North Carolina Oral Health Collaborative

Haven’t had time to read the new HPI Report analyzing access for children and adults with Medicaid/CHIP insurance in North Carolina yet? We’ve got you covered.

Earlier this year, the American Dental Association Health Policy Institute, in collaboration with the North Carolina Dental Society and the North Carolina Department of Health and Human Services, published an analysis of access to oral health care for North Carolinians with Medicaid/CHIP Insurance.

To provide context as we continue to break down the report and discuss next steps to create a more equitable, accessible North Carolina, we put together a brief summary of the report’s highlights.

Key findings from HPI’s analysis include:

1. Supply of “meaningful” providers—meaning providers who meet a benchmark of $10,000 in Medicaid claims each year—varies geographically for both children and adults.
2. While overall utilization among children is above the national average, with 58.9 North Carolinian children seeing a dentist within the past year versus 51.7 percent nationwide, there are also areas where utilization falls below 25 percent.
3. Dental care utilization among Medicaid-insured adults is low, at 18.7 percent statewide, versus 23.2 percent nationwide.
4. Medicaid-insured individuals are less likely to secure appointments compared to their privately insured counterparts.

Dr. Mark Casey, dental officer for the North Carolina Division of Health Benefits (NC Medicaid), penned an introduction to the report, tracing a history of innovation from the groundbreaking 1998 North Carolina Institute of Medicine “Task Force on Dental Access,” to a landmark lawsuit requiring NC Medicaid to raise reimbursement rates, and to the creation of “Into the Mouths of Babes”.

“NC Medicaid and its partner, the North Carolina Dental Society, agree that there is much work left to do to fulfill the promise of better oral health for the disadvantaged in our state,” wrote Casey. “However, it is also important to take note of the progress that has been made over the last 20 years from a time when the vast majority of publicly insured children were not receiving an annual dental visit.”

Casey also recently sat down with NCOHC for an interview about the HPI Report and his takeaways, which you can read here.

The HPI Report authors found that 90 percent of Medicaid-insured children live within 15 minutes of a participating dentist. It is important to note that this figure includes the entire pool of participating providers, not just “meaningful providers.”

When you filter for meaningful providers and break the data down geographically, access gaps begin to emerge.

The HPI Report authors outlined two important factors that contribute to North Carolina’s access gaps: the supply of dentists and the demand for dental services.

In the images above, red areas signify more than 2,000 Medicaid/CHIP-insured patients per meaningful provider. The grey areas, which are especially significant in the western and eastern parts of the state, lack a Medicaid office altogether.

When comparing supply versus demand, a clearer picture emerges, highlighting Northeastern and Western North Carolina as the two regions with the most pressing access disparities.

Looking forward, there are both good and bad signs for North Carolina…and there is a lot of work that can be done to increase access and equity in care.

On average, Medicaid/CHIP-insured patients have a more difficult time securing appointments compared to their privately insured counterparts. What work can be done to end this disparity?

HPI projected a net increase in practicing dentists in North Carolina in the coming years. Can North Carolina provide adequate incentives to encourage new providers to practice in underserved, rural areas?

Be sure to stay tuned for NCOHC’s perspective on the findings in the HPI Report and the collaborative’s suggestions for next steps to increase access and equity in oral health care! We will publish a full analysis soon. In the meantime, here are a few of our immediate takeaways:

1. In rural NC, innovative approaches to practicing dentistry — such as teledentistry and school-based care— can significantly improve access to those with Medicaid/CHIP insurance.
2. We need North Carolina stakeholders to work together and find innovative ways to incentivize newly graduated dentists to serve patients in underserved regions.
3. We are excited to work with stakeholders, both in private practice and public health, to find ways to increase the number of dentists serving Medicaid/CHIP patients, and similarly, to increase the number of patients participating dentists serve each year.

What changes do you think will help North Carolinians? Get involved by heading over to NC4Change and signing up for a focus group today!

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!

At the beginning of the new year, the American Dental Association Health Policy Institute released a new statewide report on oral health access for North Carolinians with Medicaid dental coverage.

As those of us at NCOHC read through the report, we saw both encouraging signs and cause for concern. For more perspective, we spoke to Dr. Mark Casey, dental officer for the North Carolina Division of Health Benefits (NC Medicaid).

Our conversation with Casey covered two important points. First, how are we measuring access to providers, and how could that measurement be improved? Second, what strategies can be implemented to increase use of benefits to ensure that more North Carolinians are accessing oral health care?

What is a “meaningful provider,” and how can the metric be improved to better measure access?

From the report: Out of 2,295 pediatric providers who accept Medicaid/CHIP insurance, HPI found 1,522 to be meaningful providers. For adults, 988 of the 2,160 Medicaid/CHIP providers were found to be meaningful providers.

The HPI report measured Medicaid participation with a “meaningful provider” benchmark of $10,000. This means that a provider who accepts Medicaid/CHIP insurance is considered a meaningful provider if they file $10,000 or more in claims with NC Medicaid each year.

This kind of benchmark offers important insight, filtering out providers who may only see a handful of cases each year, and revealing a map that better shows where access points truly exist.

But while $10,000 has been a standard benchmark, Casey thinks that the number should be higher, given changes over time in reimbursement rates and baseline cost of care.

“It really doesn’t take much in the way of claims activity to hit the $10k threshold these days,” said Casey. “The fact that this level of participation has not changed for 20 years ignores the inflationary pressures on costs to provide treatment and increases in reimbursement rates for providers.”

Casey said that he would like the reimbursement threshold to be $25,000 or $50,000.

He also mentioned that some organizations opt instead to measure meaningful providers by the number of Medicaid or CHIP patients treated in a year, a benchmark that would not be subject to change due to inflation or changes in reimbursement rates.

How do we increase the percentage of Medicaid-enrolled children and adults who use their benefits and see a dentist each year?

From the report: HPI found that 90 percent of Medicaid/CHIP-insured patients live within 15 minutes of a participating dentist, but only one-fifth of Medicaid-enrolled children and one-fifth of Medicaid-enrolled adults live in areas with an enrollee-to-meaningful provider ratio that is less 500-to-1.

To increase participation among this population, Casey discussed a two-fold approach.

First, he said that he believes more coordinated, innovative education initiatives between interested stakeholders would help encourage parents to take their children in for routine care.

Second, Casey said that a closer look at the population of participating dentists is important as well.

“I think we have a large number of providers who are on the low end of the Medicaid spectrum of participation,” said Casey. “I really do think that if the professional membership groups encouraged providers to participate—take 5-10 families as new patients for the year—we would see a spike in participation.”

According to Casey, both increasing the number of patients that enrolled providers see, and encouraging non-participating providers to begin seeing Medicaid patients, is critical to increasing access to care.

An innovative addition: hospital dental clinics

Casey discussed increasing the number of hospital dental clinics in North Carolina as an addition to the oral health care landscape that could increase access to important services, especially for some of the most underserved populations.

“With hospital dental clinics, my main goal is to provide a safe place for dental treatment for patients who have co-morbidities,” said Casey. “My thinking is not just diversion of dental emergencies from the ER, but also as our population ages, there are going to be a lot more elderly folks with chronic medical conditions that put them at risk for problems during a dental office visit.”

Casey also mentioned that hospital dental clinics could offer better options for dental patients with intellectual and developmental disabilities, a population that remains underserved in much of North Carolina.

Stay tuned for more analysis of the HPI report and NCOHC’s thoughts on the approaches needed to create a North Carolina where everyone has access to quality, affordable oral health care.

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

In the early 1990s, cervical cancer was the most common cancer among women. Today, it has dropped to fourth place, thanks in large part to successful screening programs and human papillomavirus (HPV) vaccination.

Dr. Jennifer S. Smith, a vaccine epidemiologist and professor in the Department of Epidemiology at the UNC Gillings School of Global Public Health, has worked on cervical cancer prevention for most of her career. She said that scientific advancement, especially in the realm of HPV vaccine development, has played a critical role in preventing the cancer and saving lives.

“When I first started working on cervical cancer, we didn’t have the vaccines yet,” said Smith. “At that time, we weren’t even 100 percent clear that HPV caused cervical cancer, but scientific colleagues were able to determine it through a number of really important studies around the world.”

Fast forward to 2020, HPV vaccines are now available and have the potential to prevent nearly 90 percent of cervical cancer.

HPV vaccination is recommended for universal use between 11 and 14 years of age in the United States.

NCOHC has focused on the HPV vaccine as an important preventive measure against oropharyngeal and head and neck cancer, but the vaccine can prevent a host of other cancers, too. For more on HPV and oropharyngeal or head and neck cancer, you can download NCOHC’s fact sheets for patients and providers here, and read more about dentist-administered vaccines here.

So, how do you go from a possible relationship between a cancer and a virus to a lifesaving vaccine?

According to Smith, epidemiological research, the study of causes and distribution of diseases, is a critical part of the process. With HPV, one of the first steps toward an effective vaccine was the discovery of its relationship to cervical cancer.

HPV is the most common sexually transmitted infection (STI), with about 43 million infections in 2018, according to the CDC. HPV infection is very common and is often harmless. In many cases, people who contracted HPV don’t even know they had it.

“As an epidemiologist I want to understand disease natural history,” said Smith. “All of that plays right into understanding, for example in the case of HPV, the specific individual infection types that cause invasive cancers. All of that epidemiology data goes right into the development of the vaccines.”

After decades of research, strong links have been discovered between HPV and cervical cancer, anal cancer, cancer of the penis, vagina, and vulva, and oral cancers. In total, 21,100 women and 14,700 men will be diagnosed each year with an HPV-related cancer, according to the CDC.

“The current generation of HPV vaccines are estimated to prevent about 90 percent of invasive cervical cancer cases, so it is a really good example of how understanding the virus and how it causes cancer informs vaccine development in order to prevent death,” said Smith. “That is ultimately what we’re after—we vaccinate to save lives.”

The work doesn’t stop with a successful vaccine

Vaccine uptake—actually getting people to take the vaccine once it has been developed, tested, and approved for use—is the next step. Smith has been involved on this front as well, working to figure out how to get accurate information to parents as they consider whether or not to vaccinate their children.

Smith helped start Cervical Cancer Free America, a network of coalitions with the goal of eliminating cervical cancer through vaccination, screening, and education.

“We started Cervical Cancer Free America working in a number of states to try and build coalitions to address cervical cancer prevention,” said Smith. “I think it is absolutely critical to think on a state-by-state level. It is critical to have local tailoring of messaging and local commitment.”

Smith referred to Dr. Noel Brewer, another UNC Gillings School of Global Public Health professor who studies health behaviors around cancer prevention and vaccination. Brewer’s work includes teaching health care providers how to communicate more effectively with patients about vaccines.

“I think the very clear message is that the biggest persuader, or the biggest factor that might influence a parent’s decision to vaccinate their child, is their trusted clinical provider,” said Smith.

Providers often giving HPV vaccines are pediatricians, who may not be as familiar with invasive cancer outcomes as gynecologic oncologists, for example, who are the health care professionals taking care of cervical cancer patients.

Understanding the HPV vaccine in terms of a disease endpoint, such as cervical cancer, is vital in accurately communicating with patients and their parents.

“The question I have is, we know that HPV causes cervical cancer. We know it causes other cancers. It causes anal cancer and oral cancer in both men and women. It also causes penile cancer in men and vaginal and vulvar cancer in women. And we don’t have many good ways of screening for a number of these cancers,” said Smith. “Why wouldn’t you vaccinate your child if you knew you could prevent a virus that can cause all of these cancers?”

For parents considering vaccinating their children, the best time to vaccinate for HPV is between 11 and 14 years old. For more information on the HPV vaccine, visit Cervical Cancer Free America.

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!

If it isn’t clear by now, COVID-19 is not just another flu.

In November, the New York Times published an article with the alarming headline, “Their Teeth Fell Out. Was It Another COVID-19 Consequence?” The article followed the story of one COVID-19 “long-hauler,” the term given to those who experience a wide range of symptoms long after they initially contracted the virus, ranging in from common symptoms like coughing to more unexpected manifestations like early symptoms of Parkinson’s Disease.

Before we go further, we’re going to stop right here and clarify that most of the information in this post is anecdotal. So, it wouldn’t be correct to say with certainty that “COVID-19 causes Parkinson’s Disease.” Doctors and patients are continuously discovering new symptoms and manifestations of COVID-19, and it will take some time for researchers to study the disease and find out why certain people’s bodies react the way they do.

But it’s worth talking about the more unexpected side effects experienced by long-haulers, if for no other reason than to reaffirm just how important it is to take steps to ensure that you are protecting yourself and those you love from the virus.

Are there direct connections between COVID-19 and oral issues?

The person interviewed by the New York Times — who noticed a loose tooth while chewing a breath mint only to have the tooth fall out the next day without pain or blood — had a history of smoking. When she visited her dentist, he discovered that she had bone loss in her jaw from when she used to smoke, which likely contributed to the loss of her tooth. But why hadn’t her tooth fallen out until it did? Or, what caused it to fall out when it did? Another long-hauler mentioned in the article, a 12-year-old with healthy teeth, also suffered tooth loss. (At 12, he had no history of smoking.)

One possible explanation is that COVID-19 in some way, shape, or form, could exacerbate pre-existing oral conditions. If that is the case, there is still significant cause for concern, as nearly half of the adult population in the United States has some form of periodontal disease.

Researchers are focusing more and more on the impacts that COVID-19 has on blood vessels, which also could help explain oral manifestations and other seemingly unrelated symptoms. We know that blood vessels are the conduit for many diseases with oral manifestations like heart disease and diabetes. Tie in COVID-19 symptoms like blood clots, bleeding of brain vessels, and rashes, and the possibility of oral implications makes a bit more sense.

A clearer picture: indirect consequences of COVID-19

Beyond the possibility of scary side effects of COVID-19, there are a couple indirect oral manifestations of simply existing during a pandemic that are worth talking about.

For example, take this New York Times interview with a Manhattan dentist who has seen a massive increase in cracked teeth among his patients since the onset of the pandemic. As more people are working from home, crouching over laptops on couches and kitchen chairs, or working in stressful situations, clenching jaws and cracking teeth are becoming important concerns.

Similarly, early in the pandemic, most dental offices cancelled all routine care, only offering emergency services. While this move was necessary to ensure patient and provider safety as proper protocols were created and put in place, it did cut off an important aspect of preventive care for many. Even as dental offices for the most part have reopened, without doubt there will be some portion of the population too nervous to schedule their next cleaning or dental exam.

The bottom line

At the end of the day, there are more unknowns than knowns when it comes to the oral consequences of the COVID-19 pandemic. There are more unknowns than knowns when it comes to the consequences in general, from our heads to our toes. At NCOHC, we are certain about three things:

• First, schedule your next regular dentist appointment if you can, and if you are uncomfortable, have a conversation with your dentist about their safety protocols.
• Second, brush up on your oral health education, and make sure you and your family are taking the steps you can at home to keep your mouths healthy and happy.
• Third, there are people who can’t afford to see a dentist, and there are people who have not received proper oral health education. Advocacy for policy change is one of the most impactful things we can do to structurally change the oral health landscape, increasing access and equity in care.

If you want to get involved and build a better oral health ecosystem in North Carolina, join us today!

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!

The COVID-19 pandemic has made it very clear that telemedicine is a necessary tool in most healthcare fields. Teledentistry in particular has been an effective means of connecting patients with oral health care providers while prioritizing patient and provider safety. However, beyond the scope of health care during a pandemic, teledentistry has invaluable benefits that will continue to improve equity and access in care, even post-COVID-19.

That’s why improving the legal framework around teledentistry is one of NCOHC’s top priorities in 2021.

Why does policy change need to happen for teledentistry to be used?

Any dental provider anywhere in North Carolina can use teledentistry to some extent today. However, teledentistry is not well-defined in North Carolina’s Dental Practice Act—which makes sense, as remote care technologies are fairly recent innovations.

Fortunately, the North Carolina Division of Health Benefits (NC Medicaid) did enact temporary provisions allowing providers to bill for teledental services while the COVID-19 pandemic continues to require heightened safety precautions. Private payers in NC have also embraced teledentistry by incentivizing its use during COVID-19. NCOHC believes that these provisions should be made permanent.

Why do we need teledentistry post-COVID-19?

Teledentistry is an important means by which to increase access and equity in oral health care. There are counties in North Carolina without any practicing dentists. Expanding the use of teledentistry and permanently adopting appropriate payment models would allow many North Carolinians, especially in rural areas, to access care they might otherwise not receive.

There are several social determinants of health that affect a person’s ability to access reliable health care. Some of the biggest include lack of access to reliable transportation, the inability to take time off work and, for parents, difficulty finding someone to take care of their children while they are away.

Teledentistry can be used to help overcome some of these barriers. Obviously, dentists cannot fill a cavity remotely and a hygienist won’t be cleaning teeth remotely. Nevertheless, streamlining the process can significantly ease the burden on patients short on time, transportation, and more.

Take for example a patient who goes into the office for a routine exam and cleaning appointment and is found to have a cavity. Often, the filling is scheduled as a follow-up appointment. If basic screening is conducted remotely, the required two trips to the office, two periods of time off work, two babysitters, and so forth, could possibly be cut in half.

On the flip side, follow-up appointments to check in with patients who recently had work done can be conducted remotely, again reducing the burden on those seeking care.

For more information on teledentistry, visit our accompanying blog post, “Envisioning Teledentistry in North Carolina.”

So, what’s next?

Permanently adopting teledentistry payment models would reduce obstacles for dentists who want to offer remote care options and provide greater efficiency in care delivery.

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

Stay tuned as NCOHC works during the 2021 legislative session to ensure teledentistry legislation is passed. Head over to NC4Change and help us take steps forward for positive change today.

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!

As we move forward into the new year, it is important to be aware of policy changes that may directly affect access and equity in oral health care for North Carolinians. We sat down virtually with Ben Popkin, The Foundation for Health Leadership & Innovation’s political strategist, to gain insight into what health care professionals, providers, and patients should be on the lookout for in 2021.

Health policy consultant Ben Popkin began his career as a staff attorney in the North Carolina General Assembly’s Research Division. He has also worked in the legislature’s bill drafting division. Popkin has experience in the Medicaid transformation space, and has helped the North Carolina Oral Health Collaborative achieve great strides through his lobbying and strategic planning advice for public health groups.

Popkin will assist NCOHC in several key areas of focus during the coming year. With the COVID-19 pandemic still impacting daily life, creating a more defined structure for telehealth, specifically teledentistry, is particularly important among the oral health community.

Teledentistry and Dental Hygienist Regulations

Teledentistry is not currently prohibited, but in North Carolina there are a lack of guardrails for those who use it. Popkin says that it is important that there be “a safer and more defined structure that includes standards of the practice, such as patient protection and informed consent.” It is critical to move toward legislative changes that support the permanent adoption of teledentistry models.

Read more about teledentistry in NOCHC’s policy brief

There are several North Carolina counties that do not have any practicing dentists. Lack of oral health care is not aided by the fact that North Carolina is particularly restrictive when it comes to the services dental hygienists are able to provide. Popkin notes that allowing hygienists to provide more services — like administration of local anesthesia — would increase productivity and efficiency in dental care.

“We want to reduce obstacles to dental hygienists and even to dentists who want to provide care to underserved areas,” Popkin says. Along with moving teledentistry forward, placing a priority on giving dental hygienists an increased ability to do the job they are qualified and trained for, would lead to meaningful victories for providers and patients alike.

Regulatory vs Legislative Policy Changes

NCOHC achieved several policy victories in the past year, most notably the 16W rule change, which allowed dental hygienists to provide preventive care services to individuals without having to have first received a prior examination by a dentist.

This was a regulatory policy change, as opposed to a legislative policy change.

“The typical structure is to have the required details for an initiative laid out in statute. Once the legislature has enacted law, a respective agency would adopt the rules. After the underlying framework is provided in statute, then the rules would provide the specific details for how to implement the initiative,” explains Popkin.

In other words, a legislative policy change involves the North Carolina General Assembly support and enactment on a bill, whereas a regulatory change involves a board, such as the North Carolina State Board of Dental Examiners (NCSBDE) approving an amendment to rules they have authority over.

Changing policy through the regulatory process involves making a specific rule proposal, which would first be either approved or denied by the rulemaking body in question. If approved, the rule would then go through the Rules Review Commission, which either approves or denies the rule after checking for precise legal authority.

“When it comes to teledentistry, our focus is on the legislative approach to enact statutes because of the detail needed to guide the rules,” Popkin says.

Popkin is optimistic about a teledentistry bill being approved in 2021. When asked about the specifics needed to push a bill forward, he mentioned the importance of issue experts like Dr. Zachary Brian, NCOHC’s program director, speaking directly with policymakers.

Events like NCOHC’s Oral Health Day helped to disseminate information to legislators and the general public about the importance of teledentistry. Collaborating with high-level universities, creating public awareness, and continuous contact with decisionmakers are crucial elements of successful policy change.

NC Government in the 2020 Election

In North Carolina’s 2020 elections, the outcome was fairly stable. The Republican party remains in control of the State Senate and House of Representatives. In the Executive Branch, Democratic Governor Roy Cooper was re-elected, meaning that the Health and Human Services Department staff also remains the same.

Popkin is hopeful that NCOHC’s goals will be treated in a non-partisan way.

“In North Carolina, we have a great health policy community…My goal is to bring consensus among parties and get a win for everybody.”

Get Involved

When asked how readers who are passionate about increasing access and equity in oral health can get involved, Popkin encourages people to reach out to their elected officials. “Email or call your legislators and let them know what’s important to you. It’s not uncommon for a member of the public to initiate an effort that can become law.”

You can now engage with the legislative process easier than ever. The General Assembly’s website allows you to follow chamber discussions, committee meetings, read up on actual drafts of bills, look up regulations, and find your legislators.

Want to get involved in building a more accessible, equitable oral health landscape in North Carolina? Become a North Carolinian for Change today! Our new platform will connect you with the most impactful opportunities to get engaged in efforts to change policy and build a future where all North Carolinians can get the care they deserve.

A newborn’s growing teeth are crucial to their overall development as a child. Baby teeth are the foundation for a strong set of adult teeth because they act as placeholders for permanent teeth. Poor oral health when your child is young can often result in crooked teeth and more serious oral health complications.

For more on why baby teeth matter and how to protect them, visit this American Dental Association resource.

So, when should I start brushing my child’s teeth?

It is safe to clean your baby’s mouth shortly after birth. Using a clean, moist washcloth, wrapped around one finger, carefully massage the gums. This can be done after every feeding until their teeth start to appear at around six months.

After the first teeth start to appear, brushing with a soft bristled toothbrush can significantly reduce the risk of tooth decay. Be sure to regularly check inside your child’s mouth and under their lips for white or brown spots that may be indicative of cavities.

Brush with a small amount of fluoride toothpaste (about the size of a grain of rice) until your child is three years old. After the age of three, a pea-sized amount of fluoride toothpaste can be used to brush their teeth. By this age most children will have all 20 primary teeth. Begin teaching them to spit to avoid swallowing the toothpaste.

Allowing your child to pick their own toothbrush and toothpaste can encourage regular brushing. Just be sure to check for the American Dental Association (ADA) seal of approval.

A consistent routine is the single most important thing you can do to ensure your child has a healthy mouth; but how teeth are brushed can also make an impact. Try to use small, circular motions as well as you can — it can be tough, especially when you begin teaching your child to brush their own teeth.

Brushing should be supervised twice a day until the age of six, when children are typically able to do it alone. Clean the inner, outer, and chewing surfaces for a total of at least two minutes every time.

Check out these handy guides for parents and children about developing good oral health habits. You can even print one for your children and hang it in the bathroom.

Click the image to download a printable version or to see an additional guide for parents

What is teething?

Did you know babies are already born with all their tooth buds?

Teething is when your baby’s teeth begin to push through the gums. This typically occurs between months four and seven. However, it is important to remember every child is different and for some, this can even occur at 12 months. Slower rates of growth are not necessarily a means for concern.

The two bottom front teeth are often the first to appear, followed by the four top front teeth. The last to erupt are generally the molars and eyeteeth, which are located in the upper jaw.

For some children, teething can be a frustrating process that may cause irritability. For others, it may appear painless. You will likely notice more frequent drooling and the desire to chew on different objects. This is perfectly normal and is a form of coping with the new feeling.

To relieve some of the symptoms of discomfort, give your baby safe toys such as a rubber teething ring with no liquid inside. A wet washcloth that has been frozen for about 15 minutes may also be helpful. Continually clean around your baby’s mouth to prevent rashes if there is excessive drooling.

When should I take my child to the dentist?

It is possible for cavities to appear in the mouth as soon as the first teeth erupt. Therefore, it is important to be proactive with oral care. One of the best ways to do this is to schedule a dentist appointment.

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

During these visits, the dentist will clean the teeth and can apply a fluoride solution to fight cavities. They will also check on teeth development and give advice on how to maintain proper hygiene.

For more information about early childhood preventive solutions like fluoride varnish and dental sealants, click here to see last week’s blog post.

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

If you notice anything concerning about your child’s teeth, or hear your child complain about pain, you should also make an appointment with the dentist.

For more information about well-child visit schedules, click here.

Caring for your child’s teeth at home

A healthy diet is important for a developing child and can have a direct impact on their teeth. Too much sugar can eat away at the enamel that covers the outer layer of the teeth, leaving them more vulnerable to plaque and bacteria.

Try to limit your child’s sugar consumption to avoid the risk of tooth decay and other health complications.

If you do not have access to fluoridated tap water at home, using a fluoride toothpaste is especially important. Fluoride is safe for young children and is one of the most effective forms of preventive care. The dentist may also prescribe chewable tablets or fluoride drops for your child if necessary; another great reason to schedule regular dental appointments!

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!

Have you heard of fluoride varnish? This preventive treatment helps strengthen and protect teeth, reducing risk of tooth decay. Next time your child is at the dentist, or even at your pediatrician, you may want to ask about a fluoride varnish.

We know that fluoride is good for teeth, and we can get it in many ways. From fluoride toothpastes and mouth rinses (which you should use daily), to drinking water, regular fluoride intake is an important component of good oral health habits.

Fun fact: Fluoride is even present naturally in many foods and drinks, like bananas, avocados, coffee, wine, shrimp, and more.

So, what is a fluoride varnish?

Simply put, fluoride varnish is a more concentrated form of fluoride, painted onto the top and sides of a patient’s teeth. The varnish itself is not a permanent layer—it stays on a patient’s teeth for several hours, allowing the fluoride to seep into the enamel and strengthen the teeth. To visualize the process, it may help to understand how fluoride works in the first place.

The outer coating of your teeth, the enamel, is the hardest substance in your body, even stronger than your bones. But that protective layer gets weakened and eaten away when we consume foods and beverages high in sugars and carbohydrates, leading to tooth decay and cavities.

When fluoride is introduced, through toothpastes, mouth rinses, drinking water, varnish, or other sources, it actually works to “remineralize” your enamel. Additionally, before tooth decay even occurs, fluoride acts to further strengthen enamel, adding additional protection down the road.

To sum it all up, a fluoride varnish is a great way to add a serious layer of protection to your teeth, which can help you avoid costly dental procedures in the future.

Who can get a fluoride varnish?

Fluoride varnishes are mainly used for children, but the truth is that anyone at risk of tooth decay could benefit from the preventive treatment. However, most insurers, including Medicaid, only cover fluoride varnish for children. In North Carolina, in response to the COVID-19 pandemic, children on Medicaid can receive a fluoride varnish a maximum of once every three month period.

Given topical fluoride varnish’s important protective benefits, it will be important that Medicaid permanently adopt policies to reimburse fluoride placement for all age groups, even after the pandemic.

If you are an adult and are interested in a fluoride varnish, have a conversation with your dentist—they can likely help you find out if your insurance will help pay for it.

A similar treatment: dental sealants

Similar to a fluoride varnish, dental sealants create a protective layer to ward off tooth decay.. Unlike a varnish, sealants are actually semi-permanent (they do wear off eventually), sealing off grooves in your teeth and providing a protective layer against foods and drinks that can cause decay.

While fluoride varnish must be applied several times each year to be effective, sealants on children’s teeth are effective up to nine years, though they should be checked by a dentist regularly as they can wear away.

The bottom line

At the end of the day, dental sealants and fluoride varnish are two effective preventive treatments that are powerful tools to prevent tooth decay and costly dental treatments necessary to repair damaged teeth.

Unfortunately, we don’t live in a world where everyone who could benefit from preventive treatments can access them. If you have access to a dentist, they can work with you to identify the mix of preventive measures that best fits your needs. And if you don’t have a dentist, check NCOHC’s access map here to find an affordable access to dental services near you!

NCOHC is working to build a more perfect oral health ecosystem, one where all people, no matter where they live, how much they earn, what language they speak, or what their life circumstances are, can access the care they deserve. You can take action and join the movement today by visiting NC4Change.

When creating equitable health care systems, especially at a statewide level, policy plays an important role in driving sustainable, system-wide change. Before policy can be implemented, however, advocates must start by changing peoples’ mindsets.

We recently sat down (virtually) with Dr. Sylvia A. Frazier-Bowers to discuss her role as Assistant Dean of Inclusive Excellence and Equity Initiatives at the University of North Carolina Adams School of Dentistry. Dr. Frazier-Bowers’ goal entering her position was to be an advocate working to change the mindsets of stakeholders when it comes to equity. Her goal was to teach people to be conscious of inclusivity and equity, which is now being incorporated into the Adams School of Dentistry’s curriculum.

“Equity refers to fairness,” said Dr. Frazier-Bowers, speaking about the importance of the word equity in health care and how it differs from the word “equality.”

While equality means treating everyone the same, or providing the same inputs into a system, equity means providing everyone with the resources and assistance they need to achieve successful outcomes. Equal treatment is important, but in a world where we are all different, with different experiences, abilities, disabilities, and resources available for our use, we inherently need different things in order to be successful. When all stakeholders have the opportunity to be successful, everyone benefits.

It is no secret that historically, people in the United States have been discriminated against because of race. While we have undoubtably made huge strides toward a more just society, the impact of historical injustice lives on, and there are still structures and individuals today who perpetuate inequity along racial lines.

For a non-oral health example of system-level equity with important ties to the dental world, see NCOHC’s interview with Duke Wold Food Policy Center Director of Strategic Initiatives Jen Zuckerman.

Dr. Frazier-Bowers explained that if two groups are given the same amount of a given resource, one may still be at a disadvantage if they started out further behind. When it comes to health care, equity may actually mean giving some people more help just to overcome existing disparities.

The Adams School of Dentistry curriculum is currently being revised, and the Office of Inclusive Excellence and Equity Initiatives is working to incorporate equity education into the dental school’s coursework.

“Instead of having an insular experience of, ‘Okay everyone, we’re now going to learn about equity and justice,'” said Dr. Frazier-Bowers, “It’s going to be integrated more seamlessly throughout the four-year curriculum.”

Working with experts in equity and justice education, the school designed the Advocate, Clinician, and Thinker (ACT) framework to integrate knowledge of racial equity throughout the four years of schooling, rather than as a small section.

To further incorporate equity education into the student experience, the Adams School of Dentistry was the first to coin an Inclusive Excellence Week, offering weeklong experiences to promote equity. Working with a community of scholars from different disciplines, the Adams School of Dentistry is able to communicate regularly with content experts who can influence new ideas and portray the interconnectedness of their work. The Adams School of Dentistry’s Inclusive Excellence Week influenced dental schools at other universities to do the same.

According to Dr. Frazier-Bowers, when it comes to equity and inclusion, “Mindset is the key.”

“When I say the mindset, this refers to every time you engage in any activity,” said Dr. Frazier-Bowers. “Whether its teaching, seeing patients, being a student, or being a classmate even—think about it from a lens that considers inclusivity and equity.”

When asked about the most prevalent social injustices in dentistry, Dr. Frazier-Bowers explained how the fact that not everyone has access to reliable care is an issue. Unlike a second home or expensive car, “education and health care should not be considered luxuries,” she said.

For that reason, the Adams School of Dentistry is currently working on self-assessment and accountability measures where people can have an opportunity to reflect and search for improvement in the pursuit of equity.

“People must be willing to open their minds to truth and history,” said Dr. Frazier-Bowers.

Many oral health professionals already advocate for change and understand what needs to be done to create a lasting impact. For those who don’t, there are always ways to get involved, but you have to be willing to put in the work. The DOCSpeaks program was created by Frazier-Bowers to bridge the “knowing-doing” gap for well-meaning professionals.

According to Dr. Frazier-Bowers, it all starts with education and an open mindset. The UNC DOCSpeaks sessions are a resource that can serve as a good starting point, and they will soon be open to the public. Outside of the education system, any community with the right leaders and the right mindset can be a catalyst for racial equity.

Want to get involved and elevate your voice? From diversity and inclusion in health care to the rising cost of health care, NC4Change is a platform for a diverse, inclusive group of oral health practitioners, public health professionals, community members, and other stakeholders who share a common goal: increasing equity and access in oral health care.

Head over to the brand new NC4Change page today and sign up for a focus group, give us feedback on our policy brief, and more!

In North Carolina, nearly 90 percent of the population is serviced by fluoridated water. This is not the case in Western North Carolina, where rates are estimated to be much lower. Limited access to fluoride means detrimental consequences for many people in the western region of the state, where people are more likely to suffer from tooth decay and other oral health complications. Without sufficient fluoride access, people are more vulnerable to these conditions.

Along with the lack of regular access to fluoridated water, there are other drivers that lead to the negative oral health conditions that are so prevalent in WNC. Consuming large amounts of sugar can be a major component for accelerating tooth decay. The acids in sugar damage the enamel on the outer layer of the teeth, leaving them more vulnerable to bacteria, which leads to cavities and gum disease.

Fluoride, however, plays a significant role in overall oral health outcomes in a given area. Fortunately, even in places like WNC where access to fluoridated tap water is not as widespread, there are other means of accessing the preventive mineral.

Regular brushing is important to keep bacteria under control. There are many fluoridated options for toothpaste, which are more effective in protecting teeth than non-fluoridated options.

For children in North Carolina, physicians in primary care medical offices can apply fluoride varnish that sticks to hard-to-reach areas of the teeth. Dentists can also paint on sealants for patients to help shield teeth from bacteria and prevent cavities. Fortunately, the public health division in North Carolina has also trained dental hygienists to be able to provide some of these preventive services.

Click here to see how Kintegra Health is improving WNC children’s oral health with its Dental Access Program, sending hygienists into schools to provide preventive care, including dental sealants.

We recently spoke in a virtual interview with University of North Carolina Distinguished Professor Gary Slade about the consequences of inadequate access to fluoride. Dr. Slade, who has worked in the Division of Pediatric and Public Health at the Adams School of Dentistry since 1994, works largely on epidemiological research that focuses on oral health and dental diseases in populations.

Dr. Slade explained that data show that children with access to fluoridated water have 30 percent fewer cavities in their baby teeth. As adolescents, they have 12 percent fewer cavities. Fluoride provides clear preventive oral health benefits, which makes the low rates of fluoridated water in WNC especially alarming.

“Because fluoridation rates in Western North Carolina do not count well water or sources that are not from tap water, the numbers we have from data with regard to tooth decay and other oral health conditions are probably worse than they appear,” Dr. Slade said.

As is the case with many small towns in Western NC, cost plays an important role when it comes to providing fluoride for communities. After being accustomed to living without fluoridated water, introducing it is not always seen as a priority. Engineering obstacles in some of these rural areas may also be a deal-breaker for many.

So, what is being done to enact change?

The first and most important step is advocacy. Whether it be a dentist, engineer, public health agency, or parent who speaks up first, change must begin at a local level. Dr. Slade explained that change is not guaranteed to happen just because it seems like the right thing to do. An effort like increasing access to fluoridated water begins with someone championing the cause.

Dr. Slade also spoke about important research he will be conducting in 2021 in Kinston, North Carolina, on the preventive effects of fluoridated bottled water. It is estimated that 115 million Americans do not have access to fluoride in their drinking water at home. That is roughly one-third of the American population, a number that Dr. Slade says will not significantly change in the near future.

Kinston resides in Lenoir County, located in eastern North Carolina. Dr. Slade described it as a prime example of a city that will not likely introduce fluoride into the public water system anytime soon.

Traditionally, dentists and oral health professionals have discouraged people from drinking bottled water due to the lack of fluoride, since most companies do not include it. However, with the rise in popularity of bottled water, Dr. Slade is taking a different approach. Rather than encouraging people to avoid bottled water, the upward trend in popularity would suggest that promoting the inclusion of fluoride in bottled water may be the best approach to improving access to better oral health.

There are many reasons why fluoride access is limited in some parts of the country, but one of them may be the criticism it receives. Dr. Slade suggested that some skepticism may be due to the fact that there has not been a randomized controlled trial of fluoridated water. His study in Kinston will be the first.

The study will include 200 participants, divided into two groups. One group will be given fluoridated bottled water, and the other will be given unfluoridated bottled water. After a period of three and a half years, each participant will receive a dental examination. Because of the true randomized design, no participant or researcher will know who had fluoridated water and who had unfluoridated water until the study is complete.

Dr. Slade expects the resulting data to speak for itself.

Today, it has become increasingly more difficult to implement public fluoridated water systems. There is a significant amount of advocacy from individuals and interest groups on both sides of the issue.

Dr. Slade said that with lower levels of health literacy, it is also more likely that misinformation will stick in people’s minds. Changing that starts with advocacy and education in schools at an early age. There are a lot of questions that surround the topic of fluoride in the United States, but more importantly, there are a lot of answers. Fluoridated water as we know today, provides the easiest and most efficient form of preventive care for lifelong oral health benefits.

Want to get involved and elevate your voice? From fluoridated water and teledentistry to the rising cost of health care, NC4Change is a platform for a diverse, inclusive group of oral health practitioners, public health professionals, community members, and other stakeholders who share a common goal: increasing equity and access in oral health care.

Head over to the brand new NC4Change page today and sign up for a focus group, give us feedback on our policy brief, and more!