
What’s a fun fact about yourself?
While overseas with the military, I traveled by ship to eight different countries and even lived in the beautiful country of Japan for two years. It was the experience of a lifetime for sure.
Tell me a bit about what you have worked on as an NCOHC intern. What do you hope to take away from the work you have been doing?
First, I was able to take a deeper dive into the PFAS contamination issue in North Carolina as it relates to oral and systemic health. Although this is a very well-publicized situation, I think there are certain connections that dental providers and dental public health professionals should be guided in making. PFAS contamination in drinking water is affecting most, if not all, of our patients, so we need to understand what we’re up against and what we can do as individuals and as a profession.
Secondly, I explored the topic of cannabis use in North Carolina. With several bills in legislation in NC, and legalization having been pushed through in VA, I think it’s really important to get clinical providers and public health professionals talking about cannabis use as it relates to patient health and the dental practice. There are still many unknowns about the long-term effects of cannabis use, but we already know a lot about cannabis-related racial stigmatization and it needs to be addressed within our community. The education we provide to patients should always be driven by a desire to heal, not to impose political beliefs.
If you could tell North Carolinians one thing you have learned that you think is important for everyone to know, what would that be?
Despite being largely preventable, oral conditions like dental caries and periodontal disease continue to threaten the overall health of too many North Carolinians, with disparate access to oral care services being one driver of this “silent epidemic.” For those who want to learn more, NCOHC is doing a lot of work in this area and has reader-friendly posts on their website. Also, Mary Otto’s book, “Teeth: The Story of Beautify, Inequality, and the Struggle for Oral Health in America,” is a great reference for better understanding the issues.
Denial of, or ignorance about, oral health inequities is still pervasive, and the dental community is not immune to this occurrence. I think this sums it up nicely and is a good reminder to all of us:
“When we’re not hungry for justice, it’s usually because we’re too full with privilege.” – Carlos A. Rodriguez
What’s next for you?
I will be applying to the DPH residency program, based in the NCDHHS Oral Health Section, in hopes of joining the phenomenal community of DPH researchers, academics, and leadership professionals. Ultimately, I’m hoping to apply my skills within a community-based organization or at the state level.
We can acknowledge it. “Oral health policy advocacy” is not exactly something you hear every day, right? Imagine meeting new people at a party (fully vaccinated and masked, of course) and telling them, “I work in oral health. Not in a dental office, but in structural reform and policy advocacy.” You would get a few quizzical head tilts.
However, policy advocacy is incredibly important in our work to increase equity and access to oral health care. Plus, to effectively impact policy, those of us who are already engaged need to bring more people into the conversation. We need broad coalitions working for change to see better policy take hold, so it’s worth asking the question:
“So, how can policy impact my teeth?”
Let’s start by laying out the ways you can keep your mouth healthy.
First is hygiene. Maintaining healthy habits at home is the best way to prevent tooth decay and gum disease.
Next comes professional care. Everyone should see a dentist at a regular interval for a cleaning and checkup. That interval may vary for some, but usually, it is recommended that you see a dentist twice each year.
These seem like simple steps, but everyone has different levels of access to oral health resources, and different levels of understanding when it comes to good oral health habits.
So, how does policy fit in?
What if you don’t have dental insurance or don’t have transportation to get to the dentist? Or, what if you want to improve your habits, but are struggling to wade through mountains of misinformation to figure out if you should use fluoride toothpaste?
Under our current structure, good oral health relies in so many ways on variables that one may not always be able to control. That’s where policy reform can make a difference.
Take school-based care as an example. In underserved communities across North Carolina, dental programs that go into schools at regular intervals can provide children with the regular oral health care services they may not otherwise receive.
That care can help maintain good oral health during a child’s formative years, and it can help build healthy habits that last a lifetime. And in these settings, transportation and many other barriers are taken out of the equation.
Unfortunately, however, there remain policy barriers to expanding school-based access. School-based oral health programs rely heavily on dental hygienists, and North Carolina law can limit the type and how these services are delivered.
Many duties delegated to hygienists require a dentist to be physically present on site. Dentists generally need to be in their brick-and-mortar facility, limiting opportunities for hygienists to get out into community and provide care in settings like elementary schools.
Policy changes that allow hygienists to practice with in community-based settings — an opportunity with increasing validity given advances in teledentistry technology — and policy changes to increase the number of hygienists a dentist can supervise, among others, could significantly expand access to oral health care in non-traditional formats.
For example, a regulatory rule change in 2020 now allows public health hygienists in provider shortage areas to offer more services in non-traditional settings such as schools, without a prior exam from a dentist.
Policy can also increase efficiency in the dental office. Currently, legislation in the North Carolina General Assembly would allow dental hygienists to administer local anesthesia. This clinical function, which has already been delegated to hygienists in 44 other states and Washington D.C., would help practices increase efficiency, reduce costs, and care for more patients.
“But I have dental insurance and maintain good habits. Why should I care about policy?”
Proactive policy is not just a moral cause. Having more people experiencing good oral health is valuable in and of itself, but that reality carries positive impacts far beyond the individuals who are directly affected.
Treatments for preventable health conditions account for 75 percent of all health care spending in the U.S., and we only spend around 5 percent of health care dollars on preventive efforts. There is a huge opportunity to save money simply by boosting preventive efforts and warding off poor health conditions like tooth decay and gum disease before they can take hold.
What happens when someone with no insurance has a toothache? More often than not, that person will go to a hospital emergency department, where their pain may be managed but the source of the problem is not addressed. They may leave with a large hospital bill and likely another hospital visit in the near future if they are unable to seek care from a dentist.
If that individual can’t afford the hospital tab, the bill goes unpaid. Nationwide, uncompensated care costs add up to $42.4 billion every year. Nearly 80 percent of those dollars are eventually paid by taxpayers.
In the dental office, one experience, good or bad, can have a lasting impact. For too many people, negative experiences add up over time, travel through the grapevine, and lead to anxiety, fear, and shame that put up walls between entire communities and the care they deserve.
And as is the case for so many social determinants of health, race and racism are inextricably intertwined.
“We lived on the wrong side of the tracks being African American. There was only one dentist that I remember who was even available to us. I didn’t know what a dentist was. I didn’t know what a dentist did,” Carol said. “To the best of my memory, which was many years ago—in the mind of a child—I just remember his pulling on something in my mouth. Pulling back and forth with what looked like a pair of pliers. I screamed, I screamed at the top of my lungs because it hurt so much. And I didn’t want to go to the dentist anymore for the rest of my life.”
Carol had a traumatic experience in a dental office early in life that led to an unimaginable amount of pain. Pain that continued throughout childhood, perpetuated by a fear of returning to the dentist when cavities or other issues arose.
“Whenever I would have a toothache, I wouldn’t tell my mom. And if I had a cavity, I couldn’t sleep at night. I couldn’t rest well. It impacted my chewing, my swallowing, and my overall health because I would have pain in my ears and down the side of my neck,” she said. “But I was so scared. I was scared to experience the pain at the dentist again.”
In her community, Carol wasn’t the only one with a fear of the dental office.
“Stories travel. Stories travel really quickly. And bad stories travel much faster than the good ones. So not only did we know to be afraid of the dentist — and of course he was white, and we were all Black — not only to be afraid of this white man with this chair and this stuff in his office, but also that he hurt children, and he hurt adults. It really kept people from wanting to get the help they needed because of the physical pain.”
A Barrier to Access
Carol story isn’t a relic of the past. The same kind of fear she experienced as a child grips others today, and anxiety, fear, and shame around dental care is still a serious barrier preventing access.
“What I can tell you unfortunately is that there are many stories that are similar to mine in today’s time. That is true for dental care, and it is true across the board,” said Carol. “One, people are already afraid. Two, people don’t have to treat you well. This thing with Black Lives Matter, it’s not new. This thing with institutional and structural racism, it’s not new.”
But just as much as negative experiences can leave traumatic imprints, positive experiences can change entire outlooks on oral health care.
Carol said, “When I started going to the dentist here (in North Carolina), he had a sign in his office that said, ‘we cater to cowards.’ I said, ‘good, because that’s me!’ I told him about my experience, and he said, ‘you won’t experience anything like that here.’ His mannerisms were engaging, he would come into the room smiling and ask me what I had been up to. We would talk, and it was a whole different atmosphere. I started going twice a year, using my preventive care.”
Dentists can play an important role in helping those who are experiencing anxiety, fear, and shame, just by taking the time to understand the range of experiences that their patients may bring into the dental office.
A Willingness to Listen and Learn
“I think it’s really important for dentists to make sure they are getting outside of their comfort zone and their group, even if it’s a professional setting, to talk about things like structural racism,” said Carol. “It’s important to get into groups with folks like myself where we can talk openly and share stories and they can ask questions. And also, if they have patients who come in, just being willing to learn, being willing to listen, and being willing to talk.”
“Provide that openness, because when a person has been privileged, they really don’t know,” she said. “An example is in my family, education is a big deal. Everybody in my family did public speaking. So, when it was my turn and I was two or three I just jumped up and I did it too, because that’s what we do. I say that as an example of the fact that I didn’t know that I was supposed to be afraid of public speaking. I have been fortunate for something to be natural to me that may not be natural to most people. So just because someone has white privilege does not mean that there aren’t opportunities to learn. There are opportunities to learn.”
An Opportunity for Change
At NCOHC, we work to ensure that everyone — no matter their background, where they live, or who they are — has access to quality, affordable oral health care. We thought that Carol’s story was an important one to tell to highlight just how serious anxiety, fear, and shame as social determinants of health can be.
Is her story an indictment of dentists? No. But is it something we believe all dentists could learn from? Absolutely. The humility to step outside of your comfort zone and experience someone else’s truth can be difficult, but it can also help providers change patients’ lives.
Your furry friends need regular oral health care, just like you. Unfortunately, good information can be hard to find, care can be expensive, and too many people simply don’t know what they should be doing to keep their pets’ mouths happy and healthy.
Dr. Lenin Arturo Villamizar-Martinez, DVM, MS, PhD, Dipl. AVDC, is a board-certified dentist, head of the Dentistry and Oral Surgery Service of the Veterinary Teaching Hospital at the North Carolina State University College of Veterinary Medicine.
Dr. Villamizar-Martinez sat down with us at NCOHC to talk about animals, their mouths, and what best practices pet owners should be aware of.
What should people know about their pets and their mouths?
“The first thing that the owner needs to know is to brush their pets’ teeth daily,” said Dr. Villamizar-Martinez. “The teeth in dogs are equal to teeth in humans.”
He said that humans do tend to have more issues with cavities than their pets, but around 80 to 85 percent of dogs have periodontal (gum) disease. Regular brushing can help prevent gum disease and other issues that lead to expensive treatments down the road.
According to Dr. Villamizar-Martinez, choosing your pets’ toys wisely is another way to ensure that they maintain good oral health.
“There are a lot of products on the market for chewing,” he said. “Something that we recommend is to use any toy that you can make an indentation in with your fingernail. That toy will be soft enough to not cause a fracture on the teeth—that is a problem that we see a lot of.”
Softer toys will also rub your pets’ teeth when they are chewing, helping remove dental plaque. Harder toys like bones, on the other hand, can end up causing serious issues that lead to costly procedures.
“Research shows that these kinds of toys (bones and other hard toys) are related to complicating crown fractures, and at this point the only treatment that exists is to do root canal therapy or to extract the tooth,” said Dr. Villamizar-Martinez. “And that is expensive. When we are talking about root canal therapy, that ranges between $1,500 and $3,000. You can avoid that just by picking good toys for your dogs and cats.”
Before you jump up and search for new toothpaste or replacement toys online, Dr. Villamizar-Martinez said that there is a lot of inaccurate information on the internet. It can be hard to figure out what is actually good or bad for your pets online, and it is always better to ask for advice from your primary veterinarian.
He also recommends that pet owners visit the Veterinary Oral Health Council’s website. The VOHC reviews pet products and publishes lists of everything from pet toothpastes to toys, treats, and food that meet good oral health standards.
So, my dog is no longer a puppy (or my cat is no longer a kitten) and they aren’t used to having their teeth brushed. What do I do now?
“I’m living that experience right now,” said Dr. Villamizar-Martinez, talking about his newly adopted six-year-old dog, who never had his teeth brushed before.
He recommended to start by taking your pet in for a professional dental cleaning if possible.
“The first thing I did was put him under general anesthesia and did a professional dental cleaning,” said Dr. Villamizar-Martinez. “Then I said, ‘Now I need to start brushing her teeth !’”
He said the easiest way to start brushing a pet’s teeth is to use your finger first, mimicking the brushing motions you will eventually use a toothbrush for.
“After two or three weeks, your dog will know that it is normal and good, then you can move to a toothbrush,” said Dr. Villamizar-Martinez.
What do I do if I think my pet has an issue in their mouth?
“First, go to your primary veterinarian,” said Dr. Villamizar-Martinez.
General practice veterinarians can diagnose most oral disease, and they can run any blood tests or other diagnostics that may be necessary. If your pet has an issue, the veterinarian will be able to point you in the right direction for next steps.
Dr. Villamizar-Martinez said that many general practice veterinarians are trained to do professional dental cleanings and extractions if necessary. If your pet’s needs are more complex, your veterinarian should be able to recommend a veterinary dental specialist.
If you do find yourself taking your pet in for an oral procedure, Dr. Villamizar-Martinez said to make sure to only go to specialists who offer procedures under general anesthesia. A quick Google search will reveal many specialists who offer “anesthesia-free” procedures, but they are generally only cosmetic fixes that don’t fix the root of your pet’s disease. In many cases, Dr. Villamizar-Martinez said that these kinds of procedures can even make problems worse.
What about the cost of care?
Specialist veterinary procedures can be expensive, and unfortunately there aren’t many resources available for pet owners with financial constraints.
“Prevention is the most important thing at this point,” said Dr. Villamizar-Martinez. “That is the number one thing that is going to help.”
Dr. Villamizar-Martinez said that the NCSU College of Veterinary Medicine has been planning to start a program to offer veterinary solutions for shelter and rescue organizations that can’t afford to pay.
“We were thinking of adding some kind of pet dental care for shelters and rescue organizations who don’t have financial resources,” said Dr. Villamizar-Martinez. “Dr. Kelli Ferris, one of our faculty, directs our Mobile Veterinary Hospital. Veterinary students under Dr. Ferris’ supervision perform spay and neuter procedures. We were planning to incorporate dentistry, but the pandemic got in the way, at least for now.”
Oral health providers: Make sure to scroll to the bottom of this post to learn more about a school-based oral health grant opportunity from The Duke Endowment, the Blue Cross and Blue Shield of North Carolina Foundation, and the Blue Cross and Blue Shield of South Carolina Foundation
The COVID-19 pandemic has offered many lessons for public health, one of the greatest being the importance of “meeting people where they are.” Whether it be serving patients remotely via teledentistry or enabling dentists to deliver COVID-19 vaccinations, the oral health care community has shown resilience and innovation in expanding access to care during the pandemic.
Yet there are many more opportunities to increase access and equity in oral health care, both during and post-pandemic. One of these opportunities is expanding school-based dental programs.
In this post, we’ll take a look at school-based dental programs — what they are, why they’re needed, and how they can transform overall health in North Carolina by increasing access to oral health care for some of our state’s most vulnerable populations.
What Are School-Based Dental Programs?
School-based dental programs provide a range of oral health care services directly to students. While the extent of services offered varies, every school-based dental program brings care into the community, providing access to oral health care that many vulnerable populations may otherwise be denied.
Some school-based dental programs utilize fixed equipment in schools, while others rely on mobile clinics parked on school property. Services provided may include, but are not necessarily limited to:
Oral screenings and risk assessments
Fluoride varnish applications
Dental sealant applications
Oral hygiene instruction
Nutrition and/or tobacco counseling
Above all, the configuration of school-based dental programs is flexible, and there are impactful ways to meet communities’ needs across all types of clinical models (more on this a little later).
In particular, school-based dental programs are uniquely positioned to address the social determinants of health, many of which present significant barriers to oral health care for school-aged children. The success of these programs in driving positive oral health outcomes is also well-documented, as we will explore further in this post.
“School-based health programs can level the playing field for children otherwise unable to access oral health care services,” says Dr. Zachary Brian, director of the North Carolina Oral Health Care Collaborative (NCOHC), a program of the Foundation for Health Leadership and Innovation (FHLI). “These programs offer an approach that can significantly increase access and equity for children across our state.”
The Need for School-Based Dental Programs
The need for improving access to oral health care for children in the United States is starkly evident, as is the opportunity for school-based dental programs to address disparities and barriers faced by at-risk populations.
Dental caries (cavities) is the most common chronic disease among U.S. children, according to the U.S. Department of Health and Human Services. According to the Centers for Disease Control and Prevention (CDC), roughly 52 percent of U.S. children have had a cavity in their baby teeth by the time they are eight years old.
In North Carolina, almost 50 percent of schoolchildren have tooth decay, according to the NC Department of Health and Human Services, Oral Health Section.
Disparities in oral health status between socioeconomic groups are also widespread. The CDC reports that low-income children are twice as likely to have cavities as higher-income children. In North Carolina, the picture is just as bleak. According to an analysis by NC Child, “children from poor, rural counties [in North Carolina] tend to have the highest rates of decay.”
“We have a high percentage of schools with students who get free and reduced lunches. We have some schools where 100 percent of our students receive that free lunch because of how many of them qualify under the federal poverty level,” said Dr. Elly Steel, dental clinical director at the Cabarrus Health Alliance, which has operated a school-based program since 1999. “With these children who aren’t getting access to care in other places, bringing the care to them at their schools is really helpful.”
Oral health plays an important role, not only in children’s overall systemic health, but also in their well-being and social development. The CDC reports that, “on average, 34 million school hours are lost each year because of unplanned (emergency) dental care.”
The data in North Carolina is similarly damning, with an analysis finding that “children with poor oral health status were nearly 3 times more likely … than were their counterparts to miss school as a result of dental pain.” The study concluded that children with poor oral health status were also more likely to perform more poorly in school.
Oral health is also integrally connected with a child’s self-esteem and behavioral health: one recent study found that “various dental disorders … cause a profound impact on aesthetics and psychosocial behavior of adolescents, thus affecting their self-esteem.”
Social Determinants of Health
The social determinants of health are significant factors driving disparities in access and outcomes for North Carolina’s school-age children. Parents and caregivers often lack access to reliable transportation to take children to and from dental appointments. And even when transportation is available, however, it may be impossible to get time off work.
Location also plays a major role, with access to oral health care significantly more limited for those living in rural areas. In North Carolina, dental providers are highly concentrated in urban centers; 98+ of the state’s 100 counties are designated as Dental Health Professional Shortage Areas (dHPSAs) by the Health Resources and Services Administration (HRSA).
Why School-Based Dental Programs for North Carolina?
The need is apparent, and while efforts to improve and sustain surveillance and evaluation in oral health care have been undertaken in North Carolina, the state lacks an adequate system to provide direct preventive services and closed-loop referral for comprehensive oral health care for at-risk populations. School-based dental programs can fill critical gaps in that system by meeting people where they are and reducing barriers to care influenced by the social determinants of health.
Increasing Access, Improving Outcomes
More than 2,500 school-based health centers (SBHCs) are operating in the United States, with only an estimated 28 percent having an oral health care provider on site, according to a report in Health Affairs.
The research increasingly supports the effectiveness of these programs improving access and oral health status among U.S. children. A 2021 study published in the Journal of the American Dental Association (JADA) determined that bringing cavity-prevention programs directly into school settings reduced cavities by 50 percent, after only six visits.
“Our hygienist who works more directly in the mouth is seeing a huge improvement in many of the children that are returning for repeat visits,” said Rachel Stewart, a registered dental hygienist who works for the East Carolina University School of Dental Medicine on a school-based initiative in Bertie County, North Carolina. “Their oral hygiene is improving, they’re taking more pride in their teeth, and their teeth are looking cleaner and better.”
A 2016 study of school-based dental sealant programs also demonstrated similar effectiveness among schoolchildren in low socioeconomic areas.
School-based dental programs are cost-effective, too. A recent report concluded that “the cost to place sealants on a child in a SBSP [school-based sealant program] is approximately $100 compared with the lifetime cost to maintain a tooth that develops caries, which can exceed $2,000.”
Researchers have also estimated that implementing a national school-based caries prevention program “could reduce Medicaid spending on children’s oral health by as much as one-half.”
Dental Hygiene Workforce
North Carolina’s oral health care workforce is well-equipped to provide preventive services in school-based settings. Dental hygienists in North Carolina are highly trained, skilled, and engaged, and there is ample opportunity to leverage this expertise and experience in school-based dental programs.
Recent regulatory changes, including a change to Rule 21 NCAC 16W .0104, co-sponsored by NCOHC in 2020, aims to provide greater opportunity for dental hygienists to deliver preventive services in high-need settings such as school-based programs. These changes allow for dental hygienists to deliver preventive services in high-needs settings without a prior examination by a dentist, therefore amplifying service delivery and decreasing administrative burden. Other potential legislative changes, such as increasing the dentist to hygienist supervision ratio, could also prove similarly helpful.
The Next Step
Recently, The Duke Endowment has partnered with the Blue Cross Blue Shield of North Carolina Foundation and the Blue Cross Blue Shield of South Carolina Foundation to expand school-based dental programs across the Carolinas. Collectively investing more than $35 million, these groups are supporting dental safety-net health centers in implementing school-based dental programs in North Carolina and South Carolina.
“This initiative is a revolutionary opportunity to increase access and equity and improve oral health outcomes among schoolchildren in the Carolinas,” says Dr. Brian. “With the support of The Duke Endowment, the Blue Cross Blue Shield of North Carolina Foundation, and the Blue Cross Blue Shield of South Carolina Foundation, North and South Carolina can make significant strides in reducing barriers to oral health care and improving oral health outcomes for at-risk populations.”
If you are an oral health care provider or administrator interested in learning more about expanding your practice to serve your communities’ children in school-based settings, we invite you to join us for a free online informational session on either July 27th or August 11th.
In these sessions, in addition to learning about opportunities for community impact through school-based oral health programs, participants will have a chance to learn about the application process and the deadline for funding, as well as hear directly from current grantees about their experiences.
In addition, following the live, interactive learning sessions, participants interested in applying for the next cohort will have an opportunity to engage in 1:1 coaching where you’ll dive into your program ideas and innovative approaches to strengthen your application.
In order to build a more equitable oral health care system for all North Carolinians, it is paramount to pursue policies that encourage the development of a more diverse oral health care workforce.
The pursuit of equity can’t only focus on the patient side of the equation—those who either can or cannot access the care they need. The dental profession has historically struggled with equity, both among patients being able to access the care they need, and among those who train and enter the industry as dentists and other oral health professionals.
White males still represent the majority of dentists, while white females have long dominated the dental hygiene profession. Disproportionate representation by race, ethnicity, and gender is especially predominant among North Carolina dentists and hygienists.
In this blog post, we’ll take a look at the current demographic makeup of the oral health care workforce in the U.S., and in North Carolina specifically. We’ll discuss why provider diversity is so critical and outline potential policy solutions for developing a workforce that looks like the patients it serves.
The Importance of Diversity in the Oral Health Care Workforce
Why does diversity in the oral health care workforce matter?? The answers are many. Research suggests that more diverse racial, ethnic, and gender representation among dental providers can dramatically reduce barriers to access for the underserved and improve oral health care utilization and outcomes.
“Increasing diversity in the dental workforce is more than just the right thing to do,” said Dr. Zachary Brian, director of the North Carolina Oral Health Collaborative. “Its positive impact is also backed by evidence, with greater provider diversity helping increase access and improve utilization and outcomes, particularly for our most underserved communities.”
Beyond clinical outcomes
Diversity among dentists can help build equitable communities
Equity on the employment side of oral health care in and of itself will play an important role in increasing equity in society as a whole. In a previous NCOHC blog post, we spoke with Jen Zuckerman from the Duke World Food Policy Center. Zuckerman pointed out that equity pursuits in any industry shouldn’t be seen as solely aimed toward those able to access the industry’s services or goods.
Those pursuing equity should also ask who is financially benefitting from a given industry. What communities are benefiting from generational wealth accrued by those employed in that industry? For too long throughout American history, communities of color across the board have been structurally left out of many, if not most, opportunities to build generational wealth. From the GI Bill and red lining to college admissions, loans, and more, “the white community has continually gotten investment through policies, programs, and initiatives,” said Zuckerman. “And communities of color have continually gotten programs and services, which do not build wealth.”
At the end of the day, policies that would allow underserved communities to access care are vital, but the numerous social determinants of health that limit access in the first place must be structurally weeded out, too. Income is one incredibly important determinant of health that more diverse employment in high-paying industries like dentistry can significantly impact.
Racial Diversity: A Means to Improve Access, Utilization, and Outcomes
A recent report by the Oral Health Workforce Research Center found that “Improving the racial and ethnic diversity of the nation’s dentists is critical in efforts to reduce disparities in access to care and health outcomes and to better address the oral health needs of an increasingly diverse U.S. population.”
The impact of systemic and interpersonal racism on oral health care is also frequently overlooked: a 2019 study found that “dental visits were less common among those who reported racial discrimination while using the healthcare system or reported emotional impact of discrimination than those who did not.” The same study concluded that “those who experienced the emotional impact of racial discrimination were 25% less likely to have visited the dentist in the past year than those without such experience.”
Studies have also determined that non-white dentists care for a disproportionate number of at-risk patients in minority and underserved communities. Researchers have found that 53 percent of clinically active Black dentists reported primarily treating underserved patients at their primary practice, and another study concluded that “the Hispanic/Latino (H/L) dentist workforce is a critical component of our dental delivery system and is shown to contribute to improved access for H/L populations and underserved populations.”
Increasing racial diversity within the oral health care workforce is therefore imperative for eliminating access barriers, increasing utilization, and improving outcomes.
Gender Diversity: Increasing Access and Offering New Perspective
While there is less research concerning patient preference regarding provider gender (although we can reasonably infer an effect similar to the one revealed in studies on provider race), female dentists are noted for bringing different perspectives and approaches to the practice of dentistry.
For one, studies have shown that female dentists are more likely than male dentists to practice in urban and public health settings, and they are more likely to treat lower-income patients. These findings suggest that increasing gender diversity in the oral health workforce has the potential to improve access to care for our most vulnerable.
Research also suggests that female dentists may be better at encouraging preventive care than their male counterparts. A study published in the Journal of the American Dental Association found that “female dentists recommended at-home fluoride to a significantly larger number of their patients than did male dentists” and “female dentists also chose to use preventive therapy more often at earlier stages of dental caries.”
There is no question that female dentists bring a fresh perspective to a profession long dominated by men. Writing about the increase in female dentists, Dr. Cindy Roark, a dentist herself, notes in an article for Dentistry Today that “at its most basic level, a diverse leadership team means a healthcare organization will naturally have a greater understanding of the populations it serves.”
Where Do We Stand Today? Diversity Among Dentists and Hygienists
By Race and Ethnicity
People of color are greatly underrepresented among the dentist and hygienist workforces. A 2016 study by the American Dental Association’s Health Policy Institute (HPI) found that just 26.4 percent of U.S. dentists were non-white, despite people of color representing 38.7 percent of the total population.
The disparity is even more stark in North Carolina, where according to a recent study, 81.5 percent of dentists are white, despite white people representing only 64.1 percent of the population. Even more disproportionate, North Carolina’s dental hygienists are 92.5 percent white.
Recent trends are more encouraging. According to HPI, “from 2008 to 2018, the percentage of active white dentists [in the United States] decreased from 78.2% to 71.9%.” While Asian and Hispanic dentists made gains, however, alarmingly, the percentage of Black dentists was relatively unchanged.
In addition to being disproportionately white, U.S. dentists are mostly male. According to data compiled by the American Dental Association (ADA), in 2020, 65.5 percent of professionally active dentists were male. Women made up just 35.5 percent. Data derived from the North Carolina State Board of Dental Examiners (NCSBDE) shows that the gap is narrowing in our state, but the disparity remains pronounced.
Among dental hygienists, the gender divide is flipped. While up-to-date data for practicing dental hygienists is hard to come by, the American Dental Education Association (ADEA) reports that 94.7 percent of students currently enrolled in an accredited dental hygiene program are female.
Opportunities for Growth: Supporting Diversity in the Dental Workforce
There is no silver bullet to improve racial and gender diversity in the oral health care workforce. That said, there is no shortage of common-sense, evidence-based policies to help bridge existing gaps and build a dental workforce reflective of the people it serves.
We’ll focus on just two such opportunities in this blog post: early educational interventions and improved recruitment efforts by dental schools.
Early Educational Interventions
Limited awareness of oral health care career opportunities and lack of support for early education and “pipeline” programs present significant barriers to racial minorities and women entering the dental workforce.
Pipeline programs in particular — which provide all-inclusive support in the form of mentorship, scholarships, externships, and/or other opportunities — are fundamental in helping introduce minority students and those from underrepresented communities about dental career opportunities.
Notably, a dental pipeline program funded by the Robert Wood Johnson Foundation made initial grants to 11 dental schools to support community-based education related to opportunities in dentistry for minority and low-income students. A less comprehensive but similar “Saturday Academy” program organized by the NYU School of Dentistry introduces underrepresented minority and low-income high school students to dentistry as a viable career option and offers mentorship.
Policymakers should consider support for similar programs in order to attract a new generation of diverse students to dental education and oral health care careers.
Dental School Recruitment
No less important than efforts to introduce minorities and women to career opportunities in dentistry are dental schools’ own recruitment policies. For too long, dental schools have done little to proactively seek diverse pools of applicants, let alone admit classes that reflect the populations they will one day serve. Researchers have recently noted that “U.S. dental schools’ admission practices present a critical gateway to increased diversity, but the current pipeline of qualified minority applicants is insufficient.”
This is not to say that change isn’t happening. Many dental programs — including North Carolina’s own UNC Adams School of Dentistry and East Carolina University School of Dental Medicine — have taken steps to increase diversity in their dental programs. Data indicate that North Carolina’s dental students more closely mirror the state’s racial composite than does the dental workforce itself. An analysis of dental classes graduating 2015-2019 showed that 36 percent of UNC dental students were non-white, as were 28 percent of ECU dental students.
Potential opportunities to increase recruitment of minority, women, and otherwise underrepresented students by dental schools include, but are not limited to:
Increasing diversity on the interviewing and admissions teams/committees
Increasing diversity among faculty and staff
Emphasizing cultural competency in dental curriculum
Support for dental pipeline programs
Increased financial assistance and scholarship opportunities
In Conclusion: Moral and Practical Imperatives for Diversity in the Dental Workforce
Policymakers have both moral and practical imperatives to increase diversity in the dental workforce. The cause is just, and the science is clear: racial and gender diversity among oral health care providers increases access and improves both utilization and outcomes.
If we are to build a more equitable and accessible oral health care system for all, it is critical that we support the development of a workforce that reflects the populations it serves.
The North Carolina Oral Health Collaborative (NCOHC) is actively working with stakeholders across North Carolina to help develop a more diverse oral health care workforce. For more information on NCOHC and to get involved, please become a member of our advocacy platform, NC4Change — membership is free and there are many opportunities to engage with our work. Together we can build a more equitable and accessible oral health care system for ALL North Carolinians.
Nearly a year ago, NCOHC launched a COVID-19 oral health access map. As dental offices transitioned to only offer emergency services — and while health professionals worked to figure out how to best ensure provider and patient safety — our staff wanted to make sure that those who needed care weren’t left without any idea where to go.
There were several reasons why NCOHC hoped to highlight facilities offering emergency care across North Carolina. First and foremost, tooth decay and gum disease aren’t going to wait for the pandemic to subside. And, as anyone who has ever suffered from a toothache knows, when you have an oral emergency, you want it taken care of fast.
We also know that so many people with dental emergencies seek care at their local hospitals, which often are not equipped to handle that type of care. Even in a non-pandemic world, it is important to divert these patients to facilities that can address their concerns, rather than offer temporary solutions. Especially during a pandemic, however, reducing demand on hospital staff wherever possible is absolutely critical.
Our staff decided that a centralized map would be helpful to anyone who needed care, but didn’t know where to go. We thought a map would be a good resource, but we certainly didn’t think that more than 31,000 people would have viewed it nearly one year later.
But it makes sense. There wasn’t any centralized resource to use to find a provider near you—especially if you need to find affordable options that accept Medicaid or offer care on sliding fee scales.
Now that most offices are open for routine care again, NCOHC has decided to make the Access Map a permanent resource, displaying useful information beyond operating status. If you navigate to the map, you can see hours of operation, service type (kids and adults), and more.
Additionally, in the coming months, NCOHC staff will be updating the map with more information, such as the availability of translation resources.
Last year, soon after the COVID-19 pandemic reached the United States, those of us at NCOHC were working to devise plans in how we would work to contribute to the public health response. We came up with a couple of ideas, including the creation of our safety-net access map and the launch of the NCOHC Teledentistry Fund.
We partnered with the Blue Cross and Blue Shield of North Carolina Foundation (BCBSNC Foundation) to launch the Teledentistry Fund, awarding up to $60,000 in grants for safety-net dental providers geographically spread across NC. So far, the fund has allowed 14 safety-net clinics to purchase teledentistry software, enhancing their ability to provide a wide variety of services with their communities without risking the health of patients and providers alike.
A year later, and we have been blown away by the results.
We recently sat down (virtually) with just a sample of the oral health professionals who received Teledentistry Fund grants to hear about their experiences. Check out the video below to learn how the software helped them navigate the pandemic, and what kind of future they see for remote care technology in a post-pandemic world.
This month NCOHC welcomed a new Program Coordinator. As Sarah Heenan joins the team, we sat down with her to ask a few questions about who she is and what brought her to the world of oral health.
Tell us a little about your background, where you are from, and your educational path.
I am from the Washington, D.C. area originally. I moved to Raleigh in 2004 to pursue a degree in history from Peace College, an all-women’s college at the time. I knew that my life’s work would be realized by working with people from all different life experiences, cultures, and backgrounds. Both personally and professionally, my time at Peace College led me down a road through the higher education landscape, helping students navigate their experiences while advancing the mission of the university. This direction helped me see value in gaining my Master of Arts in Higher Education at Appalachian State University, and eventually I ended up at North Carolina State University. There I learned the value of large public land grant institutions and the value of partnership with statewide organizations to provide needed resources to the people of North Carolina. My eyes were opened to the idea of shifting to the nonprofit world, where making a difference and changing necessary landscapes is at the forefront of the work.
What professional accomplishment before coming to NCOHC are you most proud of?
Building many relationships with both internal colleagues and external partners. A recent partnership I am most proud of is the development and management of the Off Campus Consortium group at NC State. I managed relationships between private off-campus partners and the university to provide the most direct and trusting housing resources to students.
What originally drew you to working in the oral health space?
Making a difference in our society by creating change and helping to provide needed services to the residents of North Carolina.
What has been the most rewarding part of your work with NCOHC thus far?
Working with the staff and learning about all of the work the Oral Health Collaborative engages in to create systemic changes in our state.
What are the biggest challenges that you see facing access and equity in oral health care in North Carolina?
Barriers to access due to the social determinants of health.
What do you enjoy doing when not working?
I enjoy spending time getting my hands in the dirt and working to create useful and beautiful garden spaces for my family and friends to enjoy. When I’m not in the garden, I’m generally building useful furniture made out of scrap materials. My two dogs, Oliver and Sage, and my partner, are always along for wherever the adventure may take us. In the time of the pandemic, because travel was not an option, we have enjoyed watching traveling shows and dreaming about getting overseas when it is safe to do so again.
What do you want our membership to know about you?
That I am a passionate individual who loves people and working hard to make systems more efficient.