Prioritizing Oral Health: Oral Health IS Health!

Rethinking Oral Health: Bold Strategies for Transforming Health Care

Despite the undeniable connection between oral health and overall health outcomes, oral care remains a separate and often peripheral concern in many health care settings. This issue of the North Carolina Medical Journal highlights the efforts of over 70 health professionals and oral health leaders who collaborated with the North Carolina Institute of Medicine (NCIOM) Oral Health Transformation Task Force from August 2022 to August 2023. Together, they explored the current state of oral health care in North Carolina and produced a report¹ highlighting strategies to transform it, aiming to create a care delivery system where:

• Patients easily access oral health care within an inte­grated health care model.

• Oral health care providers, including and specifically those serving Medicaid patients, work within a system of high-quality, cost-effective care that is seamlessly inte­grated with a holistic approach that fosters collaboration among health and social care teams.

• NC Medicaid and other state agencies, educational insti­tutions, and diverse thought partners work together to cultivate a holistic, accountable, and equitable approach to oral health.

This is not a new vision. Experts and advocates have long preached the virtues of a more integrated and holistic health care system.

Health is not possible without good oral health. The evidence is irrefutable: oral diseases can severely impact systemic health, quality of life, and even mortality.² Conditions such as periodontitis have been linked to diabe­tes, cardiovascular disease, and respiratory issues, making it clear that oral health should not be treated as a standalone issue. Existing strategies are insufficient. We must reimag­ine how we engage with oral health in the broader health care landscape and implement the necessary strategies to get us there. We must fundamentally alter how we think about and integrate oral health into medical practice, urg­ing policymakers, health care professionals, and the public to recognize that inadequate oral health can no longer be ignored.

The Silent Epidemic: Oral Disease as a Public Health Crisis

The World Health Organization acknowledges that oral diseases affect nearly half of the world’s population,² but they are often relegated to a secondary status in health policy agendas. This neglect is astonishing, especially given the wealth of research linking oral health to chronic diseases that account for most health care costs.³ We must recog­nize that the status quo is not just inadequate; it is detrimen­tal. The systemic underfunding of oral health initiatives and lack of preventive education far too often result in treatable conditions escalating into expensive, chronic illnesses.

Barriers to Oral Health Care Access

Access to oral health care remains a significant barrier for many populations. Socioeconomic status, geographic location, cultural attitudes toward oral care, and inadequate dental coverage in insurance plans all contribute to health care access disparities. Populations in rural areas often face a shortage of dental providers, resulting in a lack of oral health care for these communities and exacerbating preven­tive needs into more emergent needs.² Addressing these barriers is critical for improving oral health equity. An article by applied behavioral sciences professor Jamie Burgess- Flowers and coauthors in this issue explores the social driv­ers that impact oral health.⁴

The articles in this issue reflect the current state of affairs for oral health in North Carolina. Like so many organizations, dental providers are facing critical workforce shortages that significantly impact the capacity to provide quality oral health services. See the statistical analysis of the dental workforce in North Carolina in this issue by Dr. Brooke Lombardi of the UNC Sheps Center of Health Services Research and coau­thors.⁵ You will also find an article by Andy MacCracken, director of the recently established North Carolina Center on the Workforce for Health, about how the organization is working to address the oral health workforce in our state.⁶ While not exhaustive of all the issues impacting oral health, this issue offers suggestions for how we can move toward the vision outlined in the NCIOM task force report, Transforming Oral Health in North Carolina.¹

Action 1: Invest in Dental Medicaid

Medicaid serves a critical population of North Carolinians with high need who often face significant barriers to care. Chief among these challenges is the lack of dental provid­ers accepting Medicaid patients. Statistics show that 45% of practicing dentists in North Carolina accept Medicaid.¹ An even smaller percentage (28%) actually provide a mean­ingful amount of care, meaning they make annual Medicaid claims of $10,000 or more. At the same time, approximately 86% of practicing physicians accept Medicaid patients.¹

The reason most often cited by dentists is the low den­tal reimbursement rates. Dental reimbursement rates for Medicaid remain largely the same as in 2008. Meanwhile, the costs of care have risen by 46% since that time, accord­ing to the Bureau of Labor Statistics Consumer Price Index.¹ In this issue, several practicing dentists and represen­tatives of dental organizations—including pediatric dentist Dr. Frank Courts, ECU School of Dental Medicine Dean Dr. Gregory Chadwick, Raydiance Swanston of Mecklenburg County Public Health, and Wake Smiles Executive Director Sommer Wisher—share their experiences with these chal­lenges and some of the successes they have implemented.^7–10

Action 2: Mandate Oral Health Training in Medical Education

Why are future physicians not equipped with the skills to recognize and address oral health issues in their patients? It’s time to make oral health training a mandatory compo­nent of medical education. Empowering health care pro­fessionals with the knowledge to identify oral diseases will break down silos that have historically separated oral and systemic health care. This shift could lead to earlier inter­ventions, accurate referrals, and ultimately better health outcomes.

Action 3: Redefine Scope of Practice for Dentists and Physicians

If we truly believe in integrated health care, the delinea­tion between dentistry and medicine must be reexamined. Dentists should be included in primary care teams, and phy­sicians should have the ability to address basic oral health issues.¹¹ By removing technological and bureaucratic bar­riers to collaboration, we can create a health care ecosys­tem that considers the mouth to be part of the body. This collaborative approach can lead to a more comprehensive health care delivery model that manages oral and systemic diseases concurrently.

The inadequacies of the oral health provider landscape in North Carolina are felt dramatically in the population of special care patients in the state. Dr. Bill Milner of Access Dental Care describes these needs and offers a national model for addressing the problem.¹²

Action 4: Harness Data and Technology for Oral Health Monitoring

Data is critical to making the best evidence-based deci­sions about the status of oral health in North Carolina and providing the necessary programs and services to move the state forward. Dr. Patrick Roberson, Section Chief of the Oral Health Section in the North Carolina Division of Public Health, and coauthors highlight the gaps in oral health data that restrict our understanding of the problems and their solutions.¹³ Technology is revolutionizing health care, and oral health should be at the forefront. From teledentistry to artificial intelligence-driven diagnostic tools, technologi­cal advancements have vast potential to improve access and outcomes in oral health. Imagine remote-monitoring devices that provide real-time data on oral hygiene practices or innovative apps that promote preventive care and edu­cation. Christine Kanan and coauthors from the CareQuest Institute for Oral Health illuminate some of the benefits of utilizing teledentistry, partially based on their work with 14 safety-net dental clinics here in North Carolina.¹⁴ We must embrace these technologies, not as optional add-ons, but as essential instruments in our health care toolkit.

Action 5: Implement Innovative Payment Models for Oral Health Access

Current reimbursement models often create a financial barrier to accessing oral health care. It is time to explore bold new payment structures, such as capitation models, that reward health care providers for effectively managing overall health, including oral health. Moreover, implement­ing bundled payment systems for combined medical and dental services could incentivize a more cohesive approach to patient care, shifting the focus from treatment to preven­tion. For those of us who are less familiar with how managed care works for dental providers, we asked James Couch and Heather Slawinski of Delta Dental to give us a dental man­aged care primer in this issue.¹⁵

Action 6: Support and Expand Community-Driven Oral Health Initiatives

Health care transformation cannot occur in isolation. Local communities must be engaged in the design and implementation of oral health initiatives. Mobilizing com­munity health workers to deliver education, preventive care, and screenings in underserved areas can have a pro­found impact. Culturally tailored and attuned programs that address local needs can empower individuals to prioritize oral health as part of their overall well-being.

Learn more about one community-driven approach to improving oral health of children utilizing a school-based dental health initiative in North and South Carolina from Dr. Amy Martin of the James B. Edwards College of Dental Medicine at the Medical University of South Carolina and coauthors. They share their experience, which was critically important to improving oral health in the counties in which they operated.¹⁶

Conclusion: A Call to Action

The time for complacency in oral health is over. We stand at a critical juncture where we must embrace bold, innova­tive strategies to tackle this silent epidemic. Oral health is not a niche concern; it is a core component of overall health that directly impacts chronic disease management, quality of life, and health care costs. By integrating oral health into every facet of health care—education, practice, policy, and community engagement—we can create a healthier society that treats the mouth as if it is as vital as any other organ.

This is not merely an invitation; it’s a challenge to all stakeholders to rethink the approach to oral health in North Carolina and stand together to make the changes we need. Our collective well-being depends on it.

Acknowledgments

The author served on the steering committee of the NCIOM Oral Health Transformation Task Force and his employer, the Foundation for Health Leadership and Innovation, provided funding for the task force.