ISSUE BRIEF

Perspectives on Innovations in Oral Health Care

R. Gary Rozier

A downward trend in dental caries in permanent teeth of of some of the new approaches being used to address oral
children that began in the 1970s has leveled out at historic health problems. These will be presented against a back-
lows. Severe periodontal disease affects a small percentage drop on trends in dental caries, periodontal disease, and
of people, and tooth loss has plummeted so that complete tooth loss, using North Carolina-specific information where
tooth loss, once a common occurrence, now is almost non- possible.
existent in upper socioeconomic groups. But not all people
have benefited equally from these positive trends. Dental
Trends in Oral Diseases in North Carolina
problems continue to affect the disadvantaged in society Notable reductions in the dental caries experience of per-
at unacceptable rates, and their disease burden is likely to manent teeth in children and adolescents in North Carolina
increase because of trends in social determinants of oral occurred over the 4 decades starting in the 1960s and 1970s
diseases. [2]. Between 1960–1963 and 2003–2004, caries experi-
Personal dental care alone usually is unable to provide a ence declined by 65% or more. The magnitude of the trend
sufficient buffer against these risks to maintain adequate appears to have slowed in the 1990s and flattened out at
oral health. Extensive disease in young children too often these low levels during the first decade of this century. Its
requires treatment in the hospital with a high chance of prevalence is projected to change little through 2040 with-
relapse. A national health goal is to “achieve health equity, out significant investment of resources or technological
eliminate disparities, and improve the health of all groups.” breakthroughs in caries prevention [3].
Achieving this goal in oral health requires that things be Dental caries experience in the primary dentition of pre-
done differently. school-aged children, already highly prevalent, increased
This issue of the North Carolina Medical Journal high- each year between 2000–2001 and 2004–2005, and then
lights several approaches being tried here in North Carolina declined over the next 5 years [4]. Figure 1 updates these
and elsewhere to address oral health problems. Initiatives trends through 2013–2014 using information about oral
fall into 4 categories: advocacy, workforce policies, integra- health from a subset of the North Carolina population. It dis-
tion of oral health and primary care, and the medical man- plays the percentage of kindergarten students with any car-
agement of caries. ies experience in their primary dentitions by poverty status
of the county. The 10 counties with the highest percentage

T
of children in poverty (mean = 40.8% in 2015) are compared
he prevention and control of oral diseases in popula- to the 10 counties with the smallest percentage of children
tions is one of the more perplexing health challenges in poverty (mean = 20.9% in 2015), conditional on the avail-
we face. Significant gains have been made in understand- ability of data provided by the North Carolina Oral Health
ing disease processes, developing cost-effective preventive Section surveillance system. The surveillance system pro-
interventions, providing quality dental care, and reducing vides robust estimates of disease trends for these 20 coun-
disease in many segments of the population. Yet, oral dis- ties, based on clinical assessments of a total of more than
eases are among the most common diseases in the world. 90,000 kindergarten students for the 4 time periods.
Untreated caries in permanent teeth was the most prevalent It appears that for these counties, the prevalence of den-
condition among 291 diseases and injuries evaluated in the tal caries continued to decline from a high point in 2004
Global Burden of Disease 2010 Study, and severe periodon- through 2013. The decreases were greater in high-poverty
titis was the 6th most prevalent [1]. counties, from 50.3% in 2004 to 38.2% in 2013, than in low-
Many underlying causes of oral diseases are embed-
ded in societies’ ills, making the dental care system poorly
Electronically published November 30, 2017.
equipped to address the underlying causes of the problem Address correspondence to Dr. R. Gary Rozier, Department of Health
in patients. Community-based public health resources are Policy and Management, Gillings School of Global Public Health,
often stretched much too thin to implement broad-based University of North Carolina at Chapel Hill, 1106K McGavran-Greenberg
Hall, CB#7400, Chapel Hill, NC 27599-7411 (gary_rozier@unc.edu).
interventions that will reduce the effects of multiple deter-
N C Med J. 2017;78(6):376-382. ©2017 by the North Carolina Institute
minants of disease. of Medicine and The Duke Endowment. All rights reserved.
The purpose of this Issue Brief is to provide an overview 0029-2559/2017/78604

376 NCMJ vol. 78, no. 6

ncmedicaljournal.com
 figure 1.
Trends in Dental Caries Experience (% dmft>0) of North Carolina Kindergarten Students by
Poverty Status of County
60

50

40

30

20

10

Note. dmft, decayed, missing and filled teeth.

Poverty counties: Northampton, Scotland, Richmond, Edgecombe, Robeson, Washington, Halifax, Vance, Warren, Lenoir.
Non-poverty counties: Davie, Mecklenburg, Lincoln, Catawba, Onslow, Granville, Pender, Alexander, Stokes, Gates.
Counties ranked by percent children ages 0-17 in poverty (2015) and 10 with the highest and lowest percentages
included if surveillance data available for all 4 cycles.
Source. Data derived from the North Carolina Division of Public Health, Oral Health Section. Povery estimates for county
are from United States Department of Agriculture, Economic Research Service.

poverty counties, which declined from 39.6% to 32.4%. umn of this issue, Howell [9] provides an analysis of tooth
A substantial decrease in the prevalence of untreated loss using the last 3 cycles of the BRFSS (2012, 2014, and
caries in the primary dentition is apparent in Figure 2. This 2016). Overall, a majority of adults in North Carolina (52.4%)
trend was particularly obvious in children living in those have never had a permanent tooth removed because of
counties with the highest percentage of children in poverty. dental disease, but percentages differed by socioeconomic
By 2013, the absolute inequality in untreated caries had been status. For example, adults who were college graduates
reduced to only 5.2 percentage points compared to 18.4 per- compared to those with less than a high school education
centage points in 2004. were 2.7 times more likely to have retained all their teeth
Less information on the oral health status of North (71.0% vs 26.2%).
Carolina adults is available than for children. The preva- Most of what we know about trends in oral health sta-
lence of periodontal diseases is unknown, not having been tus in North Carolina is derived from information provided
assessed statewide since 1976–1977. Nationally, the preva- by the surveillance system maintained by the Oral Health
lence of periodontitis for adults was 46% in 2009–2012, Section of the North Carolina Division of Public Health,
with about 8.9% having severe periodontitis [5]. Projections the oldest state dental public health program in the United
for periodontal diseases are uncertain because of the lack of States. Next year, it will celebrate the 100th anniversary of
an obvious trend in national surveys. its founding. The surveillance system has been redesigned
Tooth loss, an important population-based outcome and expanded to provide statewide clinical assessments
measure of the effectiveness of our collective efforts to of special population subgroups, including the frail elderly,
achieve optimal oral health, dropped precipitously over the pregnant women, 3rd grade school children, preschool
last 50 years. In 1960–1963, 58% of 60–69-year-old whites children, and high school students, in addition to the long-
in North Carolina were edentulous and about 45% of people standing annual assessments of kindergarten students used
of other races [6]. In 2016, 18% of those 65 years of age and in this paper for the analysis of trends in caries experience
older reported that they had lost all their teeth because of of primary teeth by county income. Authors in this issue pro-
dental problems [7]. Based on the research by Slade and col- vide information about 2 components of the redesigned and
leagues [8], the projected prevalence in the United States expanded surveillance system [10, 11].
will decline, but more slowly, reaching 2.6% in 2050.
Tooth loss provides a revealing example of socioeco-
Oral Health Inequities and Interventions
nomic disparities in oral health indicators. According to the The prevalence of oral diseases follows a stepwise social
Behavioral Risk Factor Surveillance System (BRFSS) con- gradient with the smallest amount of disease in upper socio-
ducted in North Carolina in 2016, complete tooth loss was economic groups and with incrementally larger amounts
almost non-existent in those in the highest income bracket in successively defined lower socio-economic groups [12].
(>$75,000) at 1.6%, compared to 12.6% in the lowest income Social, economic, political, and environmental factors are
bracket (<$15,000) [7]. In the “Running the Numbers” col- considered major determinants of oral health.

NCMJ vol. 78, no. 6 377

ncmedicaljournal.com
 figure 2.
Trends in Untreated Dental Caries (% dt>0) of North Carolina Kindergarten Students by
Poverty Status of County
60

50

40

30

20

10

Note. dt, decayed (and untreated) teeth.

Poverty counties: Northampton, Scotland, Richmond, Edgecombe, Robeson, Washington, Halifax, Vance, Warren, Lenoir.
Non-poverty counties: Davie, Mecklenburg, Lincoln, Catawba, Onslow, Granville, Pender, Alexander, Stokes, Gates.
Counties ranked by percent children ages 0-17 in poverty (2015) and 10 with the highest and lowest percentages
included if surveillance data available for all 4 cycles.
Source. Data derived from North Carolina Division of Public Health, Oral Health Section. Poverty estimates for county
from United States Department of Agriculture, Economic Research Service.

Oral health status differences resulting from most social of North Carolina Foundation and The Duke Endowment,
determinants are considered inequitable because they respectively, highlight in their paper the 3 major areas that
are avoidable and deemed unfair and unjust [13, 14]. The their organizations consider important for investment in
acknowledgment of the importance of social determinants oral health innovation. They long for “new approaches to
of disease and that they are not equitable has important dramatically increase access to affordable preventive care”
implications for strategies to move forward the oral health and lament “…despite multiple statewide task forces and
agenda in North Carolina. What matters now is that we set long-standing consensus that improvements in oral health
goals and develop strategies in which we consider the oral are achievable and necessary, much of the change needed
health conditions among disadvantaged groups. in North Carolina has yet to be realized.” Hopefully, articles
In designing interventions, there are those focused on the in this issue provide useful information to help understand
health of the general population, others focused on the dis- what can be done to reduce inequities in oral health.
advantaged within the population, while still others focused
on the general population but with the goal of reducing the
Workforce Policies In and Outside North Carolina
inequitable gaps in oral health status. One of our national Workforce projections are important but often imprecise,
health goals for 2020 is: “To achieve health equity, eliminate inconsistent, and subject to decisions and events outside of
disparities, and improve the health of all groups” [15]. This dentistry. The potential variability in projections of work-
goal implies that health promotion and disease prevention force needs is exemplified by the polar opposite conclu-
strategies need to consider everyone, but with different lev- sions of 2 recent efforts to assess dental workforce needs
els of intensity proportional to the level of disadvantage [16]. for the United States. As part of a study of dental education
Articles in this issue review activities underway by the in the 21st century, Eklund and Bailit [20] project a surplus
North Carolina Oral Health Collaborative (NCOHC) and of dentists in 2040 of 32% to 110%. Official projections by
Youth Empowered Solutions (YES!) to better understand the Health Resources and Services Administration [21], the
and address oral health inequities in North Carolina. The agency in the federal government responsible for workforce,
commentary by Oh and Santiago [17] from the NCOHC and estimate about an 8% shortage of dentists in 2025.
the sidebar by Le [18] from YES! describe detailed methods A comprehensive study with the aim of quantifying the
used to assess the personal dental experiences of people need for dentists in North Carolina has not been completed
from around North Carolina. Both organizations are advo- recently. But several aspects of dental workforce planning
cating for changes that will reduce the influence of social are clear. First, using relative statistics, North Carolina per-
determinates on oral health, which is essential information sistently ranks 47th among states in the number of dentists
in providing decision makers with knowledge and options to per 10,000 civilian population [22]. However, dentists are
improve oral health. concentrated in one-fifth of the state’s counties. The gap in
Eyes and Warren [19] of the Blue Cross and Blue Shield dentists per 10,000 population between North Carolina’s

378 NCMJ vol. 78, no. 6

ncmedicaljournal.com
most underserved and not underserved counties defined by and care coordination competencies taught in the 18-month
Primary Health Professional Shortage Areas status has been curriculum, along with other competencies needed for pub-
slowly widening over the years. lic health and community activities. As Grover points out,
Second, previous workforce assessments for the state the CDHC can fill an important role in helping people navi-
have relied heavily on interpretation of statewide popula- gate primary care, oral health, and social services. Currently,
tion growth, which far exceeded changes in dentist supply. a little over 100 students have graduated, so experience with
The state’s population is projected to gain 2.1 million new this model is limited. Further experience will provide more
residents between 2015 and 2035, but two-thirds of that information about appropriate roles for the CDHC, their
growth is expected to occur in the Triangle and Charlotte effectiveness, and how they fit within existing financial sys-
[23]. Thirty-three counties are projected to have no growth tems and dental practice acts.
or a loss of population in the next 20 years. More than half of In another article, the Health Policy Institute of the
counties (54) are projected to have fewer children in 2035, American Dental Association presents a measure of geo-
and 53 counties are expected to have fewer working adults. graphic proximity of the public and dentists at a sub-county
Trends in social determinants of oral diseases suggest a level (Census tract) for each state. This method provides a
growing socioeconomic divide in North Carolina, which will more sophisticated way to think about dental shortage areas
present a major challenge for workforce planning. than previously available for use in workforce planning.
Finally, North Carolina has among the most restrictive Dr. Marko Vujicic, Vice President of the Institute, provides
regulations for the scope of practice for dental hygienists some results for North Carolina in this issue [31]. The analy-
in the nation. According to an analysis by the Oral Health sis for North Carolina demonstrates, among other results,
Workforce Research Center (OHWRC) at the University of that 90% of publicly-insured children live within 15 minutes
Albany, North Carolina is 1 of only 4 states that does not per- driving time of a dentist enrolled in Medicaid. If a policymaker
mit any of 8 services the Center included in their analysis chose to define shortage areas using the data presented by
or has no law pertaining to the service [24]. The American Vujicic, he would conclude that 17% of publicly-insured chil-
Dental Hygienists’ Association has identified 40 states, so dren and 29% of the overall population in North Carolina live
called direct-access states, in which dental hygienists can in dental shortage areas. Vujicic makes no claim that living
initiate treatment based on their assessment of a patient’s in close proximity to a dentist enrolled in Medicaid is associ-
needs and provide treatment without the specific authori- ated with dental use or whether the rather robust estimates
zation of a dentist or presence of a dentist [25]. Eighteen for geographic proximity in this study implies an adequate
states have practice act provisions that allow dental hygien- supply of dentists.
ists to be reimbursed directly by Medicaid [26]. According In addition, Kranz and colleagues [32] completed a geo-
to research by the OHWRC, a broader scope of practice for spatial analysis of dental offices and Medicaid-enrolled chil-
dental hygienists is associated with improved oral health dren in 17 counties in North Carolina. They calculated driving
[27]. time from the home address of young children enrolled in
In response to the lack of access to treatment services, Medicaid to the nearest dental practice providing oral health
some workforce models for mid-level providers new to services paid for by Medicaid as documented by claims. On
the United States have emerged [28]. The models differ average, children lived only 7 minutes from the nearest den-
mainly in the degree of supervision required by a dentist, the tal practice. Greater distance to care was associated with
amount of education required, and whether a dental hygiene decreased probability of dental visits. Even with this very
license is required or not. The Advanced Dental Hygiene close proximity, however, use was less than 50%; therefore,
Practitioner (ADHP) is a model proposed by the American factors other than proximity appear to be affecting use.
Dental Hygienists’ Association. This provider can offer sim-
ple restorations and extractions without the direct supervi-
What if Dental Caries Prevention Fails? A New
sion of a dentist. It currently exists in Minnesota only.
Strategy for High-Risk Patients
Dental therapists, similar to physician assistants in medi- Substantial scientific evidence and practical experience
cine, can provide preventive services, routine restorative supports the prevention of dental disease and the promotion
care, and extract teeth. First introduced in the United States of oral health. The science supporting collective personal,
by Alaska tribal communities in 2003, dental therapists professional, and public health strategies for the prevention
are now providing oral health services in Minnesota and of dental caries in children is particularly well-developed. A
Alaska, are supported by approved legislation in Maine and recent review of prevention methods identified 30 system-
Vermont, and as of May 2017, at least 11 states were explor- atic reviews on prevention of dental caries supporting those
ing the authorization of dental therapy practice [28, 29]. strategies recommended for use in the United States [33].
In her invited commentary, Grover [30] describes the Yet, thousands of people in North Carolina lack access to
Community Dental Health Coordinator (CDHC), a new a comprehensive set of recommended preventive services
member of the dental workforce promoted by the American throughout life. Further, clinicians and scientists acknowl-
Dental Association. She emphasizes the case management edge that clinical strategies effective in preventing dental

NCMJ vol. 78, no. 6 379

ncmedicaljournal.com
caries in the average-risk child sometimes can have little reviewed in the article by Eason and colleagues [41], was
effect on those children at extreme risk [34]. one of the initial efforts in the United States to integrate
Increasingly, young children receive extensive surgi- clinical preventive oral health services into primary care.
cal dental treatment (remove and replace decayed tooth Evaluations of IMB show that this type and degree of integra-
structure or extract teeth) for dental caries in the hospital tion can reduce the need for dental caries-related treatment
operating room or ambulatory care center under general services, promote early entry into the dental care system
anesthesia at high costs and anguish to other family mem- for those children in greatest need, reduce hospital use, and
bers. National estimates suggest that as much as $450 mil- help control costs [47-49]. Eason and colleagues highlight
lion in avoidable Medicaid expenditures for hospital care the continued commitment of partners in North Carolina
occur in a single year [35]. to the oral health of young children and identify strategies
Wright and White [36] from the UNC-Chapel Hill Schools to move integration forward, specifically expanding the age
of Dentistry and Public Health provide an overview of silver for eligibility for IMB services to be consistent with national
diamine fluoride (SDF) in their invited commentary. SDF is a guidelines and increasing medical providers’ promotion of
chemotherapeutic agent first made available in the United the age 1 dental visit and its effectiveness.
States in 2015 that stops the progression of caries when Still with a goal of providing access to oral health services
applied topically to the carious lesion. It promises to make in the location where most individuals receive their primary
unnecessary some of the now standard-of-care surgical care, another model is the co-location of dental hygienists
treatment for dental caries provided in hospitals, ambula- in the primary care setting, either with separate administra-
tory care centers, and private offices. Even with acceptance tive functions or as a fully-integrated member of the medi-
as a treatment option and wide-spread adoption by den- cal practice [50]. An example of this model is the Colorado
tists in North Carolina, access to SDF application, like other Medical-Dental Integration Project (CO MDI) in which inde-
dental services, will remain a problem for some children. pendent dental hygienists are co-located in several primary
We already are hearing calls for its use in non-dental set- care practices with dedicated rooms with dental equipment
tings, including primary care, as a means to increase access [50, 51].
[37, 38]. Other approaches to integration maintain separate den-
tal and medical delivery systems but create linkages through
Integration of Primary Care and Oral Health Care treatment protocols for medical and dental services, financ-
The dental and medical primary health care systems ing mechanisms, and linkage services such as care coordina-
historically have operated separately with little integra- tors. Integration models in which physical location of clinical
tion of their education programs, clinical practices, orga- services, patient records, practice management, account-
nizational structures, regulatory agencies, or policies [39]. ability, and policies are integrated are rare, but some exam-
Separate systems contribute to disparities in oral health ples include the Department of Veterans Affairs, Kaiser
status because of missed opportunities to provide services Permanente of Oregon, and some Federally Qualified Health
in primary care locations where patients might seek care. Centers [52].
Physicians can provide preventive oral health services in Another notable development in the integration of oral
their offices, dentists can provide preventive health services health and primary care is the chairside screening in the
in their offices, and community-based health professionals dental office for medical conditions such as hemoglobin
can provide preventive oral health services in multiple non- A1C for glycemic control in diabetes or BMI for obesity
health care settings like Early Head Start programs and long- [53, 54]. Several feasibility studies have shown the dental
term care facilities. Four contributions in this issue address office to be a promising health care environment to deliver
different aspects of the integration of oral health and pri- these services. Economic studies show that treatment of
mary care [40-43]. dental problems such as periodontal disease can reduce
Most of the focus of early work in integration of primary expenditures for medical problems. One analysis estimated
care and oral health was on the expansion of the scope of savings of $64 billion over 10 years from insurance coverage
practice for primary care physicians and allied profession- of periodontal disease [55].
als to include preventive oral health services such as screen- A final integration strategy is to include community-
ing and enhanced dental referral activities, counseling, and based agencies in efforts to link patients to comprehensive
fluoride therapies [44, 45]. This work was motivated largely health services [56]. These 3 trends—the integration of oral
by the growing awareness of the high dental need, particu- health services into medical care, the integration of medi-
larly among very young disadvantaged children and their cal services into dental care, and the integration of social
poor access to dentists [46]. Well-child visits for infants and service agencies with either—provide the opportunity for
toddlers provide multiple opportunities for preventive oral greater population coverage of preventive services, access
health services for children who are unlikely to have access to care, and improved overall health.
to or make a visit to a dentist. Atchison and Weintraub [40] identify some of the bar-
Into the Mouths of Babes (IMB) in North Carolina, riers to integration of oral health and primary care. Among

380 NCMJ vol. 78, no. 6

ncmedicaljournal.com
them is the lack of access by all providers to Electronic for prevention and treatment are evolving in the state and
Health Records, also consistently identified in the literature nationally; however, dental practice act rules and regulations
as a barrier [57]. Burris [42] provides a commentary on the prevent adoption of some of these models in North Carolina.
North Carolina Health Information Exchange (HIE), known as Experience with them in other states should be monitored
NC HealthConnex. State law will require dentists and other for their application to North Carolina.
health care providers who are paid funds from Medicaid,
R. Gary Rozier, DDS, MPH research professor, Gillings School of Global
HealthChoice, or other state sources to be connected to Public Health, University of North Carolina at Chapel Hill, Chapel Hill,
the HIE and submit patient information. Implementation North Carolina.
dates are pending as is the structure for dentists’ participa-
tion, but the current deadline for implementation is by June Acknowledgments
Potential conflicts of interest. R.G.R. has no relevant conflicts of
2019 for most providers. Among the many advantages of NC interest.
HealthConnex is the opportunity to coordinate care in inte-
grated care models, particularly an already functioning one References
like IMB where the need for coordination is documented. NC 1. Marcenes W, Kassebaum NJ, Bernabé E, et al. Global burden of
oral conditions in 1990-2010: a systematic analysis. J Dent Res.
HealthConnex will permit physicians and dentists who might 2013;92(7):592–597.
be seeing the same child on multiple visits during the early 2. Rozier RG, King RS. Defining the need for dental care in North Caro-
years of life to coordinate preventive oral health services like lina: contributions of public health surveillance of dental diseases
and conditions. N C Med J. 2005;66(6):438-444.
fluoride varnish application and confirm adherence to the 3. Rozier RG, White BA, Slade GD. Trends in oral diseases in the US
recommended visit schedule. population. J Dent Educ. 2017;81(8):eS97-eS109.
The contribution by Moss [43] about including oral 4. Rozier RG. Oral health in North Carolina: innovations, opportunities,
and challenges. N C Med J. 2012;73(2):100-107.
health as a core benefit in Medicare Part B reminds us that 5. Eke PI, Dye BA, Wei L, et al. Update on prevalence of periodontitis
integration strategies need to consider multiple levels, from in adults in the United States: NHANES 2009 to 2012. J Periodontol.
the delivery of individual clinical services to the develop- 2015;86(5):611-622.
6. Fulton JT, Hughes JT. The life cycle of human teeth. Chapel Hill, NC:
ment of regulations and policies that allow and facilitate University of North Carolina; 1964.
these efforts. General advancement and awareness of scien- 7. North Carolina State Center for Health Statistics. BRFSS 2016
tific knowledge about the bi-directional relationship of oral Survey Results: North Carolina. SCHC website. http://www.schs
.state.nc.us/data/brfss/2016/nc/all/RMVTETH3.html. Accessed
health and general health, along with the high prevalence of September 30, 2017.
oral diseases in cohorts of adults born before the preven- 8. Slade GD, Akinkugbe AA, Sanders AE. Projections of US Eden-
tive dentistry era and dental insurance have contributed to tulism prevalence following 5 decades of decline. J Dent Res.
2014;93(10):959-965.
support for a dental benefit in Medicare. Two bills to include 9. Howell EE. Oral health trends from the North Carolina Behavioral Risk
dental, vision, and hearing services in Medicare have been Factor Surveillance System 2012-2016. N C Med J. 2017;78(6):413-
introduced in Congress [58]. Although some recommenda- 416 (in this issue).
10. Buchholtz KJ, Tomlinson SE. Highlights of North Carolina Oral
tions have been made, a national consensus on strategies Health Section’s 2015-2016 kindergarten assessment data. N C Med
for including these benefits in Medicare is lacking [59]. J. 2017;78(6):387 (in this issue).
While policymaking at the national level plays itself out, 11. Romaszewski JK. The journey to improving access to dental services
for individuals in assisted living facilities across North Carolina. N C
approaches to increasing access to care for elderly adults in Med J. 2017;78(6):398-401 (in this issue).
North Carolina need debate. Moss presents 2 delivery sys- 12. Schwendicke F, Dörfer CE, Schlattmann P, Foster Page L, Thomson
tem options for consideration. WM, Paris S. Socioeconomic inequality and caries: a systematic re-
view and meta-analysis. J Dent Res. 2015;94(1):10-18.
Conclusion 13. Whitehead M. The concepts and principles of equity and health. Int
J Health Serv. 1992;22(3):429-445.
Substantial progress has been made in improving oral 14. Watt RG, Heilmann A, Listl S, Peres MA. London Charter on oral
health inequalities. J Dent Res. 2016;95(3):245-247.
health outcomes in North Carolina, but further progress will 15. National Center for Health Statistics. Chapter 39: Social Deter-
require strategies that not only maintain these gains, but minants of Health (SDOH). Hyattsville, MD: Centers for Disease
also develop creative ways to consider social determinants Control and Prevention; 2016. https://www.cdc.gov/nchs/data/hp
data2020/HP2020MCR-C39-SDOH.pdf. Accessed September 30,
of dental problems, some of which are beyond the traditional 2017.
boundaries of existing dental and public health systems. 16. Marmot M. Fair society, healthy lives: strategic review of health in-
The priority we place on the oral health of young chil- equalities in England post-2010. The Marmot Review; 2010. http://
www.instituteofhealthequity.org/resources-reports/fair-society
dren continues to yield positive results. Although based on -healthy-lives-the-marmot-review/fair-society-healthy-lives-full
limited data, the percentage of children enrolled in kinder- -report-pdf.pdf. Accessed September 30, 2017.
garten who are affected by dental caries and the proportion 17. Oh EY, Santiago MZ. Why an equity lens is essential for achiev-
ing oral health for all: exploring collaboration as a path to systems
with untreated caries continued the decline that started in change. N C Med J. 2017;78(6):390-393 (in this issue).
2004. These benefits likely carry over to older children. 18. Le C. The critical role youth play in addressing oral health inequities.
The deep divide in North Carolina counties, according to N C Med J. 2017;78(6):411-412 (in this issue).
19. Eyes K, Warren SE. Working together for oral health in the Carolinas.
poverty and population density, makes workforce planning N C Med J. 2017;78(6):417-418 (in this issue).
challenging. Promising workforce and integration models 20. Eklund SA, Bailit HL. Estimating the number of dentists needed in

NCMJ vol. 78, no. 6 381

ncmedicaljournal.com
 2040. J Dent Educ. 2017;81(8):eS146-eS152. 2016;35(12):2168-2175.
21. US Department of Health and Human Services, Health Resources 40. Atchison KA, Weintraub JA. Integrating oral health and primary care
and Services Administration. National and State-Level Projections in the changing health care landscape. N C Med J. 2017;78(6):406-
for Dentists and Dental Hygienists in the US, 2012-2025. Rockville, 409 (in this issue).
MD: US Department of Health and Human Services; 2015. https:// 41. Eason K, Close K, Casey M, Earls M. A commentary on pediatric oral
bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/nation health in North Carolina. N C Med J. 2017;78(6):386-389 (in this
alstatelevelprojectionsdentists.pdf. Accessed September 30, 2017. issue).
22. Spero J, Burgette J, Fraher E. North Carolina’s oral health workforce: 42. Burris C. Connecting oral and physical health via Health Information
challenges and strategies. Chapel Hill, NC: Cecil G. Sheps Center for Exchange. N C Med J. 2017;78(6):410-412 (in this issue).
Health Services Research. http://www.shepscenter.unc.edu/work 43. Moss ME. Integrating oral health care services within Medicare. N C
force_product/north-carolinas-oral-health-workforce-challenges Med J. 2017;78(6):402-405 (in this issue).
-strategies/. Accessed September 30, 2017. 44. Silk H. The future of oral health care provided by physicians and al-
23. Tippett R. Population loss & shifting age composition, 2015-2035. lied professionals. J Dent Educ. 2017;81(8):eS171-eS179.
UNC-Chapel Hill Carolina Population Center website. http://de 45. Hummel J, Phillips KE, Holt B, Hayes C. Oral Health: An Essential
mography.cpc.unc.edu/2016/02/18/population-loss-shifting-age Component of Primary Care. Seattle, WA: Qualis Health; 2015.
-composition-2015-2035/. Accessed September 30, 2017. http://www.safetynetmedicalhome.org/sites/default/files/White
24. Oral Health Workforce Research Center. Variation in dental hy- -Paper-Oral-Health-Primary-Care.pdf. September 30, 2017.
giene scope of practice by state. OHWRC website. http://www.oral 46. Silberman P, Wicker DA, Smith SH Jr, DeFriese GH. Assuring access
healthworkforce.org/resources/variation-in-dental-hygiene-scope to dental care for low-income families in North Carolina. The NC In-
-of-practice-by-state/. Accessed September 30, 2017. stitute of Medicine Task Force Study. N C Med J. 2000;61(2):95-98.
25. American Dental Hygienists’ Association. Advocacy: direct access. 47. Pahel BT, Rozier RG, Stearns SC, Quiñonez RB. Effectiveness of pre-
ADHA website. http://www.adha.org/direct-access. Accessed Sep- ventive dental treatments by physicians for young Medicaid enroll-
tember 30, 2017. ees. Pediatrics. 2011;127(3):e682-e689.
26. American Dental Hygienists’ Association. Advocacy: reimburse- 48. Kranz AM, Preisser JS, Rozier RG. Effects of physician-based preven-
ment. ADHA website. http://www.adha.org/reimbursement. Ac- tive oral health services on dental caries. Pediatrics. 2015;136(1):107-
cessed September 30, 2017. 114.
27. Langelier M, Continelli T, Moore J, Baker B, Surdu S. Expanded 49. Stearns SC, Rozier RG, Kranz AM, Pahel BT, Quiñonez RB. Cost-effec-
scopes of practice for dental hygienists associated with im- tiveness of preventive oral health care in medical offices for young
proved oral health outcomes for adults. Health Aff (Millwood). Medicaid enrollees. Arch Pediatr Adolesc Med. 2012;166(10):945-
2016;35(12):2207-2215. 951.
28. Brickle CM, Self KD. Dental therapists as new oral health practitio- 50. Braun PA, Cusick A. Collaboration between medical providers and
ners: increasing access for underserved populations. J Dent Educ. dental hygienists in pediatric health care. J Evid Based Dent Pract.
2017;81(9):eS65-eS72. 2016;16 Suppl:59-67.
29. Koppelman J. States expand the use of dental therapy: access to 51. Braun PA, Kahl S, Ellison MC, Ling S, Widmer-Racich K, Daley MF.
care increases when dentists are authorized to hire midlevel provid- Feasibility of colocating dental hygienists into medical practices. J
ers. The Pew Charitable Trusts website. http://www.pewtrusts.org/ Public Health Dent. 2013;73(3):187-194.
en/research-and-analysis/analysis/2016/09/28/states-expand 52. Jones JA, Snyder JJ, Gesko DS, Helgeson MJ. Integrated medical-
-the-use-of-dental-therapy. Accessed September 30, 2017. dental delivery systems: models in a changing environment and their
30. Grover J. Community Dental Health Coordinators: cultural “connec- implications for dental education. J Dent Educ. 2017;81(9):eS21-
tors” for oral health. N C Med J. 2017;78(6):383-385 (in this issue). eS29.
31. Vujicic M. A new way to measure geographic access to dentists in 53. Glick M, Greenberg BL. The role of oral health care professionals in
North Carolina. N C Med J. 2017;78(6):391-392 (in this issue). providing medical services. J Dent Educ. 2017;81(8):eS180-eS185.
32. Kranz AM, Lee J, Divaris K, Baker AD, Vann W Jr. North Carolina 54. Greenberg BL, Glick M, Tavares M. Addressing obesity in the den-
physician-based preventive oral health services improve access tal setting: What can be learned from oral health care profession-
and use among young Medicaid enrollees. Health Aff (Millwood). als’ efforts to screen for medical conditions. J Public Health Dent.
2014;33(12):2144-2152. 2017;77(Suppl 1):S67-S78.
33. Sicca C, Bobbio E, Quartuccio N, Nicolò G, Cistaro A. Prevention 55. Avalere Health. Evaluation of Cost Savings Associated with Peri-
of dental caries: a review of effective treatments. J Clin Exp Dent. odontal Disease Treatment Benefit. Avalere Health LLC; 2016.
2016;8(5):e604–e610. http://pdsfoundation.org/downloads/Avalere_Health_Estimated_
34. Braun PA, Quissell DO, Henderson WG, et al. A cluster-randomized, Impact_of_Medicare_Periodontal_Coverage.pdf. Accessed July 5,
community-based, tribally delivered oral health promotion trial in 2017.
Navajo Head Start children. J Dent Res. 2016;95(11):1237-1244. 56. Lowe B, Barzel R, Holt K. Integrating Sustainable Oral Health Servic-
35. Bruen BK, Steinmetz E, Bysshe T, Glassman P, Ku L. Potentially pre- es into Primary Care in School-Based Health Centers: A Framework.
ventable dental care in operating rooms for children enrolled in Washington, DC: National Maternal and Child Oral Health Resource
Medicaid. J Am Dent Assoc. 2016;147(9):702-708. Center; 2016. https://www.mchoralhealth.org/framework/docs/
36. Wright JT, White A. Silver diamine fluoride: changing the caries Integration-Framework.pdf. Accessed July 3, 2017.
management paradigm and potential societal impact. N C Med J. 57. Harnagea H, Couturier Y, Shrivastava R, et al. Barriers and facilita-
2017;78(6):394-397 (in this issue). tors in the integration of oral health into primary care: a scoping re-
37. Milgrom P, Horst JA, Ludwig S, et al. Topical silver diamine fluo- view. BMJ Open. 2017;7(9):e016078.
ride for dental caries arrest in preschool children: a randomized 58. Willink A, Schoen C, Davis K. Consideration of dental, vision,
controlled trial and microbiological analysis of caries associated and hearing services to be covered under Medicare. JAMA.
microbes and resistance gene expression. J Dent. doi: 10.1016/j 2017;318(7):605-606.
.jdent.2017.08.015. 59. Willink A, Schoen C, Davis K. Dental care and Medicare beneficia-
38. Wong A, Subar PE, Young DA. Dental caries: an update on dental ries: access gaps, cost burdens, and policy options. Health Aff (Mill-
trends and therapy. Adv Pediatr. 2017;64(1):307-330. wood). 2016;35(12):2241-2248.
39. Mertz EA. The dental-medical divide. Health Aff (Millwood).

382 NCMJ vol. 78, no. 6

ncmedicaljournal.com