When Dr. Amanda Stroud was a seventh grade student at Happy Valley School in Caldwell County, she came home one day with a message from a dentist who’d visited her school.
“I got sent home with a note saying, ‘Your child has cavities and you need to find a dentist to fix them,’” Stroud recalls. “My parents were people who worked 40 hours a week every week, and they never missed work for anything,” she explains. “But they also didn’t have enough money to have dental insurance. … That was considered an extra.”
Stroud and her family were some of the many individuals, including many in rural communities, who lacked dental care in North Carolina. The medical community knows oral health isn’t just about protecting teeth; poor oral health can lead to malnutrition and other health conditions, according to the Harvard T.C. Chan School of Public Health.
Stroud’s experience as a 12-year-old motivated her to pursue dentistry as a profession; she graduated from the East Carolina School of Dental Medicine in 2015. It also motivated her to increase her oral surgery skills for serving low-income patients at a new “mini dental residency” last month at the Mountain Area Health Education Center.
‘Safety net’ clinics
MAHEC’s residency is offered to safety net providers, meaning dentists who work at safety net dental clinics.
The clinics are “nonprofit dental facilities where low-income families or individuals can go for dental care,” explains the N.C. Department of Health and Human Services. These clinics, located in almost every county in North Carolina, provide services on a sliding-fee scale to low-income patients who have no dental insurance. Oftentimes, being a safety net provider means “you’re the only dentist in this rural community,” Dr. Katherine Jowers explains. “If you’re going to be a safety net provider and move to Ahoskie or [someplace else rural], you’re on your own.”
Jowers is MAHEC chair of the Department of Dentistry and Oral Health and director of an oral health program at UNC.
Stroud has practiced as a safety net dentist since 2015 and is dental director for AppHealth Care, the public health department serving Allegheny, Ashe and Watauga counties. It’s also a federally qualified health center serving Allegheny and Ashe counties.
“We have a lot of patients who are in need of dentures,” Stroud says of her patients. She does tooth extractions — done because the tooth is dead — nearly every day. She says approximately half her patients need 12-14 teeth extracted at one time, and she recalls one time when she extracted 27 teeth from one person. (Humans usually have 32-34 teeth.)
While some dentists specialize in surgery or gum diseases, the MAHEC program is geared toward general dentists who are likely to encounter patients with a range of issues that stem from the lack of dental care. Many patients don’t see dentists because they can’t afford it.
The residency, a collaboration with the N.C. Oral Health Collaborative, ran four weekends from March 30-April 29 and provided hands-on clinical training in dentoalveolar surgery, or surgery on the gums, teeth and jawbone. Stroud and two dentists from Western North Carolina Community Health Services arrived at MAHEC’s Mary C. Nesbitt Biltmore Campus in Asheville on Fridays for lectures and practicing on nonhuman soft tissues, such as pig jaws. On Saturdays, the dentists operated on patients who needed those procedures.
The residency focused on treating patients with complex oral health needs caused by a long-term lack of oral health care. Asheville native Jowers says, “There are so many people that get lost in the shuffle of the glamour of Asheville, and they don’t get enough attention.”
Jowers continues, “My heart is in supporting … the guy who wears overalls to his appointment because it’s the nicest thing he’s got. There’s a lot of people that live out here, and they all need help.”
On Saturdays, the three safety net dentists practiced procedures with a more experienced oral surgeon “right there at their elbow,” Jowers says. The residency paired “book learning” with hands-on, “in the clinic doing it with someone helping you learning,” she explains.
Many of the surgeries dealt with abscesses. “An abscess is an infection that is borne typically from a tooth issue — typically decay that has reached the tooth tissue,” Stroud explains. The infection can eat away portions of the bone and cause damage to sensitive oral nerves. Abscesses are extremely painful, and in worst-case scenarios, the infection from untreated abscesses in children and adults can result in death, she adds.
Getting dental care
Beyond the safety net providers, preventive dental care is beyond the reach of those who struggle financially.
Provider shortages are among the barriers rural communities face regarding oral health care, according to the Rural Health Information Hub, which is supported by the Health Resources and Services Administration at the U.S. Department of Health and Human Services. Other barriers include a higher rate of poverty in rural areas, difficulty finding providers willing to treat Medicaid patients, geographic isolation and lack of public transportation.
While not all states offer adult dental coverage under Medicaid, North Carolina does, according to the National Academy for State Policy. However, it requires that a procedure or service be “medically necessary,” which means preventive care does not qualify.
Individuals who don’t meet the “medically necessary” threshold or who lack dental insurance entirely often visit an emergency room for oral pain rather than visit a dentist, Stroud says. However, many ERs don’t have dentists on staff; Stroud says she is unaware of any locally. ER clinicians often can only prescribe an antibiotic to the patient and advise visiting a dentist.
Such a suggestion, while well-intentioned, is often unhelpful to the broader oral health crisis. “If they can’t afford to get [dental] care originally, they probably can’t afford to get oral surgery,” Stroud says.
The dental school conundrum
The MAHEC training in dentoalveolar surgery for general dentists is intended to fill that gap. Complicated oral surgery isn’t explored in great depth during dental school, says Jowers. Instead, dentists have to specialize in those types of care, which requires them to pursue advanced training. “In dental school, you get kind of a broad, thin film of knowledge,” she explains. “They’ve shown you everything, once, you’ve tried everything once — well, then you’re out there [practicing].”
Unlike medical school, which requires a residency for specialized training, dental school has no such requirement, Jowers continues. “More people than not go right out and start practicing without a residency under their belt. … So, a lot of dentists are out there learning as they go,” she continues. “But you’re not going to get out of your comfort zone and try something you don’t know how to do well,” especially the complex oral surgeries that come with a longtime lack of oral health care.
Educational costs can be another reason dentists don’t obtain specialized training, Jowers says. After earning either a doctorate of dental medicine or a doctorate of dental surgery, dentists can be itching to pay off student loans. With that in mind, MAHEC’s residency costs participants $1,200 for nine classes. By way of comparison, in-state resident tuition for advanced dentistry training at UNC Chapel Hill Adams School of Dentistry for the 2022-23 school year ranged from $5,000 to $8,000, not including other fees, for a full load of coursework.
Upon completion, the three dentists received 32.5 hours of continuing education credits. Dentists in North Carolina are required to complete 15 hours of continuing education each year, according to the N.C. Board of Dental Examiners.
Stroud says the education gave her confidence to treat more oral issues caused by a lack of dental care.
While dentists have the opportunity to augment their education with daylong classes, books or videos, it’s having hands-on experience for complex procedures that matters.
“You’re sort of stuck [at your ability level],” Jowers explains. “You never really get that much better at some things because you just aren’t comfortable cutting that jaw open, removing the bone and getting at that third molar.”
For that reason, Stroud adds, MAHEC’s residency “has been paramount to helping more patients get care.” She adds, “I’ve already sped up my suture technique,” estimating she is five or 10 minutes faster in suturing.
If Stroud sutures three patients more quickly each day, she continues, she could possibly add one more half-hour appointment — one more patient — to her workload.
Stroud tells Xpress she has already used what she has learned at MAHEC in her practice. “I’ve already been able to reach out to more patients and say, ‘I’m more comfortable doing this now.’”