For Immediate Release
Date: Feb 20th, 2014
Contact: Nikki Stone, DMD Dental Director, UK North Fork Valley Community Health Center Hazard, Perry County, Kentucky
UKCD’s First Regional Dental Program: The First Ten Years
In 2001, just after the first-ever Surgeon General’s report on oral health, Kentucky completed its only state-wide survey of oral health. Not surprisingly, the study revealed that the heaviest burden of decay fell in the eastern Appalachian region of our state. The University of Kentucky College of Dentistry (UKCD) initiated a range of discussions on how to help improve oral health for the vulnerable populations in this part of the state. Plans were already underway for the construction of a new building in Hazard (Perry County) to house the UK Center of Excellence in Rural Health and its Family Medicine Residency Program. With a little nudging, Dr. Raynor Mullins, then Chief of Division of Dental Public Health, was able to convince Rep. Hal Rogers and others to expand the blueprint of the new building to include a dental suite. Additionally, Dr. Cindy Derer, a Lexington dentist, was serving as President of the Board of the Ronald McDonald House Charities of the Bluegrass, and a request was made to RMHC Global for a mobile dental clinic to serve the children of eastern Kentucky.
In July 2004, UKCD’s first regional dental program opened with a 5 operatory fixed dental suite adjacent to the medical clinic and a mobile unit soon followed, arriving in May 2005. In the spirit of a true multi-disciplinary partnership, the Deans of both the College of Dentistry and Medicine, Sharon Turner and Jay Perman, presented in tandem at the official Roll-Out Ceremony that was attended by many advocates and supporters of the new program representing both Lexington and Hazard.
The clinic applied for distinction as a Federally-Qualified Health Center (FQHC), and was awarded their first HRSA (Health Resources and Services Administration) grant in 2006, funding that would be used to offer a sliding fee scale to uninsured and underinsured residents of Perry and surrounding counties. Dubbed the “UK North Fork Valley Community Health Center” by the newly-formed board, this clinic would be only the second FQHC in the nation to have a partnership affiliation with a University.
Dental services began in the fixed clinic, where the majority of patients were uninsured and clinically exhibited decades of dental neglect. Under the leadership of Dr. Ted Raybould, General Practice Residency (GPR) Director at UKCD, the general practice residents program was organized to enable five-week rotations at the Hazard site. Qualitative outcomes of this early program indicated that residents were taken by the sincere gratitude of the patients who were extremely thankful for such high quality care in a beautiful facility and excellent staff. Most of the patients reflected a high level of dental anxiety related to pain, infection, and the hopelessness that had come from years of having no access to regular, affordable dental care.
Mobile dental services soon began in Letcher, Knott, Leslie, and Perry (LKLP) Counties, serving elementary school and Head Start children. Nearly 5,000 children were seen that first school year, and the baseline data was disturbing, especially when compared to national data and the HealthyPeople 2010 goals. A staggering 58% of Head Start children and almost 70% of elementary school children had untreated tooth decay, and nearly 20% had urgent dental needs (pain/infection/rampant decay). At nearly every Head Start center visited over the four-county area, at least one child in each center had all 20 baby teeth grossly decayed with multiple abscessed teeth. Compared to national data, the children in this service turned out to have the 2nd highest untreated tooth decay rates in the nation, second only to the isolated Alaskan Native/Native American populations.
Our dental team shed a few tears that first year after seeing the severity of the poor oral health of children right in our own hometowns. I had been hired to direct the new program when it opened in 2004 and then transitioned to working with the mobile dental outreach program full time. As a 9th generation Letcher County native, I had worked at the Mountain Comprehensive Health Corporation dental clinic in Letcher County for several years prior to doing dental outreach, and had seen many children with tooth decay and several with active infections in that dental office, but nothing could compare to what I saw when I began overseeing this LKLP community-based dental outreach.
We were astonished at how many children had never been to a dentist, how many did not even own a toothbrush, and how much rampant tooth decay affected our children, most of whom actually had Medicaid dental benefits. My previous clinic employment served primarily Medicaid and uninsured patients, and at that time there were about 15 active dentists in the area, most of whom also accepted Medicaid. But neither I nor my colleagues were aware of the multitude of children in these communities who were not able to access oral health care. Recently published Kentucky Medicaid data confirmed that utilization rates for children remain alarmingly low across the state.
My dental team, also lifelong residents of this area, could not understand why the parents hadn’t taken their children for dental care. This was clearly a critical breakdown in the system, and our subsequent investigations demonstrated a variety of complex reasons that underpinned this historic problem. Transportation was a major issue for the majority; even seeking care within their own county was difficult for some families with unreliable vehicles, increasing fuel costs, and potential lost work. Access to specialty pediatric dental care was basically non-existent at that time, with families often having to drive 2 hours or more into unfamiliar places. Additionally, health behaviors showed that inaccurate cultural moirés regarding the importance of baby teeth were extremely prevalent. Finally, drug abuse and the apathy and neglect that accompany that lifestyle also seemed to play a significant role. An astonishing number of children were in continually transient circumstances, moving from home to home, and often changing custody from parents to grandparents to foster parents. This breakdown in fundamental family oversight of the continuity of health care combined with the establishment of a dental home were concepts foreign to these families who were focused more on daily survival.
For very young children with the majority of their teeth badly decayed, we soon realized that access to specialty pediatric care was a major issue. In fact, in the fall of the first year, nearly 80 Head Start children (aged 2-5) were identified as having urgent dental needs, and all of them were referred to their choice of the handful of regional pediatric dentists or to UKCD in Lexington. Unfortunately this approach showed that at the end of the school year, only 8% of these children in extreme need had completed their dental care, only six children’s families were able to successfully navigate the oral health system.
The following year, a new pediatric dentist, Dr. Seth Hyden, opened up a dental practice in the region. As a GPR resident, he had rotated through the Hazard program and we had become friends and concerned colleagues. In fact, we asked him to locate his practice to Hazard, but he chose to set up in his hometown of Prestonsburg. However, he was committed to identifying ways to help address our needs, and an opportunity to compete for some grant funding allowed us to purchase operating room dental equipment and set up a four way partnership between our dental outreach team, the Head Start program, the local Appalachian Regional Hospital, and Dr. Hyden. We began extensive case management efforts and he began travelling an hour to Hazard early every Thursday morning so that the children with urgent dental needs could be treated in the operating room right in Hazard, rather than in unfamiliar places further away. After that partnership was formed, over 60% of children had their care completed the following year, a huge success.
With the increased local knowledge of our program, school nurses and family resource directors began reporting to us that many elementary children came to school in pain on a daily basis or frequently missed school due to toothaches. Out of every ten children we saw at our community schools, two of them were in pain or had abscessed teeth. When presented with the first year of data showing all of the different elementary schools, the superintendent of Perry County schools at that time, noted immediately that the two schools with the lowest tooth decay rates were the same two schools that had the highest standardized test scores.
Our strategic planning activities included consulting with the state dental director, Dr. Jim Cecil, and examining evidence-based public health practices with the goal of replicating the best practices and gold standards of other successful population-based prevention programs around the nation. Support from UKCD’s new Center for Oral Health Research Director, Dr. Jeff Ebersole, allowed opportunities for grant support to conduct further surveillance research to appropriately document the findings from this innovative new regional program.
The situation was likened to fighting a forest fire with a squirt gun, so the only strategy that could help to gain control of the fire would be to deploy extra firefighters who would concentrate their efforts on soaking the next mountain down (the one not yet on fire) and keep the fire from spreading! The next mountain became our metaphor for the incoming generation of children in eastern Kentucky, and instead of water, the dental outreach team began to soak the mountain with fluoride varnish and dental sealants.
The big question, “Would this new strategy work?” would clearly take time to answer. Ten years later, the data show that the answer is, resoundingly, “Yes!” Slowly but surely, each school year, the tooth decay rates kept decreasing a few percentage points at a time, with an overall drop of 16% to date, and the urgent dental needs have been cut in half. Population-based preventive strategies do work, all of the evidence in eastern Kentucky and elsewhere clearly document this fact and the improvement in the health of the children of the region are the tangible benefits of the program.
The intangible benefits are not as easy to measure, but play just as important a role. We have noticed that this new generation is growing up with little to no dental anxiety. They enjoy their dental visits on the mobile at their schools, and often ask if they can have another turn! Through one-on-one as well as classroom-based oral health education, they better understand the importance of their baby teeth, and they are teaching their own families about the importance of dental care. The culture is truly changing. School officials have seen that the children are able to concentrate and learn better in school, and they miss less school for dental visits and dental pain. Finally, children with healthy smiles are showing more self-confidence and self-esteem, which might possibly be the biggest obstacle children in poverty struggle to overcome.
Dr. Rob Kovarik and Dr. Raynor Mullins of the UKCD Division of Dental Public Health helped form the Kentucky Oral Health Network (KOHN) to share the lessons learned from this first regional dental program and other successful efforts with partners state-wide, including the very successful CenteringPregnancy Smiles program in western Kentucky, which helped focus oral health efforts on pregnant women as well. All of these efforts were influenced by the new Center for Clinical and Translational Research.
In 2013, the Robert Wood Johnson Foundation did a nation-wide search for workforce innovations in the provision of preventive oral health services. The dental outreach program in Hazard was one of 25 programs identified by RWJ as one of those promising preventive programs. We have a long way to go to reach the national goal for good oral health in eastern Kentucky. The long multi-generational history of this problem in eastern Kentucky must be solved by a collective commitment of the healthcare, educational, business, and political infrastructures to change the lives of our children and thus the future generations of our region. These ideas were also shared with many like-minded leaders searching for solutions at the recent Shaping Our Appalachian Region (SOAR) Summit in Pikeville, a bi-partisan effort led by Gov. Steve Beshear and Rep. Hal Rogers.
Many more strategies need to be explored, but ideas can be shared and adopted from other successful programs around the nation and the world. Moreover, these best practices can be replicated in other Kentucky counties, reaching children not just in eastern Kentucky, but all across the Commonwealth! Our children are worth it, they are our collective future.
One of my dental hygienists has a young child at home, and came across a Winnie the Pooh quote that described what a regional dental outreach program is all about. Pooh says, “You can’t stay in your corner of the woods waiting for others to come to you… You have to go to them sometimes.” Indeed, Pooh.