Marion resident Megan, 41, is mom to four children ages 4, 9, 12 and 13. Her youngest child has disabilities and requires 24/7 care. “If something was different with my daughter, I would be working,” she explains. “I used to be a CNA and I loved it. That’s not an option anymore.” To preserve her family’s privacy, Megan asked Xpress to use her first name only.
Megan’s husband works full time, and his modest income exceeds the level that would allow the adults in the family to qualify for Medicaid, though their children are covered under N.C. Health Choice. After not seeing a dentist for three years, a bad toothache that kept getting worse drove Megan to explore her options.
“I even looked at regular dentists and told them I didn’t have insurance. It was like, ‘It will be this much money out the door for us to even look at you,'” she recalls. Desperate, she contacted the McDowell County Department of Social Services and learned that Mountain Area Health Education Center offers dental care on a sliding fee scale at its Glenwood clinic.
Filling out the required paperwork and scheduling her first appointment didn’t take long, Megan says. Because MAHEC offers only 60-minute visits at the clinic, and a dentist sees patients there one day a week, attending to Megan’s dental needs — a root canal, a tooth extraction, fillings and a cleaning — took a total of about eight visits spread over the course of a year, from November 2017 to the beginning of this month. Megan paid $40 for each visit.
“If I had to pay triple what I had to pay with my sliding scale, it’s still better than walking into a dentist’s office and paying full price,” Megan says. The MAHEC dentists were gentle and understanding about her dental anxiety. “They never hurt me, and now I have a happy smile,” she says.
Barriers to care
About 40 percent of Americans don’t have access to dental care, says Dr. Jeff Heck, MAHEC’s CEO. And in rural areas, a shortage of dentists and other barriers reduce access even further.
That’s a big problem. “Poor dental care leads to poor health, and poor dental care is also a social poverty stigma that makes it hard for people to get jobs,” Heck says.
In line with its mission to train the next generation of health care professionals for Western North Carolina, MAHEC is working to increase the supply of rural dentists to help change those outcomes. With the signing of an agreement with St. Luke’s Hospital and Isothermal Community College, MAHEC launched a collaborative initiative to provide dental care and train dentists and dental assistants at a facility that will open on St. Luke’s campus in Columbus in the spring.
Twelve of the 16 counties MAHEC serves in WNC are federally designated dental health professional shortage areas, and the state as a whole projects a shortage of 459 dentists by 2025.
North Carolina residents seek dental care at their local emergency room at a rate more than double the national average, 2017 research at the UNC School of Public Health revealed. In rural areas — where the shortage of dentists is more acute — the rate of dental emergency room visits in 2014 was nearly twice that in metropolitan regions.
Emergency departments aren’t well-equipped to provide dental treatment, which has often advanced to a severe state by the time a patient seeks care. Instead of receiving dental work to resolve the cause of the problem, Heck says, patients get antibiotics, increasing the problem of antibiotic resistance. Perhaps even more troubling, they receive painkillers, which can lead to addiction.
According to a commentary published in the Journal of the American Dental Association on July 25, “ED physicians often prescribe opioid and other analgesic medications to manage acute dental pain.” And while dentists reduced the amount of opioids they prescribed by over 50 percent between the 1990s and 2012, the commentary noted, “An examination of a nationally representative data set suggested no reduction in the rate of opioid analgesic prescriptions for dental pain in emergency settings.”
Reducing the number of emergency room visits for dental problems better addressed in primary and preventive care settings requires accessible clinics close to where people live.
But data assembled by the UNC Cecil G. Sheps Center for Health Services Research show that nearly three-quarters of all new dentists who entered practice in the state over the past four years settled in five counties already well-served by dentists.
The most effective strategy for increasing the number of health care professionals — including dentists — committed to serving rural communities, Heck tells Xpress, is training those practitioners in rural settings. That’s why, in addition to its main campus in Asheville, MAHEC is working to develop four rural care and teaching sites over the next five years.
Besides the new Columbus center, MAHEC plans to locate a new facility in the far western area of the state, Heck says.
Two graduates of MAHEC’s medical residency program now serve as family physician rural fellows at the organization’s health centers in Burnsville and Bakersville, constituting a third training hub, while a fourth clinic now operating in Lake Lure rounds out MAHEC’s training sites.
“We will be sending more learners in more health disciplines to those two locations over time,” says Jennifer Maurer, MAHEC’s external communications manager. She points out that providing services in these communities reduces transportation challenges and the need to take time off from work for appointments.
Supporting excellent teaching and training programs in rural areas, Heck says, will enable MAHEC to “get people who find that practicing in rural areas is professionally rewarding and personally satisfying so that they want to practice there.”
A new initiative starting at the UNC School of Dentistry this spring will place 10 percent of each new dentistry class in a rural-practice track, Heck says, with a goal of increasing the number of dentists practicing in underserved rural areas. Some of those rural-track dental students will receive clinical training in MAHEC facilities.
Isothermal Community College has long been interested in offering a dental assistant training program, says Michael Gavin, the college’s director of marketing and community relations. With no prerequisite other than a high school diploma and starting salaries for dental assistants nearing $40,000, demand for local training is strong.
And for residents of Polk and Rutherford counties, tuition for any ICC program can be covered in full by the Powers Promise, an endowed scholarship that means “finances shouldn’t be a barrier to completing a program like this,” Gavin says.
The cost of outfitting a clinical training facility and hiring instructors, however, is steep.
But when the hospice program at St. Luke’s Hospital relocated to a larger facility in Landrum, S.C., the program’s former facility at 130 Forest Glen Drive became available for a new use.
ICC’s Columbus campus sits next door to St. Luke’s, Gavin explains. A collaborative plan emerged to create a training center for aspiring dentists and dental assistants through a partnership with St. Luke’s and MAHEC.
Beginning in fall 2019, ICC will enroll a cohort of up to 10 dental assistant students, while a rotating group of eight dental students from the UNC School of Dentistry (with up to four on-site on a given day) and one dental resident from MAHEC’s residency program will also work out of the center.
Foothills Medical Associates, a physician practice affiliated with St. Luke’s Hospital, will provide primary care at the facility. According to Maurer, additional learning opportunities for primary care and pharmacy residents, nurse practitioner and behavioral health students and other care providers will be available through MAHEC’s partnership with Foothills Medical.
Meeting the need
MAHEC’s new facility will complement the services provided by Collins Dental Center to Polk and Rutherford county residents. Also located in Columbus, Collins Dental Center originally opened in 2006 and began operating as part of Blue Ridge Health, a nonprofit community health care system headquartered in Hendersonville, in July 2017. The facility serves residents from birth through age 21.
“We work really closely with Blue Ridge,” comments Heck. “We actually have a residency training program in family medicine that we share with them.”
Most of MAHEC’s work at its new Columbus dental facility will address the needs of adult patients, including preventive dentistry and fillings, as well as more complicated services such as crowns, bridges and dental surgery. “The facility will be well-equipped with all the modern supplies we have to have to provide complex dentistry,” says Heck.
Providing advanced dental care in coordination with primary care, Heck says, increases the benefits of both services, since dental health is closely linked with overall health.
“Collaboration between primary care doctors and dentists is important because there are a lot of dental problems which lead to significant health problems and, likewise, significant health problems that lead to significant dental problems,” Heck says.
Following a complete renovation, the Columbus facility will begin serving patients and training future health care providers in late spring. The facility will accept Medicaid and Medicare, private insurance and direct payment. Fees for those without dental coverage will be on a sliding scale based on the patient’s income.
MAHEC patient Megan looks forward to continuing to use the Glenwood clinic, and she plans to see if her husband can also qualify for dental care there this year. Having a low-cost resource in their own community, she says, is “pretty awesome.”
Megan wants to bring attention to dental options for low-income families in rural areas. “I see people all the time, kids and parents, with their teeth falling out,” she says. “I just hope that people actually know that this kind of program is out there. I had no idea.”