North Carolina Oral Health Collaborative

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

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

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

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

North Carolina Medicaid Oral Health “Secret Shopper” Survey

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

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

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

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

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

Addressing Payment Disparities

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

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

Strengthening the Oral Health Care Safety-Net

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

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

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

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

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

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

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

Doing nothing simply isn’t an option.

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

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

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

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

Dr. Eleanor Fleming’s Keynote Address

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

 

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

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

 

Panel Discussion

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

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

 

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

 

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

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

 

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

 

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

 

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

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

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

 

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

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

 

Day Two: Equity in Action

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

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

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

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

You can find the full event recording below:

 

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

A root canal is a dental procedure in which the soft center of the tooth, the pulp, is removed. The pulp is a collection of nerves, blood vessels, and connective tissue that aid the tooth’s growth.

A person will need a root canal if the pulp is inflamed or infected, commonly called pulpitis. The procedure eliminates bacteria and can save the natural tooth by preventing reinfection. Unlike other parts of your body, a tooth’s pulp cannot heal on its own. Once it has been damaged or infected, the only option is to remove it, either with a root canal or a whole tooth extraction. 

A tooth’s pulp can be damaged in a number of ways. The most common are decay from an untreated cavity, a chipped or cracked tooth, or too many dental procedures on the same tooth. The pulp can also be damaged by a tooth injury that does not break the tooth.

You may need a root canal if you have severe pain while chewing or biting, gum pimples, intense sensitivity to hot or cold, or gum problems such as swollenness, tenderness, decaying, or darkening.

Performing a Root Canal

A root canal can be performed on a person of any age who has experienced damage to a tooth’s pulp. General dentists (non-dental specialists) can perform root canals on any tooth, but they commonly refer patients to an endodontist if the procedure is needed on a more complex tooth, such as a molar. An endodontist is a specialist who has completed two or more additional years of training after dental school. Part of their additional training focuses on root canals.

A root canal can be completed in one or two appointments and is a rather painless procedure. It begins with an anesthetic to numb the tooth, with the patient remaining awake. The pulp is then removed through a small opening in the top of the tooth.

After the pulp has been removed, the dentist may use a topical antibiotic on the tooth to prevent reinfection. The dentist then fills the tooth with a sealer paste and gutta-percha, a rubber-like material. The procedure is ended by the dentist filling the opening with a temporary sealant.

The temporary sealant will need to be replaced with a permanent restoration, typically a crown, after a root canal. Your dentist will likely schedule the restoration a week or more after the root canal. The extra time helps to make sure that if any problems with the root canal arise, they can be identified and fixed before the restoration is in place. 

Your mouth will usually be numb for around 2-4 hours following a root canal procedure, but you should be able to return to normal activities such as school or work directly afterward. However, if you have a root canal, you should not eat again until the numbness has completely gone away. You also may experience soreness and mild discomfort for a couple of days.

Cost of a Root Canal

Root canal pricing will vary by geographic region, the complexity of the root canal procedure to be performed, as well as other factors. Since molar root canals are more challenging and often performed by an endodontist, the fee is typically higher.

Without insurance, a front tooth root canal can cost an average of $600-$1,100, while a molar ranges from $800-$1,500. With insurance, the price for a front tooth procedure can go down to just $200 and a molar procedure at least $300. Click here for more information about dental insurance.

The price can also differ depending on where you live, as there is a higher demand and less access for dentists in smaller cities and towns.

Preventing Root Canals

As with most oral disease, dental issues that can lead to a root canal are almost entirely preventable. Good oral hygiene and regular preventive dental visits are two important steps to reduce the chance of needing a root canal. 

Beyond tooth decay, however, oral trauma can also lead to the need for root canals. For anyone playing contact sports or other activities that risk a blow to the face, consider wearing a mouth guard to protect your teeth. 

Where Do I Get a Root Canal?

If you have a dentist and think you may need a root canal, your regular provider should be your first stop. If you don’t have a dentist or can’t afford to see one, there are many options across North Carolina for free or reduced-cost care. 

You can find access points that accept Medicaid insurance and offer care on sliding fee scales for those without insurance by visiting NCOHC’s access map. Not all clinics on the map provide surgical procedures like root canals, but most should be able to diagnose the problem, discuss different treatment options, and point you in the right direction to receive the care you need. 

About the author: Sydney Patterson is a senior at East Carolina University studying public health. She plans to attend dental school following graduation. Sydney is from Hayesville, North Carolina, and she works as a dental assistant at Staton Family Dentistry.

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

Oral Health Day will look different this year. As the first two-day Oral Health Day event, you can expect new and exciting opportunities to engage with experts and also play a role in shaping the future of oral health in North Carolina.

Click here to register today and join us on June 22 and 23!

We are thrilled to announce that Dr. Eleanor Fleming will headline Oral Health Day 2022 as the keynote speaker. As the assistant dean of equity, diversity, and inclusion at the University of Maryland School of Dentistry, she is the perfect person to keynote this year’s event, themed “Equity in Action.”

Keynote: Dr. Eleanor Fleming

Fleming earned her PhD at Vanderbilt University, DDS at Meharry Medical College, and MPH at East Tennessee State University. She also completed a Dental Public Health Residency at Boston University. She has worked in a variety of positions, including as Dental Officer for the Centers for Disease Control and Prevention and Associate Professor of Dental Public Health at the Meharry Medical College School of Dentistry.

Fleming is a subject matter expert in infectious disease and chronic disease epidemiology. She has been a principal investigator in numerous studies and has informed public health surveillance at state, national, and international levels. Fleming holds leadership positions in the American Association of Public Health Dentistry and the American Public Health Association.

Among numerous accolades, she has been recognized as one of the American Dental Association’s (ADA) “10 under 10” (2021), recognizing leaders in the dental field who are less than 10 years out of dental school. She has also received the National Dental Association New Dentists Colgate Leadership Award (2020), the ADA Foundation Henry Schein Cares Dr. David Whitson Leadership Award (2018), and the Ernest Eugene Buell Award (2016).

Equity in Action

NCOHC believes that health care is an inherent right for all. In North Carolina, there are severe disparities in oral health care access and outcomes, often driven by social drivers of health such as financial difficulties and inadequate access to transportation.

Oral Health Day 2022: Equity in Action will focus on the structural changes we need in order to create a future where all have access to the care they deserve.

Click here to register today and join us on June 22 and 23!

Along with Fleming’s keynote on June 22nd, Dr. Lewis Lampiris will moderate a panel of leaders in health care to discuss equity issues and policy solutions. Head over to the Oral Health Day 2022: Equity in Action page to meet this year’s panelists.

Lampiris received his DDS from Temple University’s Kornberg School of Dental Medicine and MPH from the University of Illinois at Chicago. Early in his career, Dr. Lampiris served as a dental officer in the U.S. Army Dental Corps.

Later, he worked in private practice in Chicago before serving as chief of the Illinois Department of Public Health, Division of Oral Health for nine years. Immediately after, he served as the Director of the ADA’s Council on Access, Prevention, and Interprofessional Relations.

Lampiris recently retired from the University of North Carolina Adams School of Dentistry where he served as Associate Clinical Professor and the Director of the Dentistry in Service to Community (DISC) program. He is the recipient of the American Association of Public Health Dentistry’s Distinguished Service Award (2013), the ADA’s Presidential Citation (2010), and the Association of State and Territorial Dental Directors Distinguished Service Award (2007).

Hands-On Workshop

On June 23rd (Day 2), all participants are invited to join NCOHC for a thought-provoking and interactive workshop. In this unique session, we will work together to identify actionable solutions to increase access and equity in oral health care in North Carolina and beyond.

As a collaborative organization, we believe it is vital to hand the microphone over to you. Sustainable solutions to our biggest challenges can only be found — and achieved — when we work together. We fully expect Oral Health Day 2022: Equity in Action to be a catalyst for system-wide change!

Click here to register today and join us on June 22 and 23!

2022 NCOHC Oral Health Equity Award

We are also thrilled to announce the 2022 NCOHC Oral Health Equity Award. On Day 1 (June 22nd) of Oral Health Day, NCOHC will present this signature award to an organization that has implemented solutions reducing disparities and improved oral health outcomes in North Carolina. To find out more about the award, please click here.

We look forward to seeing you at Oral Health Day 2022: Equity in Action on June 22 and June 23!

On March 28, 2022, the Poor People’s Campaign held its first Moral Monday march in Raleigh since the COVID-19 pandemic began. The rallies, which began in North Carolina in 2012 and have radiated across the United States since, have long covered a wide range of issues that disproportionately impact those living in poverty.

Covering issues ranging from fair housing to union-friendly labor policy, prison reform, and more, the Poor People’s Campaign describes itself as a “national call for moral revival,” building on the movement of the same name launched by Rev. Dr. Martin Luther King Jr. in 1967.

The March 28th rally in Raleigh came in preparation for a Poor People’s March on Washington, again echoing Dr. King’s movement, expected to take place on June 18, 2022.

As he did for many Moral Mondays prior to the COVID-19 pandemic, Dr. Howard Eisenson attended the March 28th rally in Raleigh. He plans to attend the March on Washington on June 18th as well.

Before heading over to Raleigh, Eisenson sat down with NCOHC to talk about his career as a physician, his advocacy work, and a health care policy proposal that an increasing share of Americans support: single-payer health insurance.

While NCOHC has no position on national health care reform policies like single-payer or a public option, our work centers around structural reforms that promise to increase access and equity in oral health care. This blog post is not an endorsement of any national policy reform initiative. Rather, it is meant to explore what single-payer insurance is and why many Americans are working to change the way health care is administered in the United States.

“What many of us feel it’s time for in the wealthiest country on earth is a health care system that serves everybody, that provides for the common good,” said Eisenson.

Eisenson was the Chief Medical Officer for the Lincoln Community Health Center (CHC) from 2012 to 2021. Today, in semi-retirement, he still works for a program called “Just for Us,” a collaboration between the Lincoln CHC and the Duke Division of Community Health.

Working in home health care has been an eye-opening experience for Eisenson. Insurance plans often have very narrow networks, high co-pays, and other barriers that prevent homebound patients from accessing the services they need.

“I’ll give you a quick example from last week,” he said. “I went out to see a patient one morning. ‘How are you doing?’ ‘Terrible,’ she said. I asked her, ‘well, what’s the matter? What’s going on?’ She said, ‘I heard that my insurance won’t pay for my insulin anymore. Pharmacy tells me that.’”

Another call to the pharmacy revealed that her insurance no longer covered her Lantus insulin.

“No doubt what happened is the pharmaceutical manufacturer raised the price,” said Eisenson. “So, we had to find a substitute insulin product. We did, but it took much worry on the part of the patient, phone calls to the pharmacy, a fair amount of my time, re-writing the prescription, a lot of downstream administrative work that would have been avoided had there been one insurance plan that served everybody.”

The Poor People’s Campaign’s list of demands includes the expansion of Medicaid in every state and adoption of a single-payer health insurance system. Eisenson believes that this step is vital if the United States is to achieve equitable access to health care services.

“When you have a publicly funded plan, their main mission at the end of the day is to provide value to the public. That’s what we need. Health care is not your typical consumer product. It’s not like buying a refrigerator where you can shop around for as long as you want,” said Eisenson. “A market-driven approach to health care is inadequate – it leaves too many people out.”

“And we need to cover things like dental care. Who wants to have a mouth full of rotting teeth, or no teeth? And yet dental care is accessible to so few people,” he said. “Dental emergencies occasion so many emergency room visits. Untreated dental problems make so many chronic health problems worse. Not to mention what they do to quality of life. Dental care, vision care, hearing aids, all of these things ought to be included in a comprehensive health package and made available to everyone.”

What Is a Single-Payer Health Care System?

In single-payer health care systems, one entity — usually a government — is charged with administering health insurance for an entire population. Basically, a national insurance system would take the place of our current network of private insurance companies. The actual delivery of health care would remain private, but the financing mechanisms would be controlled by the federal government.

Essentially, a single-payer system would operate like the current Medicare system, only everyone would have access to it.

Supporters argue that a single-payer health care system provides many benefits, including:

• Savings created by increased efficiencies
• Access for everyone, regardless of employment status or financial situation
• Reduced health care spending per capita

However, a transition to a single-payer system wouldn’t be easy or without downsides. For instance, more than 600,000 people in the U.S. currently work in the health and medical insurance industry. Many jobs would be lost in a transition to a single-payer system.

“You can’t just push people out of their jobs without making provisions for them to land on their feet,” said Eisenson.

Lateral transitions and re-training programs are a tall order for those who have made careers in the insurance industry. Yet, creating these opportunities is a need that many prominent advocates for single-payer health care do recognize.

Agreement on Principle: A First Step Toward Single-Payer Health Care

“There are so many details to work out, but the first step is to agree on the common principal,” said Eisenson. “I think most Americans would agree that access to quality health care should be a human right. If someone has a fire in their house, the fire department doesn’t check to see first whether they have paid their fire insurance. If someone is having an emergency and needs the police or an ambulance, nobody is checking to see if they deserve to have help. Everyone gets to send their children to school. These are common goods. Those of us working toward single-payer think that health care should also be a common good.”

The Bottom Line

At the end of the day, change must happen to achieve equitable access to health care. At NCOHC, we believe that diverse coalitions of advocates passionate about improving our health care systems are the key to discovering and implementing the best solutions. That means diversity in cultures, backgrounds, experiences, and viewpoints, and we welcome all to take a seat at the table in this conversation.

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

At NCOHC, we see integrated care structures at the center of a more equitable, accessible health care system. Oral health is an important part of a person’s overall health, and our bodies benefit most when our medical and dental needs are met in a “whole-body” approach.

The same goes for mental health, another often siloed health care practice. Not only do our medical, dental, and mental health needs overlap, but deficiencies in any of the three can have serious impacts on the rest of our bodies.

Oral Health and Mental Health: A Two-Way Street

Many social determinants of health have significant impacts on both oral and mental health. For example, while food access has well-documented impacts on oral health, it also affects mental health. One study conducted during the COVID-19 pandemic found a 257 percent higher risk of anxiety and a 253 percent higher risk of depression among food-insecure individuals.

The same goes for economic stability. Societal forces like income, housing, and transportation that can prevent someone from accessing oral health services often carry negative mental health consequences as well.

The comedian Moses Storm discussed his own poverty in his recent HBO Max special, saying that “poverty is a disease, and its most sinister symptom is fear. It’s something that I carry with me to this day… It’s no revelation that poverty is a major stressor, and we know that chronic stress causes damage to the cerebral cortex, the part of your brain that’s in charge of risk/reward, long-term planning.”

Can Oral Health Affect Mental Health?

Oral health itself can impact mental health, too. Poor oral health is strongly associated with fear, anxiety, and shame. Among children, untreated tooth decay can lead to school absenteeism, learning deficiencies, and difficulty socializing and making friends. Among adults, similar impacts can be seen maintaining employment, relationships, and more.

Similarly, people living with mental illnesses like anxiety and depression can face difficulty maintaining daily routines. This and other effects of mental illnesses, such as excessive smoking or drinking as coping mechanisms, impact oral health.

A 2016 article in the Canadian Journal of Psychiatry discussed the fact that “many psychiatric disorders, such as severe mental illness, affective disorders, and eating disorders, are associated with dental disease.”

The bottom line is that poor oral health and mental illnesses are often, in a way, symptoms of each other, results of a network of stressors, barriers to care, and societal factors that many people face. As such, they are intertwined, both impacting each other in many ways.

According to Storm, “Basically all the tools that get you out of poverty get damaged by being poor.”

That sentiment is reflected by the compounding effects of poor health, and poor health and poverty are also intertwined in this kind of feedback loop.

The Need for Systems-Level Change

Whether brushing teeth and visiting the dentist to improve oral health or adopting mindfulness routines and seeking behavioral health care to improve mental health, self-care routines are vital. But, the burden of improvement can’t always be placed on the individual.

Many of the societal factors that impact mental health are structural in nature. While they are important, meditation sessions, mindfulness routines, and daily walks must be accompanied by structural improvements to health care access, income, affordable housing, transportation, and so much more.

The same goes for oral health, and health care in general. Too many people simply cannot access the care they deserve. Solving this problem is one of the most important things health care professionals can do to improve and ultimately save lives.

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

Dentists may be one step closer to administering HPV vaccines in pursuit of whole-person health. Earlier this year, the American Dental Association (ADA) Code Maintenance Committee approved new CDT codes for oral health care provider-administered HPV vaccinations. This is a crucial step in addressing HPV, the most common sexually transmitted infection and a leading cause of oropharyngeal cancer.

The human papillomavirus (HPV) is the most common sexually transmitted infection in the U.S. At first glance, it may seem harmless compared to other sexually transmitted infections and diseases. In many cases, people don’t even know when they have contracted HPV.

But HPV is responsible for 12 percent of cancers worldwide, including cervical cancer, penile cancer, and many oral cancers. In fact, according to the CDC, HPV is thought to be responsible for 70% of all oropharyngeal cancers. 70%!

The vaccine has been proven to prevent both HPV and associated cancers. Specifically, of the 36,500 annual cancer cases caused by HPV, it has been found that 33,700 could have been prevented through vaccination.

Why Oral Health Care Provider-Administered HPV Vaccines?

“HPV is the leading cause of oropharyngeal cancers (cancers in the throat, back of the mouth, base of the tongue, and tonsils) in the United States,” said NCOHC Director Dr. Zachary Brian, who serves on the Code Maintenance Committee as a representative for the American Association of Public Health Dentistry (AAPHD) . “It’s more than appropriate that oral health care providers not only educate about HPV-associated risks but also serve on the frontlines to administer this life-saving vaccine.”

Brian, along with Dr. Sharon Perlman, a dental provider and CCARE Lynch Syndrome co-founder, drafted the new HPV vaccine code. Perlman also served on the Code Maintenance Committee as an AAPHD representative.

“We are lucky to have a strong advocate in Dr. Perlman,” said Brian. “She was a critical component in the drafting and passage of this new code.”

With oropharyngeal cancers claiming one life every hour in the U.S., and just over 50 percent of adolescents not completing the HPV vaccine series, there is clear room for improved prevention through increased access and education.

In 2021, NCOHC spoke with Dr. Jennifer S. Smith, a vaccine epidemiologist who has worked to improve HPV vaccine acceptance to prevent cervical cancer. She said that while the HPV vaccine has proven to be a valuable preventive tool for many forms of cancer, acceptance continues to be an issue.

One of Smith’s colleagues, Dr. Noel Brewer, found that informed providers who understand potential outcomes need to be part of the vaccination process. For example, the pediatricians who often administer HPV vaccines may not be as familiar with the realities of cervical cancer compared to oncologists who take care of cervical cancer patients. The perspective of a health care professional familiar with the disease endpoint – in this example cervical cancer – is vital in answering questions and encouraging vaccine acceptance.

Similarly, dental professionals can play a valuable role in educating people about oropharyngeal cancers and the benefits of HPV vaccination.

The best time to vaccinate against HPV is between 11 and 14 years old. Parents will understandably have questions, not just about the vaccine itself but about the health outcomes it can help prevent.

“Dental professionals already play a vital role in early detection and oral cancer literacy,” said Brian. “This uniquely positions us to engage in direct prevention as well.”

What is the Code Maintenance Committee, and Why is an HPV Code Important?

The ADA’s Code Maintenance Committee evaluates and votes on changes to the CDT Code, or the Code on Dental Procedures and Nomenclature. The procedural codes are meant to ensure a level of consistency in dental treatment, and they are used to file insurance claims for oral health care services.

“The adoption of the code marks the first of many steps, and it opens several doors,” said Brian. “It signals broad agreement on oral health care provider-administered HPV vaccines to payers and policymakers, and it provides a framework to integrate HPV vaccination into the practice of dentistry.”

At NCOHC, we’re pleased to see the dental profession moving in this direction, and we believe these changes can make a profound difference in preventing HPV and, ultimately, oropharyngeal cancers.

What’s Next?

The adoption of the new CDT codes alone won’t allow oral health care providers in most states to begin HPV vaccination.

In some states such as Illinois and Oregon, where dentists are already authorized to administer various vaccines, there likely won’t be much delay in adjusting their regulatory frameworks to allow for HPV vaccination. However, in most states, including North Carolina, state law will need to change for oral health care providers to be authorized to administer the vaccine. \

“We will need to modify state law to incorporate HPV vaccination into the scope of practice for oral health care providers,” said Brian. “For that to happen, it will be critical that we work closely with our partners across the state, including our medical counterparts and other advocacy groups.”

Insurers will also be important partners in this effort. While the necessary legal changes are being made, payers will also need to engage to encourage and support oral health care providers’ administration of the HPV vaccine.

“Once the policy has been updated and the reimbursement framework is in place, the dental profession will have a significant opportunity to improve population health,” said Brian. “The dental community could rapidly increase the availability of the HPV vaccine and add a much-needed perspective to cancer prevention efforts.”

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

COVID-19 has impacted virtually every aspect of human life for the past two years. From retaining steady employment and income to maintaining preventive medical care, healthy habits, and more, things got a bit more difficult for most everyone, and a whole lot harder for many.

COVID-Oral Health Connection

Earlier in the pandemic, we published an initial overview of the ways that the virus has impacted oral health. As we enter 2022, with a hopeful light at the end of the tunnel, we are taking another look at the connection between COVID-19 and oral health to break down the many ways the pandemic impacts our mouths.

Here’s a brief review of what we know so far.

Loss of Taste and Smell

From the beginning of the pandemic, loss of taste and smell have been prominent symptoms of COVID-19. As the first recognized oral manifestation of the virus, loss of taste was an early indicator of infection, even as testing and other precautionary measures were still ramping up.

Loss of taste and smell, which are typically grouped together in part due to the similar nature of the two senses, continue to be significant issues for many diagnosed with COVID-19. They are also often among the longer-lasting impacts of the disease. Like many COVID-19 symptoms, however, people who have contracted the virus have a wide range of experiences with the loss of these senses.

In some cases, loss of taste and smell lasts a short period of time before returning to normal, and many who contract COVID-19 don’t lose these senses at all. But in others, sensory loss lasts months, and there are even some cases where the loss of taste and smell seems to be permanent.

Treatment for COVID-related Loss of Taste and Smell

“There are frustratingly few interventions” to treat taste and smell loss, according to a Journal of the American Medical Association (JAMA) commentary. One of the only successful options is olfactory (smell) training. This treatment basically involves regularly smelling a variety of scents. While the mechanisms that make this remedy work are still largely unknown, it has demonstrated a significant level of success.

Physicians and researchers at Thomas Jefferson University Hospital are currently developing another potential treatment: topical platelet-rich plasma (PRP). PRP, which is commonly used for injuries like tennis elbow and muscle pulls, has shown promising results in early trials for treatment of loss of taste and smell.

Dry Mouth and Oral Lesions

While loss of taste and smell were among the first widely known symptoms of the virus, dry mouth has become the most common oral manifestation of COVID-19, present in 43 percent of cases.

Dry mouth has the potential to lead to or intensify existing oral disease. Saliva is an oral health powerhouse — it helps defend against decay-causing acids and bacteria. With less saliva, people who contract COVID-19 and experience dry mouth are at greater risk of tooth decay and gum disease.

Researchers have also found a significant correlation between COVID-19 infection and oral lesions. Again, the exact mechanisms connecting the virus and the oral manifestation are not clear, and there is a wide variety of types of lesions that have been documented. Ranging from canker sores to herpes-like sores, oral thrush, and more, these lesions were found in 20.5 percent of patients in a study surveying 2,491 cases of COVID-19.

Treatment for Dry Mouth and Oral Lesions Due to COVID-19

According to the Mayo Clinic, dry mouth treatment options include:

• Stay hydrated
• Reduce caffeine intake
• Don’t use alcohol-based mouthwashes
• Stop using tobacco
• Use a humidifier at night
• Use an over-the-counter dry mouth mouthwash

Oral lesion symptoms associated with COVID-19 vary widely. Minor canker sores generally clear up on their own with no treatment, and there are a variety of mouth rinses and topical products available for more persistent sores. For other symptoms like oral thrush, antifungal medicines may be necessary. Because of the wide variation in lesions, the best approach if you are experiencing these symptoms is to consult your dentist.

Understanding COVID-19 and Its Oral Manifestations

To say the least, COVID-19 is an incredibly confusing virus. The list of potential effects is seemingly endless and disconnected, ranging from flu-like symptoms like fever, cough, and sore throat to:

• Shortness of breath, and difficulty breathing
• Headaches
• Loss of taste and/or smell
• Oral lesions
• Brain fog
• Pink eye, light sensitivity, and sore or itchy eyes
• Rashes
• Swollen or discolored extremities
• And more

Some of the most prominent symptoms are very similar to the flu, suggesting that COVID-19 is a respiratory disease. But researchers are continuing to find evidence indicating that COVID-19 might be a vascular virus – a disease of the blood vessels.

Looking at COVID-19 as a blood disease can help demystify the variety of seemingly disconnected symptoms. In the dental community, we are familiar with the important role of blood vessels in the mouth-body connection. With COVID-19, blood vessels could be the link between stroke-like brain impacts, respiratory problems, and oral manifestations.

COVID-19 and Oral Health Equity

Beyond direct connections between COVID-19 and the mouth and the nearly endless list of symptoms associated with the virus, there is another long list of impacts that make their way back to our mouths. Nearly every social determinant of health has been exacerbated during the COVID-19 pandemic, and they all have oral health repercussions.

Prior to the pandemic, the U.S. poverty rate was at its lowest point since 1959. Despite supplemental programs to offset income loss early in the pandemic, poverty rates for adults and children alike have increased. Many people struggled (and continue to struggle) to get enough food, retain steady employment, and maintain stable housing — all of which have known links to oral health and overall health.

The bottom line: Outside of the dental office, it has been much harder for millions of people to maintain good oral health habits during the pandemic.

Inside the dental office, things also became harder when the pandemic hit.

• There is a plethora of anecdotal evidence from dentists across the country who have seen more patients with stress-induced cracked teeth.
• Fear of seeking care due to possible COVID-19 exposure continues today, putting people at risk of more extensive treatment needs down the road.
• The widening income gap and shaky employment situations have left many without the insurance necessary to maintain regular preventive appointments.
• Dental staffing shortages, a problem before COVID-19, have become more severe during the pandemic, especially among hygienists and assistants.

Oral Health & COVID-19: Where Do We Go from Here?

The list of connections between COVID-19 and oral health could go on and on. For example, dental researcher Faleh Tamimi is leading a study of similarities between COVID-19 and periodontal disease co-morbidities, finding that people with COVID-19 and gum disease are 3.5 times as likely to be admitted to an ICU and 4.5 times as likely to be put on a ventilator. In the months and years ahead, we’ll continue to keep a close eye on this and other research exploring the link between COVID-19 and oral health.

At the end of the day, however, one thing is clear: the many ways COVID-19 impacts oral health continue to be significant.

The pandemic could, and should, be an opportunity as well. With so many in need, and with so much focus on health care, we have an incredible opportunity to look at structural changes to dramatically increase access to care.

NCOHC and our incredible coalition of partner organizations and advocates are taking strides to map out the future of oral health care – a. future that includes everyone, everywhere. Learn more about current initiatives and ways you can get involved today at oralhealthnc.org/nc4change.

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

It is time to celebrate! National Dental Hygienist Week is the second week of April each year (April 4-10). During this week, NCOHC wants to celebrate the students excited about becoming future registered dental hygienists. This is the time of year potential dental hygiene students are preparing and submitting applications and anxiously awaiting acceptance letters. Let’s explore the process prospective dental hygiene students must go through to prepare and apply to a dental hygiene program and the road they travel to become dental hygienists.

Dental Hygiene Programs

North Carolina has thirteen Commission on Dental Accreditation (CODA) approved dental hygiene programs. These include 12 Associate of Applied Science degree programs at community colleges throughout the state and one baccalaureate program at the University of North Carolina Adams School of Dentistry.

For dental hygienists to practice in North Carolina, they must graduate from a CODA-approved dental hygiene program. CODA is the sole agency that accredits dental and dental-related education programs and is nationally recognized by the United States Department of Education (USDE).

Dental hygiene programs must go through accreditation — a rigorous self- and peer-reviewed process — every seven years to ensure they provide a quality education and comply with CODA’s Accreditation Standards and Commission Policies.

Prerequisite Admission Requirements

The education process for a dental hygienist is quite extensive. Before being accepted into a CODA-approved dental hygiene program, it is strongly recommended that students complete required general education/dental hygiene prerequisite courses due to the rigorous nature of the dental hygiene curriculum.

Prerequisite courses for dental hygiene programs include but are not limited to:

• anatomy and physiology (one or two courses)
• microbiology
• chemistry (class and lab)
• communications
• English (two courses)
• math
• psychology
• sociology
• a humanities/fine arts elective (i.e., critical thinking)

These courses can take a student a year or two to complete prior to being accepted into a hygiene program.

Dental Hygiene Program Admission Process

Admission into dental hygiene programs is very competitive due to the limited number of students each program accepts. For example, 80-100 students may apply to a dental hygiene program that only has 20-30 seats available.

The selection process is usually based on a point system. Points are awarded for specific requirements, including but not limited to:

• general education/dental hygiene prerequisite courses (more points will be assigned for an A earned in a course vs. a B or C)
• high school or college GPA
• the Assessment Technologies Institute (ATI) Test of Essential Academic Skills (TEAS) score
• completion of a dental assistant program and/or dental assistant work experience

Applicants with the highest number of points are admitted into the program.

Dental Hygiene Curriculum and Program Requirements

After being accepted into a dental hygiene program, students begin an intensive two-year program that requires them to complete traditional classroom and hands-on clinical coursework with a grade of “B” or better.

The dental hygiene curriculum includes:

• orofacial anatomy
• infection/hazard control
• medical emergencies
• preclinic lecture and lab
• dental radiography
• general and oral pathology
• periodontology
• nutrition/dental health
• dental pharmacology
• community dental health
• dental materials and procedures
• professional development
• dental hygiene theory courses
• clinical courses throughout the program

In clinical courses, students are required to treat patients in dental hygiene clinics located on their school’s campus. They learn to manage and treat patients’ needs and provide preventive oral health care.

When I was the program director for Catawba Valley Community College’s dental hygiene program, dentists and even one pharmacist were constantly surprised to learn about the rigorous nature of hygiene programs. One dentist told me that she wasn’t aware of the extensive knowledge hygienists gain in school, and teaching our students gave her even more respect for dental hygienists.

Examinations and Licensure

During the last semester of dental hygiene school, students apply for and complete national and regional exams and begin the licensure requirements. The National Board of Dental Hygiene Examination (NBDHE) is an eight-hour comprehensive exam administered by the Joint Commission on National Dental Examinations (JCNDE).

Exam Requirements for Dental Hygienists in North Carolina

There are state-specific exam requirements for dental hygiene students, as well. In North Carolina, dental hygiene students take the American Board of Dental Examiners (ADEX) exam administered by the Council of Interstate Testing Agencies (CITA), a regional testing agency. The ADEX exam consists of two components – the Patient Treatment Clinical Exam (PTCE) or the Manikin Treatment Clinical Exam (MTCE) and the Computer Simulated Clinical Examination (CSCE).

Licensure

After students complete the national and regional examinations, they must complete a North Carolina State Board of Dental Examiners (NCSBDE) licensure application. The application process requires completing an extensive application, a background check, a nominal licensure fee, a passing score on the NBDHE and CITA exams, and successful completion of the Infection Control/Sterilization and Jurisprudence examinations.

Finally…a Registered Dental Hygienist

The NCSBDE issues a candidate a dental hygiene license once their application is completed and approved. At last, the dental hygiene student has earned the status of a Registered Dental Hygienist!

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

The NCOHC team recently had the rare opportunity to venture out of our homes and wipe the dust off our desks. With masks in hand, we made our way to our Foundation for Health Leadership & Innovation office to meet Mary Otto, journalist and author of the critically acclaimed book “Teeth” while she was here in North Carolina.

Otto is a health care reporter and a leading voice in oral health journalism. If you haven’t read “Teeth,” the book is an eye-opening account of the pervasive inequities that exist in oral health care and their devastating impacts.