The Connection Between 100 Million Mouths and Oral Health Equity

It all began with an audacious aim and an audacious number.

“This project started from a bold idea that we could reach millions of Americans who may not have access to a dentist by enlisting the greater health care workforce as partners in oral health,” said Shenam Ticku, BDS, MPH, instructor in Oral Health Policy and Epidemiology at Harvard School of Dental Medicine. “Our Champions can train their peers and create more advocates for oral health.”

Ticku and Hugh Silk, MD, MPH, professor in the department of family medicine and community health at UMass Chan Medical School, co-lead the 100 Million Mouths: Creating Primary Care Champions for Equitable Oral Health Campaign, which aims to recruit and train health professionals who will develop oral health curricula at primary care training sites in every state. The Campaign, which is based at the Center for Integration of Primary Care and Oral Health (CIPCOH), aims to create 50 Oral Health Champions (one in each state) in the next decade to work with health profession schools and programs to integrate oral health into their primary care curricula and bridge gaps in oral health access.

Ticku and Silk are leading the work along with colleagues Judith Savageau, MPH, professor in the department of family medicine and community health at UMass Chan Medical School, and Christine Riedy, PhD, MPH, chair and Delta Dental of Massachusetts associate professor of oral health policy and epidemiology at the Harvard School of Dental Medicine.

“The project is to create 50 state champions who will work to implement some oral health curricula in every health school in the country,” said Silk. “We named it 100 Million Mouths because 100-plus million people do not visit a dentist in any given year but are likely to visit their primary care provider. So, if we could have oral health promotion and disease prevention addressed by primary care graduates in their practices, we could improve the health of that many people.”

The initiative was originally funded by Health Resources and Service Administration (HRSA) and is now part of CareQuest Institute for Oral Health’s grantmaking efforts. It aligns very closely with the Institute’s efforts to create an oral health system that is more accessible, equitable, and integrated. Parrish Ravelli, manager of grants and programs at CareQuest Institute, has been involved with the project since it began.

“The oral health care system wasn’t and isn’t built to meet the needs of everyone,” Ravelli says. “When we think about the opportunities to evolve, we must think about the role that everyone can play, regardless of their area of practice. Our hope is that this investment will be foundational to growing a new health care workforce that is directly contributing to meeting the oral health needs of everyone, especially those who have been left out.”

The Need to Integrate Oral Health into Overall Health

Many Americans visit their primary care provider more regularly than they do a dentist. Additionally, disparities in access to oral health exist across income, race, geography, and immigrant status. In fact, more than 56 million Americans live in areas with a shortage of dental professionals.

Giving more primary care providers tools and training to advise patients about their oral health could fill a critical gap and advance oral health equity. Right now, Silk notes, many PCPs are not trained in oral health risk assessment and management despite the availability of evidence-based curriculum.

And it’s clear that patients want more and better connections between their oral health care and overall care. CareQuest Institute’s 2022 State of Oral Health Equity in America survey, the largest nationally representative survey focused exclusively on adults’ knowledge, attitudes, experiences, and behaviors related to oral health, found that 96% of adult Americans know that there is a connection between the health of the mouth and the rest of the body.

“When we listen to people in communities, we better understand the problems we are trying to solve and we create opportunities to solve them together,” Ravelli says. “Both our research and our relationships with trusted community partners show us that integrated, whole-person care is where the oral health field is heading.”

Campaign Progress to Date

The Campaign launched in 2021 with Oral Health Champions from six different states across the US: Alabama, Delaware, Hawaii, Iowa, Missouri, and Tennessee. Now in its second year, Champions have recently joined from eight additional states: Arizona, Georgia, Kansas, Kentucky, Maine, New Jersey, New Mexico, and Ohio. Champions represent a range of personal demographics and professional backgrounds, including physician assistants, nurse practitioners, pediatricians, family medicine doctors, med-peds physicians, dental hygienists, and a pediatric dentist. The goal, within a decade, is to have at least one Champion in each state.

“We’ve started with those states that need the most in terms of a variety of metrics and outcomes such as numbers of dentists and rates of caries,” said Savageau. “We also want to have champions who work with vulnerable populations to address health equity and social justice in every aspect of oral health education. For example, one champion works with a lot of Head Start preschool programs, and one is working with the Navajo Nation, whose rates of cavities are very high.”

Once Oral Health Champions are accepted in the program, they receive training that gives them a toolkit to engage with health profession schools and programs in their home states to increase oral health teaching. CIPCOH provides a comprehensive oral health curriculum, evaluation, a small stipend, and ongoing technical support. Champions are taught to use existing national and state resources, and to partner with local and state experts such as the state dental director, department of public health, and local academic and community-based dentists and dental hygienists. Using their small stipends, Champions can help engage patient representatives in the planning and teaching of learners to garner that personal perspective. The time commitment for Champions is around five hours a month after an initial eight-hour training period.

Riedy noted the speed of the spread of the project.

“In just a relatively short time, we are already seeing how Champions are creating their own communities of practice in their states to integrate oral health into primary care education and training,” Riedy said. “For example, Dr. Michael Metts (Iowa) worked with MercyOne Family Medicine faculty and residents to provide fluoride varnish education as part of a new quality initiative for pediatric application of fluoride varnish at a Federally Qualified Health Center.

Champions are excited about the progress, too.

“I have always understood the importance of oral health, and I have worked on multiple projects to improve access to oral health,” said Dr. Wanda Gonsalves, a family medicine Champion from Kentucky. “The 100 MMC gives me an opportunity to not only continue the work that I have been doing, but it also provides a national network of like-minded individuals working collectively to fill this major gap in primary care training. Additionally, this Campaign’s focus on integrating oral health into primary care curriculum with an equity lens, and providing us with tools to that, is very valuable.”

That equity lens will continue to shape CareQuest Institute’s overall grantmaking efforts. This project is a quintessential example.

“We’re already seeing the success of this investment through both the deep commitment of the Champions and the way that educational institutions are rethinking how they approach oral health,” Ravelli said. “Investing in strategies like this — strategies that seek to systemically move the needle in partnership with communities — is essential to the role that the CareQuest Institute will play.”

Editor’s Note: Learn more about the 100 Million Mouths Campaign and the Center for Integration of Primary Care and Oral Health. Additionally, quotes and information from this blog post originally appeared in articles on the UMass Chan Medical School website and the Harvard School of Dental Medicine website.