Sidebar: A Crisis of Opportunity: A Collaborative Approach to Oral Health Policy in North Carolina

A Collaborative Approach

Effective oral health policy requires collaboration. Recent changes, including the elimination of the prior exam requirement for dental hygienists delivering preventive care in high-need settings (a regulatory modification to Rule 21 NCAC 16W) and proposed legislation^a to codify teledentistry, were made possible by leveraging the influence and input of a diverse coalition. Professional, regulatory, and governmental entities that authentically engage with advocacy organizations, community groups, and the public will have greater success in achieving lasting, sustainable change. This approach to policy development is what made the change to Rule 21 NCAC 16W a reality and will be critical in advancing systems-level changes in the future. The previous status quo, with less ambitious policy driven by disparate and disconnected entities, is no longer workable.

The challenges facing oral health care access and equity in North Carolina are great. So is policy’s ability to address the systemic barriers and social determinants of health that drive them. This article attempts to introduce a mere handful of such challenges and potential evidence-based policy solutions, underscoring the importance of collaboration and transparency. Real, meaningful oral health policy demands it.

Workforce

North Carolina’s oral health workforce is maldistributed and underutilized. Just 15% of active dentists practice in rural areas, severely limiting access to oral health care for the nearly 40% of North Carolinians living in those communities [1,2]]. Compounding the issue, one of the country’s most restrictive dental hygiene acts further constrains the hygienists delivering essential services that disadvantaged populations need most [3].

Policy change is a conduit to utilizing North Carolina’s oral health care workforce more effectively. Communitybased access points (“meeting people where they are”) such as school-based programs can be supported through changes to hygienists’ scope of practice, direct access for hygienists in rural and underserved communities, and the embrace of teledentistry. An increased focus on care coordination—promoting integration of dental, medical, and behavioral health care and addressing barriers to appointment compliance—may also be encouraged through payment policies supporting community dental health coordinators (CDHCs).

Payment Reform

“The nation will never drill, fill, and extract its way out of what amounts to a public health crisis,” yet the dental community has lagged in adopting value-based care and alternative payment models [4]. The incentivization of evidence-based, non-surgical, preventive care focused on quality health outcomes can begin to be achieved through Medicaid transformation and private payer reimbursement policies.

Payment reform can also help mitigate barriers to oral health care imposed by the social determinants of health. Reimbursement for transportation assistance and care coordination, both fundamental in addressing appointment compliance, are just two examples [5].

Structural and Interpersonal Racism

The impact of structural and interpersonal racism is often overlooked in oral health care. Due in part to a legacy of racism that has influenced disparities in socioeconomic status, oral disease rates differ among racial groups in North Carolina. Among North Carolina kindergarteners, “the prevalence of dental caries was 30.4% for white, 39.0% for Black, and 51.7% for Hispanic students” [6]. Reducing or eliminating inequities in oral health requires taking a hard look at racially driven economic, educational, and other injustices that have resulted in disproportionately poor outcomes.

In particular, policy has a role to play in addressing racism’s insidious effect on oral health among the roughly 37% of North Carolinians who are nonwhite [7]. Policies addressing structural racism such as investments in education, community-building, and healthier living environments may directly and indirectly influence oral health care access and outcomes, and work toward achieving oral health equity. Additionally, policies that incentivize the development of a more racially diverse oral health workforce and support for racial and cultural sensitivity training among dental providers and staff may be warranted.

The Way Forward

A piecemeal approach to addressing the state’s oral health and oral health care disparities and inequities is unlikely to succeed in North Carolina. Rather, comprehensive, community-driven policy changes addressing systems-level barriers will require both political will and diversity in perspective. Working together is critical if we plan to build a healthier landscape, one where every North Carolinian recognizes oral disease as preventable and has equitable access to optimal oral health care.