Having served 25 years at FirstHealth of the Carolinas, I can reflect on how pent up the dental needs were 25 years ago, and how needed safety-net clinics still are today. Without us, a substantial part of the population goes untreated, undiagnosed, and without preventive care.

Over my 35 years in public health dentistry, I’ve had the opportunity to meet so many “dental war­riors” who won’t stop until the oral health of under­served populations is improved. We constantly have more patients in need of care than we can provide for in a timely fashion, but know that for the ones we touch, it has been life changing.

One parent of a patient from the first year of FirstHealth’s operation said it best in comments shared with the community and our stakeholders: “My children are 8 and 13 years old. They had never been to the dentist before because we have no insur­ance and could not afford to pay dental bills. For us, FirstHealth is a life-saving, or should I say, tooth-sav­ing program.”

FirstHealth of the Carolinas (FirstHealth) is a comprehensive, not-for-profit health care network based in Pinehurst, North Carolina, serving 15 coun­ties in the mid-Carolinas. The FirstHealth system is comprised of four hospitals and offers all major medical and surgical specialties, as well as numer­ous subspecialties in addition to primary care clinics, convenient care clinics, hospice, and fitness centers. The FirstHealth Dental Care Centers were estab­lished to provide access to comprehensive dental care to underserved children up to age 21.

How did a health care system get involved in den­tal care for underserved children? It all ties back into our organization’s core purpose: to care for people. Back in 1996, school health nurses in FirstHealth’s service area named dental care the number one unmet need among low-income children. How severe was the need? In the affluent Moore County, known for its golf resorts and equestrian living, 50% of schoolchildren received free or reduced lunch at the time FirstHealth began opening dental care cen­ters, according to unpublished data from the Moore County Board of Education. Because of low dental Medicaid reimbursement rates, the frequency of bro­ken appointments, and the near capacity of estab­lished practices that did not typically treat children or regularly accept patients on public assistance, relying on the private practices was not a viable option. This scenario is repeated throughout North Carolina and is the reason that 100+ safety-net den­tal clinics exist in our state; in Moore County, com­munity stakeholders concluded that the best way to address access to dental care was for FirstHealth to take the lead.

FirstHealth opened three dental care centers on October 19, 1998, with funding from the Kate B. Reynolds Charitable Trust and The Duke Endowment, one each in Hoke, Montgomery, and Moore counties to care for the area’s most vulnerable children. The Foundation of FirstHealth’s Community Benefit Fund also contributed capital and continues to this day to help offset the cost of providing care to children on Medicaid and to those who are uninsured.

The clinic was immediately overwhelmed with emergency patients due to pent-up care. Because there had been only minimal dental care options for Medicaid beneficiaries or uninsured low-income chil­dren in Moore County or the surrounding counties, children often didn’t get dental treatment until there was an emergency, like an abscessed tooth or a pain­ful infection. In fact, 70% of the patients seen in the first year of FirstHealth’s dental clinics’ operation had either never seen a dentist or had not seen a dentist in more than a year.1

Take Nicanor for example, who came to us in the first weeks we were open. I will never forget his tear-streaked, swollen face as he walked up to the front desk. Because he was in pain, had difficulty eating, and was unable to pay attention in school, he came to our newly opened FirstHealth Dental Care Center for evaluation. Today, he is 33 years old and still credits our safety-net clinic for teaching him the importance of good dental health all those years ago.

The dental staff suffered along with their patients in the early days because they came from private dental practices where emergency situations were the exception rather than the rule; they were moved and shaken that almost every child who came in was crying. All I could say at the time was, “Hang in there. It won’t stay this way forever.” And it didn’t. By work­ing with patients consistently, more than half of all appointments are now for preventive and diagnostic care.1

The FirstHealth Dental Care Centers now have four practice locations: a full-time six-chair tradi­tional free-standing clinic in Southern Pines; two part-time school-based dental centers on the cam­puses of East Middle School in Biscoe and West Middle School in Mt. Gilead, with two chairs each; and a portable dental care program with two portable chairs serving elementary schools, a high school, and daycares. Community support has been critical to the centers’ success from the start. Staff at the centers is comprised of full-time and part-time dentists and auxiliaries; some staff members who work in the clin­ics on Saturdays come from local practices. This col­laboration allows the practice to increase access to care by expanded, non-traditional office hours that increase patient capacity.

Data from the North Carolina Department of Health and Human Services revealed that the per­centage of kindergartners with untreated decay in the target counties decreased over a six-year period before and after the introduction of FirstHealth Dental Care, from 33% to 21% in Montgomery County and from 23% to 17% in Moore County.2 However, the COVID-19 pandemic decreased access to preventive dental care for children of all ages, lead­ing to worsening oral health and erosion of some of those gains.3 The 2022–2023 school year data for Montgomery County show that the untreated decay rate for kindergartners has bounced back up to 24.4%, and the untreated decay for kindergartners in Moore County has increased to 18%.4 Studies show that 20% of the children have 80% of the decay in North Carolina.4

FirstHealth takes great pride in providing care to more than 30,000 dentally vulnerable children for the past 25 years. This milestone gives me even more reason to reflect on what is a celebration for all safety-net clinics of oral health accomplishments over this period (Table 1).

Table 1
Table 1.Oral Health Accomplishments in North Carolina in the Past 25 Years

FirstHealth serves almost three times as many patients each year as it did at its beginning. FirstHealth sees double of the percentage of Hispanic patients, has incorporated the children of FirstHealth employ­ees, and has helped to increase the insured rate in its service area from 72% to 97% due to strong col­laboration with area stakeholders. The most excit­ing transformation has been the ability to fulfill the premise of public health that the community is the patient, and FirstHealth has “come to the patient” through our school-based programs.

Safety-net clinics, in partnership with dental public health organizations and committed Medicaid private practice providers, have been and will always be the backbone for access to dental care for underserved children.

Acknowledgments

In addition to the funders mentioned in the article, the following have provided recent grants to FirstHealth Dental Care Centers: Blue Cross and Blue Shield of North Carolina Foundation, Delta Dental Foundation, Office of Rural Health, the North Carolina Academy of Pediatric Dentistry, and America’s ToothFairy.