Promoting a Lifetime of Healthy Smiles

On this chilly winter day at Moss Hill Elementary School, students are waiting in line — to see the dentist.

“You are doing such a great job,” Dr. Francisco Rios says, peering inside the mouth of his first patient. ​“Can you bite down? And open wide? Now put your tongue back in and close. Awesome! You have a perfect score. Give me five!”

After the exam, the fourth grader heads back to his class with clean teeth and a prize bag.

Dr. Rios and his team have set up shop this morning at Moss Hill in Lenoir County, N.C., thanks to a school-based oral health program funded by The Duke Endowment, Blue Cross and Blue Shield of North Carolina Foundation and BlueCross BlueShield of South Carolina Foundation. Nearly two dozen clinics and health departments, along with East Carolina University and UNC Chapel Hill, provide services. As a result, students at more than 100 schools in rural and underserved areas across the Carolinas have access to preventive care — including x‑rays, exams, cleanings, fluoride varnish and sealants.

Dr. Rios, chief dental officer at the Kinston Community Health Center, will visit 13 schools in Lenoir this year, sometimes checking as many as 25 students — and their 800 incisors, canines and molars — in one day.

More often than you might expect, he sees children coping with painful decay. Long-term complications can be prevented if caught early enough, but untreated cavities can lead to serious health issues, not to mention missed school days and fragile self-esteem. When he and his team spot a problem, they contact the caregiver to start a treatment plan.

At Moss Hill, they’ve turned a small teacher workroom into a makeshift dental office. Bright lights shine next to portable exam stations; an X‑ray machine stands in a corner.

Most students arrive ready to flash their best smiles. Others need a little coaxing. Some say it’s their first visit ​“with a real dentist.”

By the end of the day, he will have found a half dozen cavities, a few wiggly teeth and several emerging molars. Answers to his question about brushing ranged from every other week, to 20 times a day.

Dr. Rios knows how transportation, tight family budgets and other barriers can prevent children from getting the oral health care they need — and he’s thrilled that he can help. After falling in love with science as a young boy in Puerto Rico, he felt called to medicine as a way to serve others. He earned scholarships to study dentistry and spent most of his career in private practice. In 2015, after Kinston Community Health Center expanded its dental clinic, he jumped at the chance to join the staff.

At the schools, Dr. Rios does what he can to put anxious students at ease. He remembers his own first visit to a dentist, when he had to have a painful tooth pulled. 

“Just like some of these kids, I was not privileged to go to a dentist when I was little,” he says, ​“so I’m very proud that I can offer these services today.”

Improving Oral Health in the Carolinas

Experts says that school-based oral health programs can reduce barriers to care and decrease missed education time for children. They also help ensure that children receive recommended preventive care such as sealants, which are 80 percent effective in preventing dental disease.

But while the programs have proven to be effective, widespread replication has been a challenge. Hurdles — such as navigating the education system, engaging families and ensuring that programs have a sound clinical and business model — have stood in the way.

To understand the issue, The Duke Endowment funded a case study of eight school-based programs to evaluate their comparative effectiveness in improving dental outcomes. The evaluation focused on assessing capacity building, collaborative referral management practices and financial performance.

Three key lessons surfaced:

1. Programs should have the flexibility to use the service delivery model that best addresses the needs of their communities.
2. They should focus equally on clinical plans and business plans to ensure long-term sustainability.
3. Programs need support to produce data reports and should be willing to receive technical assistance.

Using those lessons, and with technical assistance from the Medical University of South Carolina’s College of Dental Medicine, the Endowment developed its school-based oral health initiative, beginning with a Request for Application that went to select counties identified as dental shortage areas in the Carolinas.

The Endowment conducted site visits in the fall of 2018; Trustees approved grants for 10 sites that November. Each grantee went through six months of readiness training, and then became eligible to be part of the initiative’s first cohort. Last summer, 12 new grantees were selected for Cohort II.

The $35 million initiative is aimed at increasing preventive services that reduce cavities and improve oral health. Blue Cross and Blue Shield of North Carolina Foundation and BlueCross BlueShield of South Carolina Foundation have partnered with the Endowment in the work.

With more than 4.1 million Carolinians living in areas without adequate access to oral health services, the foundations saw a pressing need for action. According to the American Dental Association, both states rank in the bottom third of all states when it comes to the number of dentists per resident.

“Oral disease is highly preventable, yet millions living in North Carolina and South Carolina still suffer from it, affecting chronic conditions such as diabetes, cardiovascular disease and stroke, as well as school and work attendance, health care costs and overall quality of life,” says Stacy Warren, a Health Care program officer at the Endowment. ​“As philanthropists committed to improving health in our region, we recognize that oral health is closely tied to all aspects of well-being and an area of health where the opportunity to affect change is ripe.”