Waiting for an ECU dentist
By Marion Blackburn
As a boy, Thomas Story remembers going to the hospital after he lost an eye in a gun accident on his family’s farm in Perquimans County. But as for visiting the dentist? Well, he says, you just didn’t. Now 62, he saw a dentist for the first time in decades this year at a clinic at a Washington, N.C. church. After waiting several hours along with hundreds of others, he had all his teeth pulled.
It was a blessing, he says, because it brought an end to the decay, pain and infection that often left him unable to eat or drink. He suffered his whole life because he didn’t have the money to pay a dentist, plus it would have required a lengthy trip to the closest one many miles away.
“I feel better and I’ve gained weight,” he says. “I can eat better with no teeth than with rotten ones.”
It’s hard to imagine that people endure such hardship in our time, but rural North Carolina is full of tragic accounts like Story’s. Adults like him who have gone years without dental care suffer infections, swollen gums and worn-down teeth. Hundreds of children lose their adult teeth because cavities set in as soon as they erupt. The health of people with diabetes, obesity or high blood pressure often fails to improve because they can’t chew healthy foods. For some, gum disease turns lethal when combined with heart disease.
There is hope. ECU’s $60 million School of Dental Medicine, set to open in August, will serve people like Story. At full enrollment, it will graduate around 50 new dentists each year who will have the training needed to provide broad care to people living in rural areas—places where they may well be the only dentist for miles around.
Dr. Gregory Chadwick, associate dean, at the site of Ross Hall, which will open next year
“This state has a genuine focus on helping its citizens achieve great things, but that’s tough to do when many are suffering from chronic conditions such as bad dental health,” says Dr. James R. Hupp, former dean of the school and professor of oral and maxillofacial surgery. “Our School of Dental Medicine is going to allow individuals who are crippled by severe pain and disfigurement from dental disease to overcome those obstacles and have better job opportunities, better overall health and better focus during their education. These things will help the state move forward, and all its people move forward. That’s where our school will have a major impact.”
And ECU will do it in a unique way, pioneering a program unlike any other in the nation. Far beyond the walls of Ross Hall, the new dental school building, ECU will build and staff 10 dental practice centers serving some of the poorest, most isolated areas of the state. The clinics will house faculty dentists, dental residents and fourth-year dental students who will complete their training not in a building on campus, but where they are needed—working with people with no one else to treat them, in situations very much like the real-world ones they’ll have after graduation.
“We’re taking a different approach,” says Dr. Gregory Chadwick, associate dean for planning and extramural affairs and clinical professor of endodontics. “At most traditional dental schools, the education is within the walls of the institution. We’re changing the model for dental education.”
Relief for rural counties
ECU responded when the state needed more teachers, nurses, business leaders and doctors. Now, without a doubt, the state needs dentists. ECU’s new dental school joins a sister program at UNC Chapel Hill, which since 1950 has operated the state’s only dental school. As ECU’s school opens, Carolina also is on schedule to open a new Dental Sciences Building, a 216,000-square-foot facility scheduled for completion in early 2012. ECU will focus on providing general dentists; UNC will have additional emphasis on specialty studies and research.
At a Glance: ECU School of Dental Medicine
Ross Hall is on schedule to open next summer in what many consider record time for such a major, publicly funded initiative, given that it was launched during a severe recession. A final hurdle was cleared in June when the General Assembly included $3.5 million in the state budget for this fiscal year and $5 million for next year to complete the hiring of what eventually will be 66 faculty members and about 100 staff. That brings the state’s investment to roughly $95 million. Ribbon-cutting for the three-story, 100,000-square-foot facility will come next spring, just six years after the UNC Board of Governors voted to start only the second school of dentistry in North Carolina.
The facility is named for Ledyard E. Ross ’51, a Greenville orthodontist who donated $4 million to the university in 2010 to help start the dental school. The first class of 50 students have already begun arriving; they will study in remodeled spaces in the Brody School of Medicine building and Laupus Library until Ross Hall opens.
An integral part of the dental school will be the 10 community service learning centers that ECU will open around the state. Each of these centers will have 16 dental chairs, where four or five fourth-year dental students under the supervision of onsite residents and faculty will treat local residents at reduced charges. Plans call for each center to be staffed by two to three hygienists and five or six dental assistants. It’s expected that the hygienists and assistants will be hired locally. The faculty members assigned to each center will reside in those communities. Each center will cost about $3 million.
Ross Hall will have 160 operatories, rooms much like a dentist’s office with surgical-grade lighting, sinks and air systems. Students and faculty will use those facilities to hone their skills while providing care to patients under a three-tiered pricing system. East Carolina received a $1.76 million federal grant to help with construction of the centers in Ahoskie and Elizabeth City.
Meanwhile, construction on UNC Chapel Hill’s $92 million Dental Sciences Building also is on schedule, with completion expected in November. The facility will allow Carolina to enlarge its dental classes. ECU and Carolina are following a joint plan they developed to improve dental care statewide.
Who’s in the first class of dentists?
Classes begin Aug. 15 for the first class of ECU dentists. Who are they, and where do they come from? Here’s an overview:
Class size: 52
African American: 5
Average age: 24.7
Age range: 22–35
All are North Carolina residents and represent 28 counties. All have bachelor’s degrees. Eight also have master’s degrees.
Source: Dr. Margaret B. Wilson, associate dean for student affairs, ECU School of Dental Medicine
A dental school on the Brody model
The curriculum of the ECU School of Dental Medicine will offer a distinctive mix of course work that in many ways resembles the model that East Carolina developed for the Brody School of Medicine, which focuses on training family doctors to serve rural counties.
First year—Students study the cardiovascular, nervous, endocrine and reproductive systems of the body. They will learn normal, abnormal and clinical medicine. Some work will be done with dental models, known as simulators, to learn fillings, crowns and other “hand skills.”
Second year—Students learn how the human systems apply to dental health, especially how a dysfunction in another part of the body can affect the head, neck and oral cavity. They will do more advanced practice with models, as well as some time working with patients doing basic procedures such as fillings.
Third year—Most of the students’ time will be spent taking care of patients under the supervision of faculty members in the Ross Hall dental school clinics.
Fourth year—For ECU students, this year will take place in one of 10 university-owned and operated dental offices throughout the state. “ECU believes that the best way to encourage practice in underserved areas is to physically train dental student in these communities,” says Dr. Todd Watkins, assistant dean of dental education informatics.
The 2006 Joint Plan for Dentistry, a study conducted by the two UNC campuses calling for a coordinated response to this need, holds some startling facts. North Carolina ranks 47th nationally for dental care, a statistic that derives from the state average of about four dentists for 10,000 people; the national average is nearly six dentists for 10,000 people. Today, four North Carolina counties (Tyrrell, Jones, Hyde, Camden) have no dentists at all. Three counties have one dentist, 28 have just two.
Like most health care professionals, dentists tend to locate in urban areas because that’s where the most potential patients live who have insurance or the ability to pay out of pocket. Even when they can lure a dentist to their sparsely populated areas, poor counties have a larger percentage of residents on Medicare or Medicaid, which many providers don’t accept for payment. Together, these trends could create a chronic and potentially devastating health care crisis.
To change that bleak projection, ECU will open 10 dental practices, known as service learning centers, in rural parts of the state. So far, four sites have been announced. Two are east of I-95—where the need is greatest—in Ahoskie and Elizabeth City. Others are set for Lillington, in Harnett County southeast of Raleigh, and in the Jackson County community of Sylva in the mountains. Anyone will be able to receive care at these practices. Patients will be charged a sliding scale of fees according to the type of provider they see—student, resident or faculty.
Because they often are uninsured, many people in rural communities who need dental care wind up in hospital emergency rooms. There they are given antibiotics and possibly pain medicine. But in counties without dentists there’s a good chance the problem will worsen, says Dr. Masud Baksh, an emergency room physician at Roanoke-Chowan Hospital in Ahoskie.
“This is one of the poorest parts of the state,” says Baksh. “There is a very large population without any kind of medical insurance. We tell them, ‘This is the extent I can help you but you have to get to a dentist to get to the real problem.’ It can be a simple toothache, to a very complicated thing—they can come in with swelling of the jaw and pain, to high fever of 103, 104, shaking.” Baksh can drain the abscess from a large cavity, but once his patients go home “it can turn into a serious problem. I have seen people become septic from untreated dental abscesses that we have to treat with systemic problems. There is a potential for getting seriously ill.”
These costs and health risks could be avoided through simple measures, he says.
“Dental decay can be easily prevented,” he says. “If they have access to dental care, it wouldn’t progress to that stage, or they wouldn’t have these problems. If these patients could go to a dental office and could have their dental care provided, it would be a tremendous help to the entire community.”
Indeed, that’s the goal. “As soon as the first center is up and operating, you’ll see a difference in that community,” Chadwick says. “The difference will be felt in a number of ways. We’ll see a difference in oral health promotion, with providers able to incorporate an oral health message. More school kids will be screened.”
But overall, it will take time. “We are the fifth-fastest growing state,” he says. “To stay even, we’re going to have to work because the state is growing so fast. We’re not going to be able to drill, fill and extract our way into better oral health. It will have to be achieved one individual at the time, by delivering a message. But we’ll clearly have more people seeing a dentist because of what we’re doing here at ECU.”
The people behind the numbers
The only dental care that many children in Hertford County receive is when a mobile office visits schools around Ahoskie once each year, says school nurse Emily Jenkins. Yet even that modest level of care brought one mother to tears. “Her children were so in need of a dentist,” says Jenkins, lead school nurse for the Hertford County Public Schools. “She had lost her job, lost her insurance benefit for dental care and knew they needed to be seen, but she couldn’t find a way to do it because of the hard times. When I told her about the mobile dentist, she was so appreciative she started crying on the phone.”
It was “one of the sweetest professional moments of my career” when Kim Schwartz, CEO of the Roanoke Chowan Community Health Center, learned she had won a $6.2 million federal grant to buy the land for, build and equip a new community health center that will team with a new ECU dental clinic in Ahoskie. The site is a field between Hertford High School (background) and the RCCHC medical offices on South Academy Street. RCCHC is a not-for-profit community health organization operating clinics in Murfreesboro, Ahoskie and Colerain.
Jenkins sees children whose teeth have eroded so far the nerves are exposed. Left untreated, those children will suffer years of pain and eventual tooth loss. Poor dental health also affects their education. “When they have poor teeth, they can’t pay attention because their mouth is hurting,” Jenkins says. “They can’t learn.”
Kim Schwartz, CEO of Roanoke-Chowan Community Health Center in Ahoskie, says ECU’s new dental center there will improve life for entire families. She’s been working for years to bring dental care to her area.
The dental center will be linked with a new federally funded health center in Ahoskie for which she received a $6.2 million federal grant. The center provides families with routine, or primary, care. It’s an important step forward for an area that suffers with long-term economic depression. “Generational poverty is different than situational poverty,” Schwartz says. Those whose families have always been poor often accept bad health—and its discomforts—as a natural part of life. “Tooth pain is so different than any other pain,” she says. “They don’t know why they have pain until we ask, ‘When was the last time you saw a dentist?’”
Dental pain sometimes drives people to almost unthinkable measures. It’s not unusual, she says, to hear of people pulling their own teeth. She tells of an 80-year-old who removed all of her teeth. “I can’t tell you how many times I’ve heard that story.”
She believes the community will prove a worthy choice for one of ECU’s first dental practices. “You can’t come anywhere that needs you more,” she says. “You can do work that makes a difference.”
A new kind of dentist
Dental education, like medical school, begins with two years of classes in basic human sciences. Indeed, ECU’s dental students will study under Brody School of Medicine professors for some of their classes. During their second year, dental students work with mannequins and other simulators to learn fillings, crowns and bridges. During their third year, they begin real dentistry with fillings, root canals and other procedures. They will work with faculty dentists at Ross Hall.
“We ran the numbers and saw that over 2 percent of the visits in our [emergency room] were dental related,” says Phil Donahue (right), vice president of Albemarle Hospital in Elizabeth City. “This shocked me, and gives you an idea of how bad the problem is. The people who are showing up—their teeth are in horrific shape.” Along with Jerry Parks, health director of Albemarle Regional Health Services, he stands on the site where the ECU dental clinic will be built across the street from Albemarle Hospital on North Road Street.
But during their fourth year of school, ECU dental students will do something very different. Instead of studying in a classroom on campus, they will practice their new skills in one of the 10 service learning centers. While some of their time will be spent at Ross Hall, they will complete rotations in other communities here in eastern North Carolina—and across the state.
At least part of their fourth-year practice will take place in these special dental offices established and staffed by ECU’s dental school. Faculty members will live in these small towns. Hygienists and dental assistants for the service learning centers will be hired from the community, providing additional jobs. Chadwick says he’s not aware of any other institution taking this approach.
It’s hard to imagine the situation changing in rural areas without some help, Chadwick says, citing the costs of establishing a dental practice as the first impediment. And since many residents of these areas are on Medicaid or Medicare, the returns can’t cover the investment. Plus, many dental students graduate “$200,000 to $300,000 in debt,” he says. That burden is piled atop other financial demands—house payments, kids, personal expenses—forcing many new dentists to begin practicing in urban areas where patients either have insurance or can pay for their dental care out of pocket.
That year of on-the-job training has benefits for dental students, too. “When I graduated, I worked in a community health center as a solo dentist,” Chadwick remembers. “I realized there was a big transition between working in a dental school and working in a community in a more rural area. There are different needs. Now, we have the opportunity to bring dental education into the picture and give students hands-on experience with faculty in those communities, so they can be successful in that environment later on.”
The campus of Southwestern Community College in Sylva, in Jackson County, will be the site of the ECU dental clinic serving the mountain region. Most county agencies are located nearby on County Services Road. The county health department operates a dental clinic, but director Paula Carden says it “cannot meet the demands for dental care because the need is so huge. The free clinic in Cashiers has a waiting list of more than 500 people from Jackson County and two neighboring counties. We have hosted the Mission of Mercy Dental Clinic three or four times, and people line up for hours to receive these services.”
That’s one of the reasons Alex Crisp, 23, of Burlington chose ECU. The son of a dentist, he’s known for many years that would be his career choice. Now, he says, he can follow his dream and take part in the excitement of creating a new course for dental education.
“I feel like Columbus traveling uncharted waters,” he says. “There’s something great that I’m going to be a part of, and some great ideas behind this curriculum. One of the reasons I decided to come to ECU was because I knew we were going to go into a rural place and have an impact on people lives.”
Nevertheless, change will take time. It will be four years before the first students graduate from the dental school. There are 16 faculty members currently on campus; the number should grow to 67 over the next three years.
“As soon as the first center is up and operating, you’ll see a difference in that community,” Chadwick says. “The difference will be felt in a number of ways. We’ll see difference in oral health promotion, and a difference for our partners. But, if you have several people at your front door, who are hurting and swollen, you have to work your way through the urgent needs first. We’ll not be able to take care of all the urgent needs immediately, but we want to be able to find ways to treat those patients first. Then, we can work with larger groups, and help them understand, for instance, that you don’t put your baby to bed with a bottle of Coca-Cola in it, because they’re going to have a tremendous amount of tooth decay if you do.
“We’ll talk to pregnant women, mothers of infants and young children—here are the things you need to be doing,” he says. “Because if you don’t have oral health, you’re not healthy.”
Juanita Johnson, a registered nurse and community case manager at the Community Care Clinic in the Chowan County community of Tyner, population about 2,000, agrees. “They come into my office and literally I’m talking about their diet, health and nutrition—and they will just take their teeth and move them back and forth in their mouth. They come in such pain, and when I recommend what they should eat, instead of soft, fast foods, they say, ‘I can’t chew.’” She met Thomas Story through her work at the clinic, where she learned of his unbearably painful toothaches.
Today, Story offers a compelling endorsement of the vision and approach taken by ECU. His experience, he believes, would have been vastly different had affordable dental care been available near his farm. His only neighbors are farmland and woods, his only companions his dogs, geese, chickens and cats. But only a few miles to the east of his farm is Elizabeth City, where ECU will host a service learning center. Had the clinic been open a few years ago, would he have sought the care that could have saved his teeth?
“I’m sure I would,” he says.
The service learning center at Lillington, in Harnett County southeast of Raleigh, will be built on U.S. 401 near the Harnett County Courthouse at a site in the Brightwater Science and Technology Campus. Shelia Simmons, CEO of First Choice Community Health Centers, ECU’s local partner, said, “We are so appreciative and welcome the opportunity to have a learning institution like this in our community.”
All inset text by Meagan Williford