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10 Things You Should Know About Your Teeth

1. Brushing Your Tongue Can Help Bad Breath

The tongue may actually hold more bacteria than your teeth. With its many crevices, your tongue does a great job of trapping bacteria and can cause your entire mouth to smell bad. Similarly, the roof of your mouth can store bacteria, so make sure you brush them both. During the COVID-19 pandemic, “mask breath” can be a serious inconvenience. So, make sure you’re taking the necessary steps to maintain proper oral hygiene!

For more tips and tricks, download this helpful guide.

2. Keep a Routine

No matter what your habits may be, maintaining a dental routine is what really matters. While elaborate toothbrushes and other oral health tools each have their own function and benefits, they will not work without consistency. Similarly, a standard, run-of-the-mill toothbrush, if used for two minutes twice a day, can keep your mouth clean and healthy.

No matter the toothbrush or toothpaste you use, keeping up with a morning and evening routine for oral hygiene, along with healthy eating habits, are the most important steps to keeping your teeth happy and healthy.

3. Start Young

If you have children, the best time to visit a dentist is no later than their first birthday, or after their first tooth erupts. Taking preventive action early can help ensure that your children’s teeth stay healthy and strong as they grow, without major dental complications. Be sure to schedule regular dental examinations once every six months.

For more information on what to expect during your child’s dental appointments, visit this helpful page from the Mayo Clinic.

4. Oral Health Isn’t Just a Mouth Problem

Poor oral health disproportionately affects low-income families and people of color. Unfortunately, studies have shown that it is harder for people with underdeveloped hygiene or missing teeth to secure employment. Increasing education, access, and equity in oral health care can help mend some of these societal concerns.

5. Dental Anxiety

Fear and anxiety surrounding dental treatment is very common. As medical professionals begin to bridge the gap between health care services, therapists are able to work with patients to screen for common conditions like this. They can then implement breathing and relaxation techniques to provide a more comfortable visit. If you are not asked, but suffer from dental anxiety, tell your dentist and dental hygienist.

Anxious about the dentist? Try taking a stress ball with you to your next appointment. During your visit, implement mindfulness strategies, such as slowing and counting your breaths.

For more ways you can learn to cope with dental anxiety, visit https://www.mouthhealthy.org/en/az-topics/a/anxiety

6. Be Wary of Acidic and Sugary Drinks

Fun fact: enamel is the hardest substance in the human body, but it isn’t invulnerable!

Too many acidic or sugary drinks may be harming your teeth. Some beverages have higher levels of acidity than others. These drinks can eat away at the enamel that covers the outer layer of your teeth, leaving them more vulnerable to plaque and bacteria.

Too much sugar can also lead to tooth decay, and soda is one of the easiest ways to consume large amounts. Try to limit your weekly number of sugary and acidic drinks to protect your enamel.

For more on how you can prevent tooth erosion, visit https://www.deltadentalins.com/oral_health/acid_wear.html

7. Vaping and Cigarettes Can Damage Your Teeth

No smoking sign

Did you know that smokers are twice as likely to develop gum disease? Not only does smoking affect your breath, it can stain your teeth and lead to more serious complications, such as oral cancer. Similarly, the nicotine in both cigarettes and e-cigarettes can interfere with blood circulation and damage gum tissue.

Learn more about smoking and periodontal disease at https://www.cdc.gov/tobacco/campaign/tips/diseases/periodontal-gum-disease.html

8. Your Saliva is Important

Your saliva is not just for drooling. It helps naturally wash away debris from the food you’ve eaten and can defend against the acid in some of those sugary drinks. You can also thank your saliva for killing some of those germs that cause bad breath.

Without saliva, your mouth would be more vulnerable to tooth decay and gum disease. Be sure to drink water and stay hydrated to maintain sufficient saliva production.

Got dry mouth? Visit https://www.deltadental.com/us/en/protect-my-smile/basics/oral-anatomy/the-importance-of-saliva.html for more information on xerostomia (dry mouth).

9. You Can Brush Too Hard

Most toothpastes contain abrasive ingredients such as calcium carbonate that help rid your teeth of plaque and bacteria. Similarly, the bristles on your toothbrush do a good job of scraping away these harmful elements. However, brushing too hard can actually damage the enamel on your teeth, leaving them more vulnerable to tooth decay.

When brushing, use about as much pressure as you would when writing with a pencil on paper. Make sure to use a soft-bristled brush instead of a medium- or hard- bristled brush. Brush in small circles for two minutes and don’t forget to floss.

10. Don’t Ignore Your Dentist

Regular dental appointments are not just for children. The recommended timeline for teeth cleanings is twice a year or once every six months. Even with good habits, consistent dental cleanings and checkups are essential. Oral health professionals will screen for oral cancers and other diseases in your mouth that are not easily caught. So, be proactive and keep your teeth and mouth healthy and safe.

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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NCOHC’s Policy Brief: Payment Reform

The North Carolina Oral Health Collaborative (NCOHC) released its first policy brief earlier this year, outlining a broad array of policy changes that, if enacted, would improve access and equity in oral health care for all North Carolinians.

Read the full policy brief here

Improving payment models can have a considerable impact on the care people receive, increasing efficiency and improving health outcomes. Payment reform refers to health care models that use reimbursement from insurers to providers to promote greater value for patients, purchasers, payers, and providers.

This third and final deep dive into NCOHC’s policy brief will focus on the payment reform section, elaborating on changes that can be made to make oral health care more efficient and affordable.

Teledentistry and Parity of Payment

Teledentistry has proven to be an effective means of connecting patients with their providers, especially during the COVID-19 pandemic. While remote care has proven to be invaluable in ensuring patient and provider safety, it is also a useful tool to increase equity in care, even in a post-pandemic world.

Unfortunately, some insurance plans do not reimburse for teledental services similarly to how they pay for in-person care.

Providers, especially in safety-net settings with thin profit margins, already frequently use teledentistry, sometimes without reimbursement. Safety-net providers will continue to use teledentistry to provide patients with essential care, and it is important that payment systems support this innovation in care delivery through equitable payment schedules.

Data suggest that patients receive the same quality of care via teledentistry as they do in person. For this reason, NCOHC recommends parity of payment across insurers.

Silver Diamine Fluoride

During the pandemic, there has been an increased focus on preventive care that reduces the amount of close-contact dental visits. One valuable resource in the realm of non-aerosolizing cavity management is the use of Silver Diamine Fluoride (SDF).

Aerosolizing refers to anything that can convert material into a fine spray that can be suspended in the air. Some dental procedures run the risk of aerosolizing the COVID-19 virus, leading providers to look to other, non-aerosolizing options.

When applied directly to a cavity, SDF can have a significant impact on reducing future urgent or emergent dental needs. As an efficient and cost-effective tool that doesn’t risk aerosolizing anything in the mouth, SDF is an ideal treatment to use during the ongoing pandemic.

Prior to COVID-19, payment for SDF varied widely. While NC Medicaid covered SDF, reimbursement was limited for patients five years old and younger. In vulnerable populations, however, many children may not even see a dentist before that age.

While NCOHC commends NC Medicaid for lifting all age restrictions for SDF reimbursement in response to COVID-19, it is important that these payment policies continue post-pandemic.

NCOHC recommends that NC Medicaid reimburse SDF placement for patients of any age. This will allow for more equitable access to this evidence-based treatment for both vulnerable children and adults.

NCOHC also recommends that the private payer sector incentivize SDF as a viable treatment through enhanced reimbursement policies.

Interim Therapeutic Restoration

Other viable options for non-surgical treatment of dental caries include Interim Therapeutic Restorations (ITRs). ITRs are non-permanent restorations placed on teeth to prevent cavities from progressing. Even though they are temporary, ITRs are effective reducing the negative impacts of caries until more permanent treatments can be administered.

Keeping in mind that many children rely on school-based care, this method of addressing tooth decay is particularly important because it could be delivered by hygienists, often at a lower cost. ITRs can dramatically help offset emergent needs in the immediate future. However, in North Carolina, this would be contingent on revision of delegated duties for dental hygienists.

Although many private payers currently reimburse for ITRs, a payment analysis should be done to ensure that they are incentivized as effective treatments through adequate payment models. Post COVID-19, NCOHC encourages NC Medicaid to also reimburse for ITRs.

Value-Based Oral Health Care Payment

As oral health care shifts toward a more value-based approach, focused on improving patient outcomes and lowering costs, it is necessary to think holistically about both the quality of care being delivered and how the care is delivered.

Care coordination management, addressing appointment compliance, motivational interviewing, and patient education to improve oral health literacy are services that should be covered by public and private payer sources to enhance patient-centered care.

These can be useful tools in helping people navigate treatment plans, coordinate transportation, and generally feel more comfortable engaging in social service support. All of these efforts can impact successful delivery of quality oral health care and improvement of patient outcomes.

Fact sheet titled "flip the incentive structure" about value-based care

Patient-centered care also means a patient-centered approach to financing.

When it comes to oral health management, emphasis should be placed on prevention. For vulnerable populations, it is often unknown when patients will be able to return for care. Bundling payment for services such as comprehensive oral health evaluations, prophylaxis for adults and children, topical application of fluoride and varnish, and sealants would incentivize providers to cover necessary services in a single visit.

NCOHC also recommends bundling nutritional counseling, tobacco counseling, and oral hygiene instruction as adjunctive non-paid services.

Payment reform and public policy must work in conjunction with one another to achieve long-lasting results. More often, payment reform drives changes in public policy. This means that Medicaid and private payers play a particularly important role in facilitation innovation in public health. As we begin to find new measures of success in value-based care, implementing these necessary changes will help improve peoples’ health and transform the oral health landscape.

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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Preventive Care During a Pandemic

The importance of preventive oral health care is often underestimated. There are many basic habits that can be implemented daily to reduce the risk of decay and other serious dental issues. During COVID-19, when there are more challenges to being seen by healthcare specialists, preventive care is critical.

Consistent dental exams are necessary during childhood; this is the time when issues are most treatable, and hygiene education can be implemented for long-term oral and overall health.

According to the American Dental Association, a child’s first dental exam should be scheduled no later than the first birthday or after the first tooth erupts. The American Academy of Pediatric Dentistry also recommends regular visits every six months after this.

The American Academy of Pediatrics has also developed a schedule of well-child visits to reinforce the overall well-being of developing children. This entails a recommended visit within the first week of birth, and then once a month for the first two months. After that, the child should be seen once every two months until the child is 18 months old. It is recommended the child be seen twice a year at age two, and then once a year until they are 21 years old.

Oral health education can have a significant impact on overall well-being. A common source of dental issues includes improper drinking and eating habits. If education is implemented at a young age to combat some of these dangerous patterns, future health concerns such as diabetes and obesity can be avoided. Other health risks associated with smoking and chewing tobacco can also be discussed during counseling in dental exams as children get older.

The pandemic has posed challenges to many, if not all, healthcare fields. COVID-19 has made it more difficult for patients to receive oral health care in a dentist’s office. Early guidelines from the World Health Organization advised people to delay their visits for non-essential oral health care like preventive care. This was a safety concern because dentists and dental hygienists work in close contact with their patients, and have a higher chance of spreading and contracting the virus. However, this has negative implications for peoples’ oral health.

The American Dental Association has emphasized the need for consistent dental care with safety precautions in place. During this pandemic, that means more PPE and sanitization. It is recommended that certain instruments which spray large amounts of water not be used. Dental hygienists and dentists are not able to see as many patients, due to increased time requirements between patients in accordance with surface sanitization protocols. Additionally, -travel and symptom questionnaires patients complete can also result in appointment postponements.

So, is it safe to go to the dentist now?

Many dental offices are open for routine care again, with significant safety measures in place. If you have any concerns about safety before your visit, give your dentist’s office a call and ask them a few questions, such as:

 

  1. What are your current COVID-19 protocols? doing to make sure that patients and providers are not spreading COVID-19?
  2. What kind of screening measures can I expect when I come in for my visit?
  3. How are you dealing with aerosolizing procedures? (This refers to the tools mentioned above that spray large amounts of water, a potential risk of “aerosolizing” the virus if it were present.)

What about mask breath? Can I do anything at home?

Due to prolonged periods of mask usage during the pandemic, many are becoming increasingly concerned about their own oral health.

Halitosis, a technical term for bad breath, is a preventable condition. One way to reduce “mask breath” is to brush your teeth at least twice a day, paying close attention to the tongue, which can hold large amounts of bacteria. Using fluoride toothpaste, fluoride mouthwash, and consistent flossing are also ways to prevent halitosis.

Do you have kids at home? Download this helpful guide and hang it in their bathroom to help keep their teeth healthy and happy!

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

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Dental Professional-Administered Vaccines

Dentists in North Carolina are uniquely positioned to begin administering some vaccinations, like those for the Human Papillomavirus (HPV) and Influenza. Currently only three states – Oregon, Illinois and Michigan – have existing legislation that allows dentists to administer vaccines. During the 2009 Swine Flu (H1N1) pandemic, dentists were temporarily added to the pool of flu vaccine administrators in certain states, such as Massachusetts. As scientists race to create an effective COVID-19 vaccine, the dental workforce could offer important support to the medical community, helping administer the vaccine to the public as efficiently and effectively as possible.

Dentists are highly qualified health providers, and are well poised to administer vaccines. Dental students attend the first two years of dental school training in coursework mirroring that of their medical student counterparts, and thus have congruent training regarding the use of medications and management of adverse reactions. Within their daily practice, dental providers routinely administer injections in anatomically difficult positions, ensuring that they are capable of administering intramuscular injections such as vaccinations into the deltoid muscles of the upper arm.

Approximately 79 million Americans are infected with Human Papillomavirus (HPV), making it the most prevalent sexually transmitted infection (STI) in the United States. HPV is responsible for approximately 70 percent of oropharyngeal cancers and more than 90 percent of cervical cancers. However, studies have shown that cancers associated with the virus are all but entirely preventable in patients that have completed the series of HPV vaccines prior to virus exposure.

In Australia, mass HPV vaccination has been correlated with a significant reduction in cervical cancer rates. While it may never be possible to completely eradicate cervical cancer, morally it is negligent not to fully utilize every avenue to contribute in the reduction of HPV associated cancers.

Many barriers restrict rural residents’ access to primary care. According to the Agency for Health Research and Quality (AHRQ), in 2017, approximately nine percent –or nearly 31 million people–sought care from a dental provider but not a medical provider. The barriers to accessing routine medical care disproportionately affect rural children, particularly in regards to vaccination. Rural children are approximately 30 percent less likely to have completed the full series of HPV vaccines. By enabling dentists to administer vaccines within their practices, rural residents will have an additional means by which to obtain these vaccinations.

Patients will benefit from the added convenience of being able to receive vaccines within the dental setting, minimizing travel burdens for patients.

Advocating for dental providers to be able to administer vaccines must start by raising the public’s awareness of the importance of HPV vaccination and promoting their understanding of dentists’ qualifications regarding vaccine administration. If successful, this policy opportunity has the potential to positively impact rural communities statewide.

Amanda Assante, Alexis Davis, Astha Patel, and Jessica Sharrow are students in Campbell University’s public health master’s program. In the fall 2020 semester, as a part of their coursework, Amanda, Alexis, Astha, and Jessica participated in an oral health practicum experience in which they dove deep into dental professional-administered vaccines with the North Carolina Oral Health Collaborative.

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Mental Health Care in a Dental Clinic?

Mental Health and Oral Health services have traditionally been thought of as separate entities. To better provide efficient, affordable care, Greene County Health Care (GCHC) is bridging the gap, integrating medical, dental, and behavioral health services for its patients.

As a Federally Qualified Health Center (FQHC), GCHC serves patients across Greene, Pitt, and Pamlico counties in North Carolina. Their focus resides in increasing access to high-quality care for the underserved, uninsured, and underinsured.

Cori Davis, a MedFT at GCHC, went into detail about her role in connecting oral and mental health.

In the time between when a patient fills out their paperwork and is seen by a dental hygienist or assistant, Davis performs behavioral health screenings and interventions. This involves sitting down with a patient to evaluate their overall mental health.

 

 

She screens for common mental health concerns such as anxiety and depression. Davis also assesses dental pain and pain management, eating and sleeping patterns, as well as social and basic needs.

Though her brief interventions on managing chronic conditions and mental health issues can go a long way, Davis often makes referrals to other GCHC therapists, if needed.

“We have a lot of great therapists here that can devote more time to a long-term case,” Davis stated.

Additionally, Davis makes referrals to GCHC’s medical clinic for patients who need medical care.

Working closely with a social worker, therapists at GCHC can work through common issues like transportation and medication affordability. Ride-sharing services and other programs to help patients access the care they need are often covered by Medicare or Medicaid.

We asked Davis if she thought her work had a genuine impact on the overall health of the patients she met with, to which she responded, “Definitely, yes.” She explained that before patients even leave the room, they are given handouts and techniques so they may leave with tangible and practicable information.

Afterwards, there is more to be done.

“Connecting them to a healthcare system that can be with them and work with them long-term is really valuable so they have all of their services they need in one building.” Davis continued, “That really helps with continuity of care and making sure they can have sustained healthcare.”

 

 

One example of how these health screenings are linked to the oral health practice is when a patient suffers from dental anxiety. Evaluating this condition allows for the therapist to work through breathing exercises and relaxation techniques. This information is then communicated to the dental assistant or dentist so that they may implement these practices throughout the appointment.

“We’re really filling the gaps with the services we do here,” said Davis, “Because the population we serve in dental isn’t the same population for the medical side.”

Behavioral health, general health care, and oral health care are often siloed, which exacerbates barriers that many face to accessing the care they need.

“We emphasize your whole health here and we want to make sure that all of you is doing well”, Davis said.

 

 

Addressing Oral Health disparities in North Carolina is tied with improving the overall health and well-being of its citizens. Combining medical, dental, and behavioral health services has become increasingly important in this process. Collectively, these related health fields strive to better the lives of everyone, especially those who have not had the privilege of reliable health insurance and access to care.

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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School-Based Care During a Pandemic

The most important element of childhood development is overall health. With schools nationwide facing unprecedented challenges during the current pandemic, setting children up with proper oral health treatment and education early on can be a determinant of their future success.

Many children, especially in communities that traditionally lack access to care, rely on school to get the oral health treatment they require. This means that during these times, it is more difficult for many children to receive the care they deserve. In a socially distanced interview, we spoke with representatives of Kintegra Health about challenges regarding school-based care during COVID-19.

Dr. William Donigan, general dentist and dental director at Kintegra Health, and Melissa Boughman, dental hygienist and dental ACCESS program director for Kintegra Health, both touched on the importance of providing school-based care to those who do not traditionally have access to oral health care.

Transportation issues are a common theme in Title I schools. Because many parents are not able to regularly bring their children to oral health appointments due to work conflicts or lack of transportation, Kintegra Health’s mobile dentistry units are essential parts of their operation. Operating out of Gastonia, North Carolina, there are two of these mobile units, as well as a dental van for follow-up visits and sealants.

“It’s so wonderful that we’ve been blessed with these mobile dental units that we can drive right up, park, and they bring the children out to us,” Boughman said.

Donigan also emphasized the importance of comprehensive oral care in the areas they serve. “Kintegra has been very responsive to the communities that we are involved in,” Donigan said. “Our mobile dentist unit goes anywhere within thirty minutes of one of our clinics.”

When asked how Kintegra is able to provide patient care during the COVID-19 pandemic, Donigan highlighted the use of intraoral photographs submitted by parents of the children, a supplement to the care provided by the mobile dental units. This increases conservation of personal protective equipment (PPE), lowers chair time, and allows patients to avoid leaving the house altogether for non-emergencies.

However, due to the use of cell phone pictures in these virtual exchanges of information, there have been concerns about image quality.

“The advantage of talking to the parent at that point is we can have them retake and resend the photograph if it’s not good,” Donigan said. “In most instances, we can get a pretty good photograph in those environments.”

Complications in oral hygiene at a young age can extend far into the future. Taking a further look at the world of oral health through the lens of a pandemic provides information about the links between COVID-19 and future health problems in children.

“Just recently, 90 percent of the people on a ventilator with COVID had periodontal disease,” said Donigan. He also mentioned that many diseases, like diabetes and high blood pressure, have relationships with what happens in the mouth. Donigan explained that many of the children Kintegra sees are already prediabetic in elementary school, and good education early in life is vital to helping them begin to lead healthier lives.

“We see the difference in the children we have seen for many years versus the newcomers, like the kindergarteners, and in some schools, pre-k,” said Boughman. “When we see them yearly, we see a big difference. We also provide education because we all know that education is the most important part of all of this. Once we clean their teeth, [plaque and tartar] will come back quickly. But if we teach them how to take care of their teeth, they can have a lifetime of great [oral health].”

Kintegra Health now works with more than 60 schools in seven school systems ranging from Gaston County to Iredell County.

“Today, at Battleground Elementary in Lincoln County, we’ll probably see about 30 children,” Boughman said. Kintegra expects to reach nearly 7,000 children this year, provided that schools are able to maintain traditional classroom meetings.

Kintegra Health staff place an emphasis on creating a relationship with their patients. “We don’t let them fall through the cracks,” Boughman said. “We call them at least three times, and then even send a postcard.” If further dental work is needed, the dental access program assistant will contact parents to explain what was done and make appointments to return if necessary.

Now more than ever, maintaining consistent communication — and being able to provide oral health treatment, when possible — is crucial to school-based care. Kintegra Health’s practice model has become a prime example of how dedicated oral health professionals can overcome the challenges posed by COVID-19.

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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Recap: Oral Health Day Part 2

Last week we had the opportunity to take an in-depth look at teledentistry at Oral Health Day Part 2. Three North Carolina dental directors and a panel of national experts took questions and presented to a crowd so large that we had to upgrade our Zoom subscription mid-event!

The dental directors at Kintegra Health, Piedmont Health, and Greene County Health Care (GCHC) kicked off the day, talking about the many ways their Federally Qualified Health Centers (FQHCs) use teledentistry to improve patient care. All three directors took questions from the audience.

“Know where you’re going and have a roadmap,” said Dr. Mattison-Chalwe, answering a question about the planning process to successfully begin using teledentistry technology in a practice.

The dental directors answered questions and discussed everything from the planning process, to tips and tricks, to getting diagnostic-quality patient information, and the ways that new technology has increased clinic efficiency.

“We got a lot closer to medical,” said Dr. Doherty, referring to the relationship GCHC’s dental facility was able to make with their medical counterparts as they implemented teledentistry protocols. “It is very easy for a provider to give us a call — a medical provider, and we just jump right in on the call and get those patients seen very quickly.”

 

Watch Drs. Donigan, Mattison-Chalwe, and Doherty in three live teledentistry demonstrations.

 

After the dental directors spoke, three nationally recognized teledentistry experts took the virtual stage. Dr. Paul Glassman, the “father of teledentistry” and professor and associate dean for research and community engagement at California Northstate University College of Dental Medicine, spoke about the process of actually “doing teledentistry,” and the future of remote care.

“This is really based on calibration and communication,” said Dr. Glassman. “It’s based on the idea that you’re going to trust the hygienist who is in the community.”

Dr. Scott Howell, assistant professor and director of teledentistry at the A.T. Still University Arizona School of Dentistry & Oral Health, walked the audience through several examples of the various ways he uses teledentistry in his clinical practice.

Dr. Howell mirrored Dr. Glassman, saying that collaboration and communication is key to successfully using teledentistry technology.

“The field team must be calibrated,” said Dr. Howell. “There has got to be trust. Trust between dentist and hygienist; the dentist has to trust the technology. And as I tell my students, this is not something that you develop overnight. It is something that takes time to develop.”

Brant Herman, CEO of MouthWatch — a provider of teledentistry software and equipment — spoke about the actual technology necessary to practice via teledentistry. He also covered common misconceptions about what it takes to incorporate remote care in a clinical setting.

One of the bigger misunderstandings highlighted by Herman is the idea that there is only one way to do teledentistry.

“It’s really just the tool. You’re just using the technology as the tool,” said Herman. “You’re facilitating the other approaches to care coordination, care delivery, through this technology. It can be all of these different services that really just use teledentistry as the backbone to connect patients, providers, and care.”

MouthWatch, LLC, was generous enough to donate four intraoral cameras for the event, which NCOHC raffled off live.

NCOHC has worked collaboratively alongside diverse stakeholders in jointly drafting teledentistry legislation, which is slated to be introduced during the 2021-2022 legislative session. This bill will work to improve providers’ ability to incorporate teledentistry technology in their practices, and will ensure that quality oral health services, aided by teledentistry, are delivered equitably throughout North Carolina.

Stay tuned as we move forward. We encourage and welcome all voices at the table, so please consider signing up to receive our newsletter, and help us create a more equitable oral health landscape in our state.

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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Reducing the Rate of Childhood Caries in WNC

From the highest peaks east of the Mississippi to the unique sounds of bluegrass music, Western North Carolina is a one-of-a-kid region. But like many rural areas across North Carolina and the United States, the communities that make up WNC face pressing challenges when it comes to oral health.

 

Across the western region, children on Medicaid receive less preventive oral health care than their peers across the state. In Regions 1 and 2, as reported by the North Carolina Department of Health and Human Services Oral Health Section, only 43 and 42 percent (respectively) of children ages 1-2 receive any preventive oral health care.

We could rattle off statistics and conclude that there simply aren’t enough dentists in WNC, but the problems faced are not so simple. While the workforce numbers and the distribution of providers across our state are an important issue, there are several layers of barriers preventing many in WNC from accessing the care they need.

When looking at third grade students, the data suggests that initiatives to reach children outside of the traditional dental home are at least partially responsible for a higher-than-average rate of dental sealants among third graders. Across Regions 1 and 2, nearly 49 percent of third graders surveyed in the 2017-18 school year had received dental sealants, compared to a statewide average of 45.9 percent.

Even with the rate of sealants in Regions 1 and 2, however, only 41.8 percent of surveyed students had no tooth decay, compared to the statewide average of 54.5 percent.

So what do all these numbers mean?

There are unique issues that vary across WNC, and each individual community faces its own challenges. For example, if you look at Region 1, only 13 percent of the population is serviced by fluoridated water. For comparison, nearly 90 percent of North Carolinians have access to fluoridated water.

So, whether the problem be access to providers, adequate oral health education, access to basic preventive measures like fluoride, or any number of other issues, significant effort is needed to improve children’s oral health in WNC.

In 2017, the Duke Endowment, Mission Children’s Hospital, and the WNC Health Network partnered to conduct an oral health needs assessment and further explore the specific issues facing WNC communities. From there, stakeholders identified strategic focus areas and formed the WNC Children’s Oral Health Initiative.

Earlier this year, NCOHC absorbed the WNC Children’s Oral Health Initiative, now called the WNC Steering Committee, to help specifically tailor efforts to increase equity and access in the region.

Meet the steering committee and further explore the barriers to access in WNC here.

As we continue our work, keep an eye out for breakdowns of the issues that WNC communities face, and the innovative approaches leaders in dentistry are taking to tackle them.

Get started by exploring how Kintegra Health is pushing forward, even during the COVID-19 pandemic, with a plan to use teledentistry and school-based care to provide preventive services to more than 6,000 elementary school students in the counties west of Charlotte this year alone.

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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NCOHC’s Policy Brief: Care Delivery

NCOHC released its first policy brief in the summer of 2020 to provide an overview of the many policy changes that could increase equity and access to oral health care in North Carolina. This is the second of three deep dives to further expand on the policies within the brief. You can read the first one here.

Read the full policy brief here

As North Carolina grapples with an oral health workforce imbalance, there are several opportunities to improve the efficiency and effectiveness of care delivery. The opportunities in this section are relatively simple—not requiring a change to scope of practice, but rather simply modernizing the Dental Practice Act to better utilize technology for patient care, and to open doors for collaboration between medical and dental providers.

Adoption of teledental service utilization

During the COVID-19 pandemic, teledentistry has proven to be an invaluable tool allowing patients and providers to connect in safe, socially distanced settings. Prior to the pandemic, teledentistry served as a vital tool for increasing access to oral health care, as well. Providers across North Carolina have effectively leveraged the use of technology in community-based and school-based settings, allowing those who traditionally would not see a dentist to receive care through teledentistry.

To learn more about teledentistry and the many ways it is used, join us for Oral Health Day Part 2 on Oct. 23 and hear from some of North Carolina’s dental directors and three renowned experts in remote care technology.

Although health clinics and other providers — in both public and private sectors — regularly have provided teledental services, NCOHC advocates that to ensure future use of teledentistry as a care modality, stakeholders need to take steps to codify its use in North Carolina.

First, NCOHC recommends permanently adopting language to include electronic service delivery within the definition of dentistry, under Chapter 90, Article 2. These changes would simply update the Dental Practice Act, since remote care technology wasn’t even on the radar when the original language was drafted. Not only will the addition of language to Article 2 further define and codify teledentistry as a care delivery modality in our state, but it will also add in consumer protections for the provisions of remote care.

Finally, and specifically to payment reform, NCOHC urges both NC Medicaid and the commercial dental benefit plans to allow for the reimbursement of teledentistry both synchronously and asynchronously. These codes, D9995 and D9996, respectively, have been a part of the national billing nomenclature since 2018. Because of the lasting impact that teledentistry could make — even beyond a pandemic setting — it makes prudent sense to permanently adopt these billing codes.

Integration of Care

NCOHC is a strong advocate for integrated care, another area where teledentistry technology could play an important role. Tools like intraoral cameras are easy to use, and simply capturing images of a patient’s mouth can assist in connecting that patient to the care they need. NCOHC sees a big opportunity for using teledentistry technology in primary care settings to capture supplementary patient information for referral to dental providers.

Finally, NCOHC outlined several options to expand the dental workforce, including the community care coordinator.

Check out what one of NCOHC’s interns, Parker Norman, recently wrote about care coordination, and take a look at how Kintegra Health, a Federally Qualified Health Center west of Charlotte, uses teledentistry and care coordination to complete a network of care for children in Title I schools.

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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A Deep Dive into Care Coordination in North Carolina

At Kintegra Health, a Federally Qualified Health Center (FQHC) serving several counties west of Charlotte, care coordination is increasing access to oral health services. Today, Kintegra’s 11 dental navigators are helping families understand their oral health needs, recording an astonishing 70 percent treatment completion rate.

In a recent blog post, Parker Norman shared how dental care management workforce models use care coordination to help providers address social determinants of health and expand access to oral health care services. In this post, she explores two examples in North Carolina.

What is Care Coordination? A Quick Review

As a recap, through care coordination, patients are connected with the resources they need to access oral health care services, including reliable transportation, comprehensive oral health insurance coverage, providers who accept that insurance, and providers who speak the same language as their patients.

Communicating with patients in their native language is especially important.

By speaking the same language as the people in the communities they serve, care coordinators can often help patients feel more comfortable. Coordinators — often referred to as “navigators” — can also promote oral health literacy through patient education delivered in a patient’s native language. With an understanding of the importance of good oral health, people are more likely to seek and utilize oral health care services.

Dental Care Management Models

Dental care management models include dental navigator models and the ADA-formalized Community Dental Health Coordinator model (CDHC). Both models aim to employ culturally competent individuals from the communities they serve. These coordinators are better able to understand vulnerable patient needs and connect them with the resources necessary to access optimal oral health.

Dental navigator models and the CDHC model are already used in North Carolina, and both are expanding access to care. Dr. William (Bill) Donigan, dental director at Kintegra Health, and Crystal Adams, a registered dental hygienist and director of Catawba Valley Community College’s (CVCC) dental hygiene program, provide insight about these models and offer recommendations for North Carolina as more are put into practice.

Care Coordination Case Study: The Dental Navigator Model at Kintegra Health

Kintegra Health first began to use the dental navigator model in 2006 as part of a school-based program, with hygienists calling parents to schedule their children’s appointments. By 2010, dental navigators joined the hygienists at schools to help schedule appointments. Starting in 2012, Kintegra hired a dental navigator for every county served by its school-based program —one navigator each in Davidson, Lincoln, Catawba, and Iredell Counties, and two in Gaston County.

By 2016, Kintegra Health was placing dental navigators in other health care areas, including pediatric medical, OBGYN, and Women Infant Children (WIC) clinics. These navigators provide patient and parent education, schedule appointments in communication with parents, and apply fluoride varnish for children. Although this program primarily serves children, some adultOBGYN patients are also served. There is limited space for adults in Kintegra’s dental clinics, so teledentistry is often used during medical appointments to bridge this gap.

To learn more about teledentistry, join NCOHC for Oral Health Part 2 on October 23rd, watch how Kintegra and other clinics provide remote care, and hear from some of the nation’s leading experts.

At Kintegra Family Health in Statesville, the pediatric medical clinic and family dentistry clinic once shared a waiting room. Since the offices were side-by-side, it was assumed that a medical provider would give a dental referral to patients and their parents, who would then schedule the appointment. Because of this, no dental navigator was employed at that location.

In 2016, almost 970 new patients saw a dentist at Kintegra Health in Gaston County, where a dental navigator was employed in the pediatric medical clinic. During the same year, only 48 new dental patients were seen at Kintegra’s Statesville location. Howeer, after a navigator began working in the Statesville WIC clinic, more than 50 new patients saw a dentist in just one month. The figure below compares expected patient volumes during one year with dental navigators and one year without.

Graph displaying Kintegra Health's new patient volume with and without dental navigators. In Gastonia with a navigator (2016), 970 new patients; in Statesville with no navigator (2016), 48 new patients; projected new patient volume in Statesville with navigator, 600

Kintegra Health has measured a 70 percent treatment completion rate for patients receiving oral health care with the help of dental navigators, compared to about a 30 percent completion rate in private practice.

With statistics like that, it is clear to see that Kintegra Health’s dental navigator model is increasing access through care coordination. There are now a total of 11 navigators employed by Kintegra Health and, during the last eight years, these navigators have helped more than 9,500 patients access dental care.

If Dr. Donigan were to start a new clinic, he said he would first employ a CDHC, rather than a dental navigator. A CDHC is trained to present the program to key stakeholders, some of whom are outside of the clinic setting, such as at school board meetings. CDHCs are also trained to use motivational interviewing techniques to expand the program.

After patient volume began to increase, Dr. Donigan would then start employing dental navigators to speak one-one-one with parents and patients. As he already does at “Dr. Donigan’s School of Dental Navigation,” he would train the new dental navigators on-site in oral health education. He would also require that they complete the Smiles for Life program, which equips primary care providers to promote oral health for all age groups, and he would require that they become Dental Assistant IIs (DA2).

Catawba Valley Community College CDHC Program

Catawba Valley Community College’s CDHC program is a year-long program with specific curriculum, training, and internship requirements. Before entering the program, a CDHC candidate must also have a professional DA2, Child Development Associate, or Registered Dental Hygienist license. It often takes longer for a CDHC to be able to find employment, compared to a dental navigator, given the formalized criteria that must first be met. However, once employed, a CDHC is already equipped with education and training.

In North Carolina, there are no CDHC-title jobs available — most jobs are marketed as general dental navigators without a specific CDHC requirement. Because of this, most students in CVCC’s program complete it as part of their continuing education and go on to work in other oral health roles. The positive outcomes of the program need to be proven to stakeholders so that CDHC jobs are actually funded before CDHCs will be employed as CDHCs.

“Let’s not look at the dollar, let’s look at the people,” Adams said, referring to the important work CDHCs could do to help people navigate barriers and access oral health care.

Adams also mentioned that while the CDHC curriculum is nationally formalized, care coordination is not “cookie cutter,” and there is no one-size-fits-all model. Different dental offices serving different populations will go about care coordination differently. At CVCC, Adams is adapting the program to make sure it is up-to-date and applicable for target populations in North Carolina. This includes educating students on things that may vary across state borders, such as insurance coverage.

CVCC will enroll its third cohort of CDHC students this January.

Dental navigator and CDHC models in North Carolina expand access to oral health care for vulnerable populations, addressing oral health inequities and improving overall oral health outcomes. The positive consequences and areas for improvement for both models should be considered as we move forward to implement future models effectively.

Over the 2020-2021 academic year, Parker Norman will be conducting a formative process evaluation of the CDHC program at CVCC. The evaluation will confirm if the program is feasible, appropriate, and acceptable, as well as inform decision-making related to the program’s improvement and ensure long-term success. Be on the lookout for the outcomes of this research, which will be applicable to other current and future programs!