To Improve Health Equity, Focus on Oral Health

A team from our Clinical Scholars program believes that addressing oral health disparities can improve overall health and wellbeing, and help end cycles of poverty. They are bringing oral health to the community through school clinics, an app, and an oral health protocol development for nurses, physicians, dentists, and dental hygienists.

In January 2018, the Hollis Innovation Academy, a K-8 school, opened a dental exam room. Though it may seem unusual to see a dentist’s chair in a school, its presence reflects years of learning within this Atlanta community. Hollis's students live in English Avenue/Vine City, an area with one of the highest poverty rates in Atlanta. They also reside in one of three ZIP codes with the highest oral cancer rates in the city.

Early in my career as an ear, nose and throat specialist, I witnessed a deeply troubling pattern: on my first visit with a patient, I would diagnose him or her with advanced head and neck cancers. There would have been good treatment options if these patients had been seen much earlier. But time and time again, all we could do was rush the patient into an operating room, put in a tracheotomy to control the airway, and set up end-of-life care. I kept thinking that someone needed to get to this issue much sooner so that people wouldn’t die from something that could be treated effectively if caught sooner.

Eventually, I decided that person was me.

I started by looking at the ZIP codes of the patients coming in with advanced stage cancer. When I drove to those areas, I saw pockets of concentrated poverty. I talked—and more importantly listened—to residents to learn about their lives. I would park under bridges and outside drug houses, offering screenings for head and neck cancer out of the back of my car. It turned out that people wanted to visit the dentist, but they faced many barriers. Often, it could be as much as a 10-mile trip to get there. Not only were there transportation issues, but there were also fears of ending up with costly bills. Combined with larger societal barriers like a shortage of dentists, low Medicaid reimbursement rates, and an unwillingness of dentists to participate in Medicaid, it became clear that we needed a larger solution than exams out of the back of my Subaru.

Seeking to take the work to a larger scale, I teamed up with colleagues David Reznik, a dentist, and Hope Bussenius, a nurse practitioner, in the Clinical Scholars program. Together, our aim is to address barriers to accessing quality oral health services so that communities throughout Georgia, regardless of income, can live and thrive.

In each of our roles, we see every day how poor oral health can devastate lives: unnecessary tooth decay, expensive trips to the emergency department, and deadly advancement of oral cancers.

As if that weren’t enough, these oral health issues can reinforce a cycle of poverty and declining health. Individuals with missing teeth lack confidence. They are often passed over for work. They also have significant bearings on healthy eating. The stories are very painful  to hear. A young boy once told me that he snacked on Twinkies because the apple he knew was healthier for him hurt his teeth when he bit into it. His mother told us that her son was missing a lot of school due to tooth pain. In fact, tooth pain is one of the primary reasons that children miss school, and that also usually means a parent is missing work to care for them.

Ultimately, addressing oral health has implications for individuals’ overall health and wellbeing. Our team has developed a unique model called OH-I-CAN (Oral Health in Communities and Neighborhoods) aimed at increasing access to oral health services for low-income students and their families.

Below are a few key strategies we are using to address disparities in oral health, and can be adapted in other communities around the country.

Start With a Community Needs Assessments

A community needs assessment is a snapshot of a community’s strengths and weaknesses. It highlights resources that already exist and identifies areas in need of improvement. Conducting a needs assessment as a first step has enabled our team to work with leaders and resources that were already thriving in Atlanta neighborhoods. This allows us to target resources to develop effective, long-term solutions. For example, our assessment showed us the pressing need in the community where Hollis is located, so we focused our efforts there.

Bring Oral Care Into Schools

Every community has a school and it makes logical sense to bring healthcare to where students go every day. OH-I-CAN has integrated dental and primary care services, as the health clinic at Hollis now does. Students can have their teeth cleaned and receive other preventive care, and those with cavities and other problems are referred to a dentist at the nearby Neighborhood Union Health Center. Eventually, the clinic will be able to see adults from the community as well.

Integrate Oral Health Into the Services That Primary Providers Provide

Regular dental care can prevent infection, tooth decay and loss, compromised nutrition, and unnecessary advancement of some cancers. By integrating oral health into primary care, clinicians can better address the total health of a patient. Such integration can also improve access to care in low income and rural communities, who suffer the most from an uneven distribution of dental professionals. One way to do this is to train primary care nurses and nurse practitioners. OH-I-CAN leaders focused on updating protocols in oral healthcare for nurses, primary care physicians, dentists, and dental hygienists at the state level. New nursing protocols, for example, enabled APRNs to provide basic preventive care—including oral hygiene instructions, oral cancer screenings, fluoride treatments, and appropriate referrals—in primary care settings.

Tap Into Technology

Many people are uncomfortable talking about their oral health. They might be embarrassed by their teeth and that they have been unable to take care of them. We are working to remove that barrier through the OH-I-CAN app. To capture patients' dental histories in such settings, the OH-I-CAN app, with versions tailored for children and adults, patients can answer questions on a tablet to create an oral health profile that is then saved to a data registry.

The OHICAN.org website includes medical and dental facts, research information, and oral healthcare training data aimed at advanced practice RNs (APRNs) and physicians. The more we can make patients feel comfortable accessing oral health, the better we can provide services and put an end to the disparities we see today.

This process has been supported by our work through RWJF and some additional funding from the Dobbs Foundation. Eventually, our hope is that this clinic will become self-sustaining and other similar models will take root.

Learn more about how our Clinical Scholars are redefining health within communities.

About the Author

Charles Moore, M.D., Emory University School of Medicine, focuses his research on the factors involved in disparity in healthcare with a particular focus on head and neck cancer incidence in medically underserved communities.