Although dental professionals recommend a visit to the
at least once a year, barriers like distance, road
conditions, lack of insurance coverage, and poverty make
it difficult for many rural residents to do so.
“We definitely want to make changes. We don't
want to just put a Band-Aid on the problem,”
said Community Health Worker Malissa Savage, who serves
rural clients in western Maryland. For many of her
clients, a trip to the emergency room for a toothache is
more common than a preventive trip to the dentist.
“It's just a matter of education and letting
them know about the resources available,” added
Savage. “A lot of them have dental benefits,
but I just don't think they know how to utilize
CHWs are usually employed by local healthcare agencies
and spend the majority of their time on the ground with
clients, connecting them to healthcare resources and
local social services while educating them in good health
Traditionally, CHWs earn certifications in primary care
topics like diabetes, chronic disease, and smoking
cessation. The recent spotlight on gaps in rural dental
access has encouraged the creation of oral health
training programs for CHWs in multiple states.
Savage was one of the first to get certified in
oral health through Maryland Area Health Education
Center West. Her training was a part of Allegany
HealthRight, a program funded by the Federal Office of
Rural Health Policy that provides oral health education
and access to dental treatment.
Since graduating from the 10-week course in 2014, Savage
covers Allegany and some of Garrett County, located on
the edge of Appalachia, where poor oral health practices
are largely the result of misconceptions passed down from
A lot of people here think that it's fine to take pliers
to pull out their teeth because they don't know about the
resources that are there.
“A lot of people here think that it's fine to
take pliers to pull out their teeth because they don't
know about the resources that are there,”
explained Savage. Among her clientele, dentures are in
high demand, not just from the elderly population. Savage
has spoken with 19-year-olds who would rather replace
their remaining teeth with dentures than seek dental
care. “They have this misconception that this
is the route to take – the sooner the better – to prevent
a headache from occurring later down the road.”
Savage said that educating young people is a vital part
of her attempts to reverse generational bad habits.
Savage applies the techniques she learned during training
to presentations that she gives several times a month.
Object lessons and visuals, like children's toys, can
help an oral health principle stick. To communicate the
importance of flossing, she squeezes Play-Doh between two
Lego pieces, comparing it to the plaque that builds up
from lack of flossing.
One of her biggest takeaways from her training is how to
be understanding of each client's situation. Through
motivational interviewing, she helps clients set
realistic oral health goals for themselves, like cutting
back on sugar.
Savage spends most of her time on the road traveling to
rural areas where resources are scarce. Clients at senior
citizen centers, food pantries, and clinics benefit from
her frequent presentations and one-on-one counseling.
Since transportation is a common barrier for rural
residents, she carries gas cards and taxi vouchers to
give to clients who need them.
Western Maryland has already experienced the ripple
effect from Savage and Regional Oral Health Pathways'
work in oral health improvement. Allegany County
hospitals have noticed a decrease in emergency room
admissions for dental care. Dental patient evaluations
show an improvement in general oral health practices. In
all, 350 clients have benefited from Savage's
individualized counseling. Her hope is for more federal
funding for Maryland hospitals to house future oral
health trainings for CHWs. “It's slow-going,
but I think that we've proven our worth,”
Savage humbly suggested.
Smiles for Life in Navajo Nation
In Arizona, similar efforts are underway to address the
significant oral health disparities of Navajo Nation,
percent of children between one and five have tooth
decay. Given the severity of dental issues in Navajo
country, the no-show rate at some dental clinics for
appointments is very high.
…if we build an understanding that oral health is
integrally linked to other chronic health conditions and
work closely with our oral health delivery system, we can
take better care of our people when we help them take
control of their oral health.
Mae-Gilene Begay, program director at the Navajo
Department of Health, is one of the masterminds behind a
training program for Navajo Nation's CHWs, who are
referred to as Community Health Representatives (CHRs).
“Navajo has suffered from the highest oral
disease rate in the country. The concept is if we build
an understanding that oral health is integrally linked to
other chronic health conditions and work closely with our
oral health delivery system, we can take better care of
our people when we help them take control of their oral
health,” said Begay.
As a first step, Begay worked with the Arizona American
Indian Oral Health Initiative and recruited Dr. Rick
Champany to train Navajo CHRs in
oral health literacy. Champany was an obvious
candidate. A dentist by trade, he has worked in various
public health dental positions across the Navajo Nation
for nearly 30 years, including Navajo Area Indian Health
Service as a dental consultant.
the course of two days, Champany trained 80 CHRs in the
for Life curriculum – a free, online resource. The
curriculum consists of eight oral health courses that
cover topics like periodontics, pediatric and geriatric
oral health, and fluoride varnish.
Having a history with the Navajo people helped Champany
gain his class's trust. “I don't pretend to
know the whole culture, but I know about the
Navajo culture. So I've learned that there are certain
things you want to minimize, because it's culturally not
good to talk about,” explained Champany.
“If there is something they don't understand,
they feel comfortable to stop me and ask a question or to
clarify certain things.”
This Smiles for Life program is just the start of the
Navajo Department of Health's dental improvement efforts.
Five CHRs are currently undergoing training as
Community Dental Health Coordinators at Central New
Mexico Community College to expand their oral health
knowledge and credentials in dental case management.
Begay sees the positives of both models.
“Community Dental Health Coordinators can work
side-by-side with other CHWs who work in the diabetes
program, the cancer program, and the smoking cessation
program. It's a win-win for our people,” she
Integrated Care for Texas Colonias
About one thousand miles to the southeast, another Smiles
for Life training for Community Health Workers took place
in Harlingen, Texas in early 2017.
Although NRHA had hosted previous CHW trainings through
NRHA's Rural Community Health Worker Training
Network, Harlingen's was the first on oral health. It
was also new for many of the CHWs present. Amy Elizondo,
NRHA's program services vice president, noted this was
the first time one participant received oral health
training during her 30-year-long career as a CHW.
The majority of the attendees work in colonias, or
Hispanic-populated communities along the U.S.-Mexico
border. This area experiences similar barriers to Navajo
Nation regarding accessing dental care. Lack of
insurance, distance, and a shortage of dental workforce
make it difficult to get timely dental care.
Because one of National Rural Oral Health Initiative's
goals is service integration, the training was also open
to primary care and dental providers. Sessions were
specifically designed for each audience. Elizondo
believes this convening of all three professions helped
start conversations about each one's contribution to the
oral health effort. “Having improved oral
healthcare is something that can help ward off other
diseases, so it's great to be a partner and provide this
kind of training for those on the front lines of oral
health,” relayed Elizondo.
Although it is still too soon to measure the impact of
NRHA's training, Elizondo believes other regions can
successfully duplicate this model, especially underserved
places like Appalachia, the Delta Region, and Alaska.
NRHA is currently working to extend the training to other
states; another CHW oral health training is set for June
Why it Works
They are from the community, and they know the
community…It's a friend and a neighbor; it's somebody
that they know and respect. So that's what excited me
about it. It's a community that's growing their own.
Champany remains an avid supporter of equipping CHRs to
be ambassadors of oral health. “They are from
the community, and they know the community. That's just
so important – to be seen as a community member. It just
gives you a little more credibility…It's a friend and a
neighbor; it's somebody that they know and respect. So
that's what excited me about it. It's a community that's
growing their own.”
Elizondo points out that a critical piece to improved
oral health is knowing your audience: rural communities
of Texas's colonias have different needs than those in
the Alaskan tundra. “It all varies, so adapting
this curriculum or working with local partners to help
fit the appropriate needs of the community and audience
is pretty vital.”
Savage has personally experienced the difference a CHW
can make on the openness of a patient. While she doesn't
get too many questions from her audiences during
presentations, one-on-one conversations with clients is
when vulnerability comes out. “Some have needed
an extra push. It's kind of like being a
coach,” she expressed. “It takes
following up and letting them know that someone cares.
That makes all the difference in the world.”