Access Blog Equity Public Health Teledentistry

Envisioning Teledentistry in North Carolina

Let’s take a moment to review an all-too-familiar scenario for many North Carolinians.

Martha lives in rural Tyrrell County, North Carolina, where there are no practicing dentists. She works a full-time job while raising her two children. So, she decides against making the hours-long round trip to the nearest dental office one county over to receive a cleaning and checkup.

Let’s face it: for Martha, the cost of transportation, the dental service itself, and the pay lost while she is away from work make for a steep price for care. On top of that, she knows that she may have to schedule a follow-up visit—and take time off from work again, find someone to pick up her children from school again, pay for gas again—if she has any cavities that need filling.

So Martha waits.

Sadly, what started as a bit of sensitivity develops into an unbearable toothache, which lands her in the emergency department (ED). In the ED, she is prescribed an opiate to deal with the pain and an antibiotic for the infection, and she is told to “follow up with your dentist.”

In a month or so, however, Martha, like so many others, ends up right back in the ED when her infection, which has never been directly treated, flares up again

Martha isn’t alone in this situation.

This story is reality for hundreds of thousands of North Carolinians who, for various reasons, cannot access oral health care.

A Better Way: The Promise of Teledentistry

Teledentistry is a promising innovative tool that could play a critical role in increasing access, especially in rural areas like Tyrrell County.

What is Teledentistry?

The use of telecommunications for dental exams and assessments, consultations between dental providers, and direct education for patients, among other uses. Teledentistry is a treatment tool that has incredible potential for increasing access to quality dental care in communities that traditionally lack access, especially in rural areas without practicing dentists.

Imagine this:

The next time Martha winds up in the hospital for her toothache, she is connected with a dentist in Chapel Hill via a live video feed. A medical professional takes digital x-rays of Marhta’s mouth and uses an intraoral camera to allow the remote dentist to take a look at her teeth. The dentist quickly diagnoses her abscessed tooth, prescribes Martha the correct antibiotic to help fight the infection, and helps her schedule an appointment for treatment.

With her oral health issue resolved, Martha finally breaks the cycle of hospital visits that she would have otherwise endured.

While Martha had never seen a dentist up until this point, she has always kept up a good habit of visiting her local federally qualified health clinic for an annual checkup. The next time she visits, she learns that the clinic now offers asynchronous teledental services in partnership with East Carolina University.

Synchronous and Asynchronous Teledentistry

Synchronous is a fancy word that means “at the same time.” In synchronous teledentistry, a dentist is connected via a live video feed to review material, assess the patient in real time, and provide direct patient counsel, if needed.

Dentists who practice asynchronous teledentistry are sent diagnostic information such as digital x-rays and pictures from intraoral cameras to review at a later date, giving them time to look at all the material and put together a comprehensive treatment plan based on the patient’s unique needs.

Digital x-rays and pictures from an intraoral camera are sent to a dentist who works through East Carolina University. She reviews Martha’s records later that week. Fortunately, this time there is no need for further treatment, but the dental provider does advise that Marhta floss more regularly.

Martha’s children have also never seen a dentist. Luckily for them, a dental clinic was recently established at their school and a dental hygienist provides them the same asynchronous teledental services that their mother received at the medical clinic.

The hygienist provides Martha’s children with fluoride treatments, dental sealants, and a thorough cleaning. The dentist who reviews their digital x-rays and other diagnostic information determines that they have no cavities, but that they both do have moderate gingivitis. The hygienist learns that the two have had to share a toothbrush, so the clinic provides them with two new toothbrushes and tubes of fluoride toothpaste.

From in-school clinics to emergency departments, teledentistry is a promising asset that could significantly improve access and equity in oral health care across North Carolina. For families like Martha’s, simple diagnostic services completed through teledentistry could drastically increase tangible access points to dental services, and in return prevent significant oral health burdens downstream.

The Tools of Teledentistry

Teledentistry can seem daunting, especially when it comes to modernizing an office to meet the technological needs of remote care. Unlike many variations of telehealth, however, the tools of teledentistry are actually quite simple. The basic necessities are:

  1. A digital x-ray system

  2. An intraoral camera

  3. Electronic patient records

Most dental practices already use digital x-rays and intraoral cameras, and practices across the country are rapidly making the switch to electronic record-keeping. Compared to other telehealth services, the startup cost for teledentistry is relatively low.

By helping break the cycle of emergency department visits for oral health crises, medical costs for patients and the healthcare system as a whole could be significantly reduced. This is especially important in our rural communities. Cutting the uncompensated care costs burdening rural hospitals across the state could go a long way in attaining financial solvency. Additionally, inserting a dental professional into the hospital setting via teledental services could be an important way to combat the opioid crisis, reducing the number of unnecessary opiate prescriptions often given to patients with oral health emergencies.

Want to Know More?

NCOHC is taking a trip later this week to tour the state-of-the-art Center of Excellence for Telehealth at the Medical University of South Carolina. Stay tuned for our report from the trip!

Also, join us on June 3, 2020, for Oral Health Day! Oral Health Day is NCOHC’s annual advocacy event at the North Carolina General Assembly. This year we will focus our discussion on pathways to successful teledentistry in our state. Click here for more information and to register today!

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

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

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Healthy Mouth, Healthy Body: Oral Health During Pregnancy

Recap: The Oral-Systemic Connection

Parts one and two of our series, “Healthy Mouth, Healthy Body,” focused on heart disease, diabetes, and how the two are linked to oral disease

Gum disease, or periodontal disease, can allow harmful bacteria to enter the bloodstream and cause chronic inflammation. This inflammation is linked to conditions like atherosclerosis, an artery disease that can lead to heart attacks and strokes.

Diabetes is connected to gum disease in several ways. Dry mouth caused by diabetes can lead to suboptimal oral health, and gum disease itself can increase the prevalence of risk factors for diabetes like elevated blood glucose levels

To catch up, be sure to read parts one and two of this series.

Healthy Mouth, Healthy Pregnancy

Even though this follows posts about heart disease and diabetes, to be perfectly clear, we are NOT calling pregnancy a disease! (And, brushing your teeth, well, cannot prevent pregnancy.)

Pregnant mothers experience significant changes in their bodies during pregnancy, and some of these changes can impact oral health. For example, hormone imbalances can lead to gingivitis in the expecting mother. Increased vomiting from morning sickness, too, can increase the likelihood of developing cavities and tooth erosion (stripping of the tooth’s enamel).

Additionally, the research into the oral-systemic connection during pregnancy draws a connection between gum disease and low birthweight in newborns. Bacteria from gum disease can release toxins in the mother’s body that causes the body to produce chemicals that may stimulate contractions prematurely.

Research also reveals that gum disease may be linked to pre-term birth, but that connection is much less certain for now.

What Does This Mean?

For expecting mothers, it is important to work dental care into the already busy health care routine during pregnancy. For individuals who qualify for Medicaid while pregnant, NCOHC is working to support the extension of dental benefits post-partum to match perinatal health care coverage, which currently lasts 60 days after birth in North Carolina. You guessed it — currently, oral health coverage for the mother ends at time of delivery.

The oral-systemic connection during pregnancy also underscores a notion we have mentioned in all three parts of this series: integrated health care models are key to optimal outcomes. Expecting mothers have a lot do deal with, including a plethora of health care needs, from OB-GYN visits to primary care, birth counseling, and more. This takes time (and time off from work), which is hard to come by for many. We understand that adding oral health care into the mix can be easier said than done.

Integrated health care models, however, offer a way to make care during pregnancy easier on the expecting mother. Clinics and medical practices equipped to serve all the needs of a mother, from oral health care to OB-GYN services, could help ensure that pregnant women receive full-spectrum care to ensure as healthy a pregnancy as possible.

For more on the oral-systemic connection, be sure to read parts one and two of this series, and check out the resources below.

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

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

Additional Sources for Information on the Oral-Systemic Connection

Access Equity Public Health Social Determinants of Health

Takeaways From the North Carolina Public Health Leaders’ Conference

The North Carolina Public Health Association recently hosted its 2020 Public Health Leaders’ Conference, drawing professionals from across North Carolina to discuss pressing issues and the public health landscape as we look ahead to 2030 and beyond.

In many ways, this year’s conference marks a turning point in North Carolina, so we sat down with Foundation for Health Leadership & Innovation President and CEO Anne Thomas to talk about the conference and her takeaways.

The theme of the 2020 Public Health Leaders’ Conference was “Shifting the Trajectory: Advancing Equity in Public Health.” According to Thomas, the importance of equity is not a new concept in public health, but the unified focus across public health leaders in North Carolina marks a promising change.

Putting Health Equity Front and Center

“We haven’t always spoken with the language of equity,” said Thomas. “I became a public health director in 1996, and we always talked about disparities, but the conversations used to be, ‘If we just tell people to change what they eat and how they live, they will be healthier.’ We can tell people how to be healthy, but if they don’t have insurance, transportation, or the proper food, and if we don’t address root causes like structural racism and poverty, we aren’t really going to make much of a difference.”

Thomas said that the intentional shift toward an equity-focused landscape in public health is significant. While disparities in health have always been a top priority for public health leaders, the focus has generally been from a clinical frame, leaving non-medical drivers like food, transportation, and housing out of the picture.

At the conference, the North Carolina Institute of Medicine (NCIOM) and the North Carolina Department of Health and Human Services (DHHS) unveiled their “Healthy North Carolina 2030” strategy, which lays out priorities to improve health in the new decade.

The focus on health equity and the overall drivers of health outcomes speaks to the new transformational vision for public health in our state to improve the health and well-being of all North Carolinians.

This excerpt from “Healthy North Carolina 2030” highlights non-medical factors like incarceration rate, reading proficiency, and suspensions as important indicators of health.

Using Social Determinants of Health to Understand Equity

Want to Know More About Social Determinants of Health?

Read our analysis of the most pressing systemic barriers to access where we break down how geography, income, language, race, and more can impact health outcomes.

To highlight health inequities, speakers at the conference discussed the importance of understanding and tackling non-medical drivers of health. Instead of simply treating patients, the speakers championed a more encompassing approach, understanding that health starts in homes, schools, and communities, not once you walk through the doors of a doctor’s office.

“The thing that has really changed is that we are talking about the non-medical drivers of heath, the root causes that have caused health inequities, and evidence-based strategies to address them,” said Thomas.

Thomas said that 20 percent of a person’s health is the result of clinical care, and 80 percent comes from other factors known as social determinants of health. To address that 80 percent, providers will pay attention to social determinants of health, and the health care systems will provide mechanisms to make things like food, housing, and transportation accessible to those who need them to be healthy.

Buying Health: Equity in Action

The concept of “buying health” is where equity becomes operationalized. Buying health refers to a value-based model where health outcomes are measured and paid for, versus the current fee-for-service model, where the cost of care is determined by the service(s) provided.

“Right now, if I go to the doctor, the office gets paid. It doesn’t matter if my health improves because there was an office visit,” said Thomas. “The concept of buying health means screening for these non-clinical factors, and if it is food that they need, or transportation, that food or transportation will actually be paid for.”

NCCARE360, a partnership between FHLI and the Department of Health and Human Services, was also an important topic of conversation at the conference, specifically regarding buying health. NCCARE360 is the first statewide network to unite health care and human services, using shared technology to coordinate person-centered care that provides for both medical and non-medical needs.

By the end of 2020, NCCARE360 will be available in all 100 counties in North Carolina.

Thomas said that buying health was an important topic at the conference, especially as North Carolina prepares for Medicaid Transformation, the state’s plan to transition from Medicaid’s fee-for-service model to “Medicaid Managed Care.” Under Managed Care, the state government will work with insurance companies to create a system that incorporates physical and behavioral health to address both the clinical needs and social determinants of health for Medicaid recipients.

“I feel like we are at a tipping point now,” said Thomas. “Equity is no longer something we just talk about. We are developing real strategies to achieve it.”

Our Oral Health Takeaways

The major themes of this conference—implementing equity, understanding social determinants of health, and transitioning towards value-based care—all apply to oral health care as well as traditional medical care. In fact, these new points of focus highlight the importance of breaking down the siloes that traditionally separate oral health from the rest of the body.

“This new focus is helping communities and providers realize that we really can’t separate the head from the mouth from the body, and we need to stop thinking in a siloed mentality,” said Thomas.
At NCOHC we believe that integrated care models that address all of a patient’s needs, incorporating oral health, medical health, and non-medical needs all under one roof, are integral in creating an equitable health future for all North Carolinians.

As we head into 2020 and plan for the decade ahead, we are excited to work hard to address social drivers of health and pave an equitable path to a healthier future for all North Carolinians.

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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Healthy Mouth, Healthy Body: Diabetes and Oral Health

Recap: What is the Oral-Systemic Connection?

New research is revealing the intricate connections between the health of our mouths and the health of our bodies. Conditions like cardiovascular disease (heart disease), diabetes, osteoporosis, Alzheimer’s Disease, and many others have significant connections to oral health.

If you missed it, be sure to read part one of our three-part series, “Healthy Mouth, Healthy Body,” where we cover the connections between gum disease and heart disease. In this post, we’ll travel from the hart through the blood vessels to explore diabetes adn its connections to oral health.

Review: The Oral-Cardiovascular Connection

Gum disease, or periodontal disease, can allow harmful bacteria to enter the blood stream and can cause chronic inflammation. Chronic inflammation is linked to many harmful diseases, like atherosclerosis, an artery disease that can lead to heart attacks and strokes.

Healthy Mouth, Healthy Blood

Gum disease and diabetes are complexly intertwined. Gum disease can increase the risk of diabetes, AND diabetes can increase the risk of gum disease.

Here’s how it breaks down:

To start, diabetes can cause dry mouth (xerostomia). Your saliva is a powerhouse, defending against cavities by cleaning your mouth and controlling its pH balance. So, if you have dry mouth, reduced levels of that cavity-fighting saliva decreases the impact of its antimicrobial functions. And, your mouth’s pH may even become imbalanced, increasing how quickly plaque can develop and build up.

Additionally, since diabetics have delayed healing, one with active oral disease can be at a greater risk of infection following a tooth extraction and other surgical procedures.

On the flip side, gum disease is also linked to multiple causes of diabetes. Unmanaged gum disease can lead to chronic inflammation and increased blood glucose levels, both of which are important risk factors for diabetes.

What Does This Mean?

Our Habits Play a Role in the Oral-Systemic Connection

When thinking about oral-systemic connections, it is important to consider the causes, as well as the connections and outcomes. For example, increased sugar intake is both a risk factor for developing diabetes and a risk factor for developing cavities and periodontal disease. There are many other habits, such as tobacco use, that also impact your oral health and the health of other parts of the body.

Emerging research into the oral-systemic connection and the prevalence of these diseases highlight just how important it is that everyone have access to both oral health care and general health care.

Gum disease and diabetes are both incredibly common conditions. Gum disease affects 75 percent of adults in the United States, and nearly all Americans (about 91 percent of adults over 20) have tooth decay, according to the CDC. More than 100 million (about 33 percent) of Americans have either diabetes or prediabetes.

At NCOHC, we focus especially on those who lack access to optimal oral health care. The demographic characteristics of communities that chronically lack access are very similar to those with higher rates of diabetes. (For more on this, see our post about systemic barriers and oral health equity).

It is incredibly important that we address systemic barriers to oral health care, and to health care in general, to make sure that vulnerable populations get the care they need to live healthy lives.

Additionally, given the links between diabetes and oral disease, medical practices that treat patients with diabetes should understand how to recognize symptoms of oral disease. Conversely, dental practices should be aware of how diabetes plays a role in oral health outcomes.

This is why we support advancing integrated care models, where dental practices and medical practices alike are equipped with the tools necessary to positively impact both sides of the oral-systemic connection.

Stay tuned for the final part of this three-part series, focusing on the connection between oral health and pregnancy. We will publish this final post on February 11.(Follow us on our brand new Facebook page and we’ll let you know when we publish new content!)

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

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

Additional Sources for Information on the Oral-Systemic Connection

Access Equity Public Health Social Determinants of Health Spotlight

Dental Practice Rule Change and Children’s Oral Health: A Conversation With NC Child’s Sarah Vidrine

On Thursday, January 16, 2020, the North Carolina Rules Review Commission gave its final approval of a rule change to ease restrictions on dental hygienists, increasing access to oral health care for children in high-need settings.

Last week we sat down with Sarah Vidrine, the policy analyst for NC Child, to discuss this rule change and how it will impact children in North Carolina.

What Exactly Does This Rule Change Do?

“It removes barriers to oral health care for kids in school-based settings, and it will ease the burden on the provider community,” said Vidrine. “For dentists and hygienists, it eliminates unnecessary barriers to allow providers to do the work they are trained to do.”

The change to Rule 16W allows hygienists located in Dental Provider Shortage Areas (HPSAs) to provide preventive care based on a written standing order from the supervising dentist rather than a dentist’s in-person exam. By decreasing the administrative burden of a prior exam, more children will have access to preventive dental care.

With 74 percent of North Carolina counties designated as HPSAs, this change opens doors for children across the state and is an important first step toward more equitable access to preventive care.

How Will This Help Children Access Oral Health Care?

Vidrine said that one of the exciting impacts of this rule change will be the increased ability for dental hygienists to go into schools to provide preventive treatment.

“School-based programs are promising because they let us meet kids where they are,” Vidrine said. “It’s a more efficient and cost-effective way to get kids dental care.”

“We treat cavities as if they are a rite of passage, but they really are preventable. The earlier we can get to kids and provide preventive treatment like fluoride and sealants, the bigger overall improvement I think we will see,” she said.

What Makes School-Based Care Different?

In schools, versus traditional care in a dental office, all kids have the opportunity to directly access care.

“School-based clinics reach kids instead of relying on parents to be able to take time off work, get their child out of school, and get them to a dentist,” said Vidrine. “Especially for families on Medicaid and families without insurance, it can be very difficult to get care, develop a treatment plan, and follow through. In school-based clinics, a lot of those barriers are removed.”

Why Is It Important That Dental Hygienists in Schools Be Able to Provide This Treatment in High Need Settings?

It really boils down to the numbers, according to Vidrine.

“In North Carolina we have both a shortage and a maldistribution of dentists. So, we have too few dentists to meet the need of the population we have, and most of these dentists are practicing in a fifth of the state,” said Vidrine. “Even with great programs through UNC and ECU that are very targeted at getting better access to rural communities, they are not going to graduate enough dentists to meet the need. Plus, we have a rapidly retiring population of currently practicing dentists.”

With the growing shortage of dentists, hygienists are necessary to fill the gaps in high-need settings.

“There are more dental hygiene programs than dental schools in the state, and they stay full and are very competitive,” Vidrine said. “We don’t have a similar shortage of hygienists in North Carolina.”

Along with waiving the prior exam in high-need areas, the rule change also allows dentists to supervise more than two dental hygienists who are practicing in high-need settings and have been duly trained as public health hygienists. Given the surplus of dental hygienists in the state, there is potential to access a much larger workforce focused on early preventive interventions.

“A dental hygienist’s role is to serve as the prevention arm,” said Vidrine. “Dentists spend a lot more time in school on treatment and interventions and less time on prevention, which is really the function of hygienists.”

The Takeaway: This Change Has Been a Long Time Coming, and We Will Keep the Momentum Moving Forward

“Advocates have pushed for similar rule changes for over 20 years, dating back to a 1999 North Carolina Institute of Medicine task force report on dental care access,” said Vidrine. “That happened before my time in oral health, but NC Child has been involved since 2015 when we started to look at policy options in collaboration with NCOHC.”

Years of effort, with the involvement of many different groups, has finally paid off. The final rule change was co-sponsored by NCOHC and the North Carolina Dental Society, the two organization’s first partnership of this magnitude.

Looking forward, the partnerships and collaboration that made this rule change a success will lay the groundwork for future efforts. Vidrine hopes that this is the first of many updates to North Carolina’s regulatory framework to further increase access and equity in oral health care.

“I think that there is an opportunity to look at things that complement this existing school-based prevention system, such as teledentistry,” Vidrine said. “And then there is a lot we can do with perinatal oral health, especially given some of the new research identifying risks for a pregnant mom with poor oral health.”

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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Healthy Mouth, Healthy Body: Cardiovascular Disease and Oral Health

Your Mouth is Part of Your Body!

It is easy to view oral health in a vacuum. We do see a dentist for our teeth and a general physician for pretty much everything else, after all.

However, thanks to new research, we are learning about new and interesting connections between health in our mouths and health throughout our bodies. The link between oral health and whole-body health is called the oral-systemic connection, and it can impact an array of conditions, from cardiovascular disease (heart disease) to diabetes, osteoporosis to Alzheimer’s disease, and much more.

Bottom Line: Poor oral health can impact overall health. It is incredibly important to see a dentist regularly, especially if you experience adverse health effects elsewhere in your body.

For dentists and medical doctors alike, it is important to keep the oral-systemic connection in mind when treating patients with periodontal disease and diseases linked to poor oral health.

In a three-part series, “Healthy Mouth, Healthy Body,” the Foundation for Health Leadership and Innovation’s North Carolina Oral Health Collaborative will break down the most prevalent examples of the oral-systemic connection and what you can do to make sure you have a healthy mouth and a healthy body.

Healthy Mouth, Healthy Heart

Cardiovascular disease, or heart disease, is one of the most common medical problems Americans face today. Even if your teeth seem far removed from your heart and arteries, there are important connections between the two.

If you have ever cut your face or mouth, you have seen firsthand just how many blood vessels are in these areas. Our faces and mouths are home to tons of small blood vessels right near the surface of our skin.

With all those surface-level blood vessels, it is incredibly easy for harmful bacteria from gum disease (periodontal disease) to make their way into the bloodstream.

What is Periodontal Disease?

Periodontitis, or gum disease, is an infection caused by plaque build-up that impacts the gum tissue and bone holding your teeth in place. At some level, periodontal disease affects 75 percent of adults in the United States.

Gum disease can release harmful bacteria directly into your bloodstream. Additionally, a side effect of serious gum disease is chronic inflammation, which is linked to medical conditions like atherosclerosis, an artery disease that can lead to heart attacks and stroke.

It is important to note that while scientists studying the connection between gum disease and heart disease have not found a causal role (one directly affects the other), there are numerous studies finding strong links between poor oral health and worsening outcomes for cardiovascular health.

What Does This Mean?

Our Habits Play a Role

When you think about the oral-systemic connection, it is important to consider causes as well as connections and outcomes. For example, consuming a lot of sugary foods on a day-to-day basis puts you at risk for diabetes, cavities, and periodontal disease. There are many other habits, such as tobacco use, that also impact your oral health and the health of the rest of your body.

The oral-systemic connection doesn’t mean that one cavity will cause an overall health crisis, but it does highlight how important it is to see a dentist regularly, especially for people who traditionally lack access (read more about systemic barriers to oral health care here).

Additionally, the oral-systemic connection highlights the need for more integrated models of health care. Traditionally, medical professionals are siloed within their area of expertise. With how interconnected the body is, it is important that health care reflect those links, with provider networks equipped with the tools necessary to assess and diagnose health problems from head to toe.

Be sure to stay tuned. Part two of this three-part series, focusing on the connection between oral health and diabetes, will be published on January 28.

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

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

Additional Sources for Information on the Oral-Systemic Connection

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Expanding Access: Pending Rule Change Will Allow More Children to Receive Preventive Oral Health Care

Oral health care will soon be more accessible for young North Carolinians who have been systemically underserved.

On December 13, 2019, the North Carolina Board of Dental Examiners unanimously voted to approve an important rule change that will increase access to quality, affordable oral health care. The change to Occupational Licensing Boards and Commissions Rule 16W will allow dental hygienists to further practice to the full extent of their licensure. The rule change has the potential to increase preventive services such as sealants and fluoride treatments to children, in high-need settings, without a dentist’s prior exam.

“With 74 of 100 North Carolina counties deemed as dental health provider shortage areas (HPSA), the state has a crisis of access to oral health services, primarily affecting our most vulnerable populations. This rule change means that we will have a real opportunity to increase access for those who are chronically underserved and ultimately prevent detrimental oral health outcomes later in life.”

—Dr. Zachary Brian, director of the North Carolina Oral Health Collaborative (NCOHC), a program of the Foundation for Health Leadership & Innovation

Before it goes into effect, this rule change, co-sponsored by the FHLI’s NCOHC and the North Carolina Dental Society (NCDS), must receive final approval from the Rules Review Commission. Approval is currently anticipated in mid-January 2020.

Here’s what the rule change means and how it could impact oral health care in North Carolina.

A Preventable Oral Health Crisis

Tooth decay is the single most common chronic childhood disease, disproportionately affecting low-income populations. Nationwide, roughly 50 percent of children in low-income families experience tooth decay, and dental disease is responsible for a collective 51 million hours of school missed each year.

Only 16 percent of children ages 6 to 9 have received a sealant on a permanent tooth.

Cost of care is a significant barrier that prevents children and families from accessing oral health care. At one-third the cost of a cavity filling, dental sealants are a low-cost solution that can dramatically reduce the likelihood that an individual will develop a cavity during childhood.

Unfortunately, North Carolina’s requirement that a child have a prior exam from a dentist before a dental hygienist can apply a sealant adds additional cost and delays to the process.

Dental Sealants and Dental Hygienist Licensure

A dental sealant is a thin coating applied to the chewing surfaces of a child’s back teeth. The application of a sealant is a simple and painless procedure that adds an extra layer of protection to the molars, teeth which are most susceptible to decay because of the pits and grooves on their chewing surfaces. A dental sealant protects against 80 percent of cavities for two years, and 50 percent of cavities for up to four years.

In 39 states across the country, dental hygienists can apply dental sealants without a prior exam or direct supervision from a dentist. This procedure is part of a dental hygienist’s education, but in states like North Carolina, hygienists can be hindered due to administrative barriers of the prior examination requirement.

How Will This Rule Change Impact Access to Care?

Without the requirement for a prior exam by a dentist, dental hygienists can offer sealants in alternative settings like schools or after-school clinics rather than at a dentist’s office. School sealant programs, in particular, are a very effective method for reaching children who would otherwise not see a private dentist.

According to the CDC, each tooth sealed saves more than $11 in treatment costs down the road. With just over one million low-income children in North Carolina, expanded access to dental sealants has the potential to prevent costly restorative treatment needs like dental fillings later in life.

What Comes Next?

NCOHC and NCDS have engaged in a new and productive partnership to co-sponsor this rule change, and NCOHC will continue to engage NCDS for productive changes to North Carolina’s oral health care landscape.

Similar to the restrictions on providing sealants and other preventive services, dental hygienists in North Carolina are also hindered in the ability to administer local anesthesia, a clinical skill that is valuable to patient comfort and whole-person care. In fact, North Carolina is one of just six states that prevents dental hygienists from administering anesthesia. NCOHC is currently evaluating this regulation for potential advocacy engagement in the future.

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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Our New Year’s Resolution: Great Oral Health in 2020

At NCOHC and the Foundation for Health Leadership & Innovation (FHLI), we are reflecting on 2019 and planning for 2020. Here are our highlights from last year and our plans for the year ahead.

What NCOHC Accomplished in 2019

In 2019 we supported communities across North Carolina, helping local leaders build relationships and collaborate with provider networks, educators, and more, to positively impact oral health outcomes.

We increased NCOHC’s educational impact, piloting an oral health practicum experience with Campbell University public health students and leading roundtable sessions at the UNC Gillings School of Global Public Health. Director Dr. Zachary Brian spoke at more than 40 workshops and presentations across North Carolina and around the country.

On the policy front, NCOHC worked hard to develop a fruitful partnership with the North Carolina Dental Society (NCDS). Together, we sponsored a regulatory rule change that will allow dental hygienists to practice to the full extent of their licensure, a change that will expand access to affordable health care for those who need it most.

Stay tuned, as the rule change is expected to be approved by the Rules Review Commission later this month!

Finally, with help from the oral health and policy advisers who make up our Collaborative Acceleration Team (CAT), NCOHC developed a Strategic Plan, setting ambitious goals to guide our work for the next five years.

be sure to check out our full Year in Review in NCOHC’s December Newsletter.

What We’ll Do in 2020

With guidance from our Strategic Plan, NCOHC will hit the ground running in the new year. We expect to see the regulatory rule change that we co-sponsored with NCDS signed into effect in the next few weeks, and we will continue to positively impact the oral health of North Carolinians through state-level advocacy.

We will continue to work with communities across the state to help local leaders increase access to oral health care. We will provide resources to these leaders, oral health care providers, and to the general public, and we will leverage our newly expanded capacity to increase NCOHC’s organizational effectiveness

stay tuned to our developing Resource Center—part of our newly redesigned website—for the latest oral health news and information for providers, policymakers, and the public.

All our work will impact NCOHC’s overall goal of advancing systemic change in oral health care. Our aim is to promote a value-based approach, recognize social determinants of health and barriers to equitable oral health care, and promote solutions to create an equitable landscape for all North Carolinians.

These are Our Oral Health Care Resolutions for 2020. What are Yours?

NCOHC is a program of the Foundation for Health Leadership & Innovation (FLHI). 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!

Access Blog Equity Public Health

Myth vs. Fact: Fluoride and Your Health

Fluoridation is one of the greatest public health successes of the 20th century.

Despite the overwhelming success of community water fluoridation at improving oral health outcomes, misinformation continues to circulate about its risks and benefits. From those that call fluoride a communist plot (really) to others that call it a deadly killer, myths about the element are widespread. In fact, over the last few decades, anti-fluoride movements have gained large followings across the country.

Separating Fact from Fiction

In reality, fluoride in municipal water supplies is one of the most important and effective advances in the history of public health.

Since its first application in Grand Rapids, Michigan in 1945, the addition of fluoride to municipal water supplies has dramatically improved oral health outcomes across income levels, age groups, racial lines, and geographic areas.

(To learn more about how income, race, and geography impact oral health, check out our previous blog post on systemic barriers impeding oral health care access)

Is fluoride expensive?

At less than 50 cents per person per year, water fluoridation is an incredibly cost-effective treatment that has proven to reduce cavities in children and adults, even helping repair tooth decay in its early stages.

But isn’t fluoride an unnatural substance we shouldn’t consume?

No. Fluoride occurs naturally in a wide variety of foods and beverages. In fact, if you’ve ever eaten fried shrimp, mashed potatoes and gravy, or raisins, you have consumed fluoride at higher concentrations than you do when drinking fluoridated tap water!

If you want to know more, check out this USDA report on foods and beverages that contain naturally occurring fluoride.

The truth is that we naturally consume fluoride every day.

However, while there is fluoride in all sorts of foods and beverages, it generally doesn’t naturally occur at high enough levels to benefit our teeth.

Adding fluoride to tap water hasn’t subjected us to a toxic hazard. On the contrary, community water fluoridation has simply ensured that many people have the same access to it in healthy, beneficial quantities.

If fluoride is in our water at higher concentrations than occur naturally, does that make it dangerous?

Not at all. Consider this:

For a 165-pound adult, 12 standard glasses of water consumed quickly is considered a lethal dose. By comparison, in order to obtain a lethal dose of fluoride, you would have to consume more than 15 12-ounce glasses of fluoridated tap water in rapid succession.

So how does fluoride work?

In the course of a day, we all consume foods and beverages that introduce cavity-causing bacteria to our mouths. That bacteria weakens our enamel — the hard, outer coating that protects our teeth.

When we brush our teeth with fluoridated toothpaste, eat fluoride-containing food, or drink fluoridated tap water, fluoride replaces hydroxide ions in our enamel. This process strengthens our teeth, prevents decay, and can even help reverse existing decay in its early stages.

How can I make sure I’m getting enough fluoride?

The best thing you can do to protect your teeth is to make sure that you brush for two minutes twice a day with a fluoride toothpaste. You can also use fluoride mouthwash, and make sure to drink fluoridated tap water to keep your teeth happy and healthy!

And yes, kids can use fluoride too. The rule of thumb is, “smear up to three years,” which means you should use just a smear of fluoride toothpaste to brush a child’s teeth until they are three years old. From 3-6 years old, use a pea-size amount of fluoride toothpaste.

Source: American Dental Association

NCOHC is a program of the Foundation for Health Leadership & Innovation (FHLI). 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!

Sources for more information:

Blog Equity Social Determinants of Health

Systemic Barriers and Oral Health Equity in North Carolina

There aren’t many people who really enjoy going to the dentist.

Who wants to have someone poking around in your mouth, drilling into your teeth, and telling you to floss more?

Reluctance to enter an uncomfortable setting is far from the only barrier keeping North Carolinians from going to the dentist. Hundreds of thousands of North Carolinians experience systemic barriers that keep them out of a dental chair.

The Foundation for Health Leadership & Innovation’s (FHLI) North Carolina Oral Health Collaborative (NCOHC) works to dismantle systemic barriers to oral health care, addressing social determinants of health to create a more equitable landscape for everyone in North Carolina.

Geographic Barriers

Where you live has a lot to do with how easy or hard it is to see a dentist. Five of North Carolina’s 100 counties are home to most of our state’s practicing dentists.

Did you know?

74 of North Carolina’s 100 counties are designated Dental Health Provider Shortage Areas (HPSAs).

So, if you are in Raleigh, you might have a choice between the dentist five minutes up the road and another one on the way to work, giving you the flexibility to fit oral care seamlessly into your schedule. But if you live in Tyrell County, you may have to plan an hour-long trip to access the closest dental office.


Cavity fillings, tooth extractions, implants, and crowns can be expensive treatments, and hundreds of thousands of North Carolinians are uninsured. Without the means to access oral health care from childhood, low-income North Carolinians often don’t receive preventive treatment early on, leaving them at higher risk of negative outcomes later in life. Beyond oral health, this has far-reaching impacts that influence a cycle of poverty that is hard to escape.

Poor teeth, I knew, beget not just shame, but more poorness: people with bad teeth have a harder time getting jobs and other opportunities. People without jobs are poor. Poor people can’t access dentistry—and so goes the cycle.

Sarah Smarsh, “Poor Teeth”

Be sure to check out NCOHC’s Resource Center for more content, like the incredibly personal and compelling essay about poverty and oral care, “Poor Teeth,” by Sarah Smarsh.

Compounding Effects

These systemic barriers to oral health care don’t occur in a vacuum. They compound, making access harder and harder. Imagine the difficulty of seeing a dentist if you live in a rural community and must schedule an hour-long trip to access care. Now imagine how much harder that would be to fit into your schedule if you are working two or three jobs to make ends meet. What would you do if, on top of all that, the dentist doesn’t accept your Medicaid insurance, forcing you to budget time for a two- or three-hour trip?

On a positive note, North Carolina’s oral care Medicaid benefits are among the best in the country. Unfortunately, they are incredibly underutilized. 76% of North Carolina’s dentists are in private practice, and few accept Medicaid insurance, making it difficult to find an in-network provider.

Language Barriers

According to the Modern Language Association of America, nearly 900,000 North Carolinians speak a primary language other than English. Most of these individuals speak Spanish, but other primary languages include French, German, Chinese (including Mandarin), Vietnamese, Arabic, Korean, and more.

For non-native English speakers, and for those who may not speak English at all, understanding dental care, finding a dentist, scheduling appointments, and coordinating with insurance companies can be daunting tasks. Making it even more difficult is the fact that many dentists in North Carolina don’t have bilingual staff or translated paperwork.

For dentists, language barriers can pose issues regarding informed consent. Even with a translator present, ensuring that the patient truly understands a procedure can be a major concern for providers.

Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) have a higher chance of suffering from poor oral health for a variety of reasons. The IDD population often has a harder time finding transportation to and from a dentist, many are non-ambulatory, and physical ailments can inhibit good personal oral hygiene habits. In addition, most dentists don’t have training to provide services for those with special needs.

In the Community

NCOHC recently partnered with Campbell University public health students for a practicum experience in oral health. As part of the program, the students worked to incorporate oral health into Harnett County’s MedFest event, a program of Special Olympics North Carolina that provides medical services to Special Olympics participants.

Read more about the program in, “Building Oral Health Champions: Reflecting on a Semester with Campbell University Public Health Students” or watch our video spotlight on Campbell University.

These are just a few of the factors that impact the IDD community. For a more in-depth analysis, check out this 2018 study by the Eunice Kennedy Shriver Center on oral health care for adults with IDD.

Racial Disparities

Oral health outcomes and access to care differ widely along racial lines. Non-white North Carolinians are far more likely to have lower household incomes, and many live in “food deserts,” meaning they lack access to healthy foods. These factors affect oral health, as well as health in general.

According to the CDC, non-white Americans have higher rates of poor oral health, with the largest disparities occurring between 2-4 years old and 6-8 years old. Childhood tooth decay is a serious issue in minority communities, and it is an issue that continues to affect oral health and whole-body health throughout adulthood.

How Do We Address These Barriers and Achieve Oral Health Equity?

Achieving equity will take a multi-faceted approach, involving people in all levels of health care, community leaders, advocates, and more. NCOHC is partnering with innovative professionals to address needs, specifically working to increase North Carolina’s dental workforce, expand service areas in underserved communities, and increase accessibility to marginalized groups.

NCOHC is currently partnering with the North Carolina Dental Society to encourage a state-level rule change that would allow dental hygienists to provide critical preventive services in high-need settings. North Carolina is one of the most restrictive states for dental hygienists. This simple rule change will help better utilize North Carolina’s existing dental hygiene workforce, increasing access in under-served parts of the state.

Other avenues to increase equity include:

  1. Working with nontraditional organizations to increase access points outside of the traditional dental office (often known as a “dental home”). This means incorporting dental care in schools, nursing homes, primary care offices, and more.
  2. Coordinating with dental offices to provide translated consent forms, descriptions of procedures, and other helpful content to non-native English speakers and those who don’t speak English at all.
  3. Encouraging innovative ways to utilize the workforce with technological solutions like teledentistry.

Stay up-to-date by signing up for NCOHC’s newsletters, and if you are interested in becoming an NCOHC member for free, join us today!