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Healthy Oral Care at Home

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

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

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

Use Fluoride Toothpaste AND Mouth Rinse

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

Mind Your Peas and Q’s

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

Figure displaying a smear of toothpaste for children under 3 and a pea sized amount for children and adults 3 and up

Source: American Dental Association

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

Know the Basics of Good Brushing

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

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

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

Change your Brush Regularly

A picture of a frayed toothbrush, with bristles flattened and sticking out in different directions

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

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

Floss Daily

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

Check your Mouth Regularly for Signs of Oral Cancer

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

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

A fact sheet with information about oral cancer and HPV

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

Know How Your Food Affects Your Teeth

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

A graphic of unhealthy food for your teeth: fast food, cereal, sodas and sugary drinks, candies, beer (especially when mixed with tobacco) and starches

A graphic of healthy food for your teeth: leafy greens, fish and lean meats, beans, nuts, seeds, milk and dairy, eggs, and tofu

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

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Social Determinants of Health: How the World Around Us Impacts our Mouths

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

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

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

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

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

Can Pollution Really Impact Oral Health?

A study in the Journal of Clinical Pediatric Dentistry found that hard dental tissue could be an environmental indicator—your teeth can say a lot about the world around you, no pun intended. Children in this study living in high-pollution areas had higher cavity rates and even had significant levels of toxic compounds in their tooth tissues.

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

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

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

Access to Resources and the Built Environment

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

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

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

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

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

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

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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An Interview with 2020 Janet Reaves Awardee Dr. Rob Doherty

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

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

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

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

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

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

 

Table of Contents

0:15 – About the Janet Reaves Community Achivement Award

1:10 – About Dr. Rob Doherty

5:32 – Opening the Janet Reaves Award

8:31 – Choosing dentistry and public health

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

12:10 – Back to school

12:40 – Impacting the community in Greene County

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

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

21:39 – Bringing residents to Greene County

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

24:25 – Collaborating with community

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

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

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

37:33 – Advice to dentists in public health

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Graduating Remotely: Dental Student Perspectives on Finishing School During a Pandemic

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

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

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

Headshots of the four students interviewed for the Graduating Remotely article

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

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

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

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

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

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

The timeline for UNC dental students is very similar.

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

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

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

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

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

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

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

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

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

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

Where are these students headed now?

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

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

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

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

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

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

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

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

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Recap: Oral Health Day 2020

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

Here are some highlights from the event

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

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

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

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

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

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

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

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

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

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

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

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

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A Dental Provider on the COVID-19 Front Lines

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

Picture of Dr. Amanda Stroud

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Maintaining Mental Health During a Pandemic

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

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

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

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

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

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

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

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

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

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

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

What can you do about the uncertainty?

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

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

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

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

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

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

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

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

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

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

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

Return to Work Toolkit

Financial Assistance for Dental Practices from Third Party Payers

COVID-19 Coding and Billing Interim Guidance: Virtual Visits

COVID-19 Coding and Billing Interim Guidance: PPE

Financial Obligations to Staff during COVID-19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Meet the Staff: Kelsey Ross Dew and Brady Blackburn

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

Kelsey Ross Dew

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you enjoy doing when not working?

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

What do you want our membership to know about you?

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

Brady Blackburn

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

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

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

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

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

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

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

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

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

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

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

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

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

What do you enjoy doing when not working?

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

What do you want our membership to know about you?

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

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Recap: Oral Health Day Webinar

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

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

Part One: Virtual Oral Health Day

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

Virtual Oral Health Day Featured Speakers

Dr. Bill Donigan, Kintegra Health

Dr. Shaun Matthews, UNC Adams School of Dentistry

Dr. Andres Flores, ECU School of Dental Medicine

Darlene Leysath, The Cornerstone CDC

Bobby White, North Carolina Board of Dental Examiners

TBD, North Carolina Dental Society

TBD, North Carolina Legislature

Part Two: Community Tours

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

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

To Watch the Webinar

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

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

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

03:46 Our Team

07:56 About Oral Health Day

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

14:50 Change to Rule 16W

17:33 Oral Health Day 2020

18:40 Why Teledentistry?

28:28 New Plans for Oral Health Day 2020

36:45 Recap

38:33 Q&A

Oral Health Day 2020 Webinar

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NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!

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Social Determinants of Health – Structural and Governmental Influences

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

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

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

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

Where can I go to access oral health care?

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

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

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

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

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

How do I pay for oral health care?

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

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

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

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

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

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

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

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

Picture of NCOHC's statewide provider access map

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

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

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

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

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

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

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

Sign up for NCOHC’s newsletter list to receive updates on stories like this one directly to your inbox.

NCOHC is a program of the Foundation for Health Leadership & Innovation. For more information and to stay up to date, subscribe to the NCOHC newsletter. If you are interested in becoming an NCOHC member, you can also fill out our membership form. It’s free!