Greta Nelson

I didn't initially want anything to do with teeth. In fact, when I changed my major, my mom said to me, "You don't like the dentist." And I was like, "Well, you know, Mom, there's something about it. I want to change someone else's experience."

Aryana Misaghi

I'm Aryana Misaghi. And this is Appalachian Care Chronicles, a podcast bringing you stories from every corner of West Virginia's health sector. Join me as we journey alongside a variety of problem-solvers, changemakers, and daily helpers who are all working behind the scenes and on the frontlines to care for our communities. Together, we'll explore what they do day to day, the steps that got them there, and the whys that continue to draw them back. How, in the face of some of the most challenging situations possible, do they manage to keep themselves and the rest of us from falling apart? Far from predictable, the paths they've walked are full of twists and surprises, discovery, and purpose. This podcast is for anyone who's ever even thought about going into the healthcare field or has a passion for caring for others in times of need.

Welcome to our fourth and final episode of season two. I'm so pleased to announce that our work sharing the stories of healthcare providers is not over yet. Appalachian Care Chronicles is coming back for a third season with four more episodes coming out this summer. Now, for this episode, we're climbing aboard a mobile dental clinic that provides free dental care to low-income West Virginians in some of the state's most rural counties. This one will be especially fun for me since I grew up around lots of dentists and even considered going into the field myself. My mom is a dentist and emphasized dental health my whole life. For our ride on the mobile dental unit, our guide is Greta Nelson, dental hygienist and dental coordinator who has spent the past 20 years taking care of people's teeth.

Greta Nelson

This is a custom gooseneck fifth wheel trailer. We have three dental operatories, we have a separate sterilization area, we have a state-of-the-art panorex all-digital X-rays. We do everything contained within this trailer that you would have in your normal brick and mortar office. Everything was thought out with this program, down to how we adhere and attach our carts to the wall. Everything has to be strapped and sturdy. We use military-grade laptops because everything has to withstand travel. We've been using this particular unit going into the seventh year, and it is the original unit with the majority of original equipment. Once we get to the site, personally, we'll have six patients scheduled, and I perform routine cleanings. I do their screenings for periodontal disease, X-rays, let them know what their current dental state is. Dr. Shah, our staff dentist, will also perform an exam for the patient that day and develop a treatment plan if they need to come back for fillings or extractions.

Aryana Misaghi

The mobile unit had its first run in 2017 in response to the deadly flooding that happened a year earlier. During the flood cleanup, dental care was one of the most requested services. Today, the mobile unit pulls up to parking lots in Boone, Clay, Logan, McDowell, and Roane counties at least two days in each county each month, in partnership with local medical facilities in those places. Dental care is especially scarce in these counties, and most general health insurance policies don't include dental coverage. Greta has seen firsthand how her work can transform people's lives. One of the first people to visit the mobile clinic in 2017 was a 33-year-old man in recovery for alcohol use disorder living in Roane County, and she's never forgotten his story.

Greta Nelson

Every day for the last 10 years, he woke up in pain with his teeth. His nutrition had declined, and he was ashamed to go out and became kind of a recluse where he, you know, he just had withdrawn from society because not only the way he looked, but the way he felt. It ended up being a full mouth extraction, which was something that we could do for him on the mobile unit. But at the very end of the process, and, you know, as he's healing, he comes back in, and we're getting ready to get him fitted with dentures. And he's like, "You know, I'm good. Because for the first time, in 10 years, I wake up, and my mouth doesn't hurt." So if you can just imagine someone being so grateful that we had removed all their teeth because that was the level of pain that he had endured for 10 years. He was fitted for maxillary and mandibular dentures, and once he was fitted, and I'm taking these before and after photos, and I'm like, "Hey, you know, smile for me." And he's like, "You know, I forgot how," just because it had been so long since he was able to show his teeth.

Aryana Misaghi

You might think that for as passionate as she is about this field, Greta's own experiences at the dentist's office must have been overtly positive. Not exactly. There is one memory in particular that is as vivid to her now as it was two decades ago.

Greta Nelson

I was nine years old, playing tag on the basketball court with the boy that I had a crush on, okay. And I was running, like, my life depended on winning this race. Straight into the basketball pole, face first, right into the pole. Knocked my front teeth out. It was a permanent tooth. So, my principal at that time, I'll never forget, she was this little itty-bitty lady. Her name was Mrs. Matar. She drove this big old Cadillac, like a boxy-style Cadillac. This was back in the days, she just swooped me up, put me in her Caddy, and we headed to the dentist's office. So all the kids, unbeknownst to me, had scoured and found my tooth. We literally get to the dentist, he has the tooth, he puts the thing back up in there, back in the socket. Luckily, it's still in there. It's been built up. It's had a root canal, all this different stuff, but it was a very dramatic dental experience.

Aryana Misaghi

Greta's experience reminds me of my own story for why I decided to go into medicine. I had had a horrible encounter with a doctor when I was in college, and I left thinking, "I'm gonna take that guy's job, so no one else has to deal with him." That kind of experience can be great fuel for a long career. But like some of our other guests, Greta explored a few very different options first. She once was a pre-law major and worked briefly in real estate.

Greta Nelson

You know, I had done some volunteer work actually when I met their dental coordinators, she was just like, “You are perfect,” like, “You need to do this work,” and she was like, "And regardless of whether you choose to stay a hygienist or go to dental school or whatever you would want to do," she was like, "You know, we need people that care." And I was always interested in it, you know, it’s just that I never had a positive experience. So through that, I was able to really realize how those first encounters make all the difference. If I know someone's fearful, I do things differently. You know, and it may be as simple as sending the instruments out differently, it may be as simple as, you know, just hiding things from them so they're not seeing what I'm about to approach them with. But, you know, you learn little tricks to make everybody's experience pleasant. I would have never thought this is where I would have ended up.

Patient

I was getting a filling done today to be able to help with some cavity issues. It's been probably around a decade at least since I was last able to go to a proper dentist appointment because I don't even know that we could actually cover what it would cost to be able to just go in and be seen for a general check-in. Well, I definitely know I'm not gonna be nearly as nervous next time because I actually understand what's going to be going on and everything. And I'm definitely going to be excited because it'll be one more step closer to being where I want to be.

Patient (to Greta)

I feel like something’s back here.

Greta Nelson (to Patient)

It is. I think it's the cotton roll and you're feeling really numb.

Patient (to Greta)

It just felt like it was something loose was right here.

Dr. Shah (to Patient)

No, you’re fine honey. You do have to stay open. We're fixing the tooth now. Okay, the cavity’s gone.

Greta Nelson (to Patient)

So now we're gonna put some material back in there, but

Dr. Shah (to Patient)

I'm gonna put something on for you to make it easier for you to stay open, okay?

Patient

This has been a godsend for me and my family, you know, my dad, he needs dentures, he's not able to get them and everything. He's got teeth that are breaking, and everything from where he's older, and he's finally able to get help. And my mom's finally able to get help, 'cause she's got teeth that are breaking in areas, and I'm able to get help now too, and everything, and I'm just grateful.

Patient’s Mother

It means more than most people will ever know. To know that my kids and my husband and I are taken care of.

Patient

Because if we were to try and go to the dentist and everything and try and pay for that, it wouldn't be an option. It'd be a decision between, do we pay the bills? Do we pay for groceries? Are we going to have what we need? Are we going to even be able to survive this month? Or do we go to the dentist and pay for one person to be able to get seen?

Patient (to Mother)

I did warn her by the way, about blood pressure, you've been checking it, you're fine if it's up any, it's just because you're nervous, and she said she understands.

Patient’s Mother

I appreciate that. I pulled my last tooth myself, so they're a little bit concerned for me.

Aryana Misaghi

The mobile unit and the clinic in Charleston both address a major need in West Virginia. Lack of access to dental care is common here, and it's associated with significant levels of untreated tooth decay. One survey from a few years back found that statewide, almost half of third graders had some level of tooth decay during their short lives. There have been some bright spots, though. More dentists are staying in West Virginia after graduation, and West Virginia University will soon offer a pediatric dentistry residency program. As important as it is, providing remote oral healthcare also comes with its challenges: weather, terrain, and even trouble with the vehicle itself.

Greta Nelson

There are so many different barriers that we have to get through to go to the community. But we've been very lucky for the most part, and the unit has been off the road, probably including COVID, less than six months in the entire seven years. And we really have found ways to adapt our program to face the challenges like if we know there's going to be weather, we get ahead of it, we have a generator. So even if the site loses power, guess who still has power? I still have power, I can still see my patients because in this population, if a patient takes off work, it is very difficult for them to take off another day of work, because it's the difference between them being able to come to an appointment today, or they wouldn't be able to come for another three months until they caught their bills up. It's a very real thing that they have to decide when they can go to the dentist because they have to work, and a lot of my patients work two jobs. We have removed most of the barriers for travel. People not only depend on it, I mean, word of mouth, you know, referrals. And then, for instance, in Welch, there's no dentist, there's not a dentist, you're going to drive 30 to 40 minutes, there's no public transportation. They have to go through so much to even get to the dentist. Forget paying for it. And if people had to pay for it, they just wouldn't.

Aryana Misaghi

Appalachian Care Chronicles is made possible thanks to the West Virginia Higher Education Policy Commission and Claude Worthington Benedum Foundation, serving communities in West Virginia and southwestern Pennsylvania since 1944. West Virginia needs great mental health professionals. If you're practicing in an underserved area and need help repaying your student loans, apply for the Mental Health Loan Repayment Program through the West Virginia Higher Education Policy Commission. Visit collegeforwv.com to apply. That's collegeforwv.com to apply.

Greta Nelson

It's really hard for me not to, like, I'm super emotionally invested in my job and what I do for people. And it is more than a smile because it does change your outward confidence, it changes how you interact with your family, it changes how you interact with someone when you're going for a job interview or ordering a sandwich or just meeting a stranger. You know, that is the first thing the majority of people look at: big, white shiny teeth. And for someone who doesn't have that nice outward, just beautiful white smile, it can be devastating.

Aryana Misaghi

The stigma around imperfect teeth is still alive and strong. Lots of folks mentioned feeling relieved during COVID because they could hide their smiles behind masks. Greta is especially conscious of how people in recovery are dealing with this extra hurdle.

Greta Nelson

You get through that. And then you're ready to re-enter society, but then you're met with that barrier, boom, I look like I have had a substance use disorder, and how am I going to get a job or how am I going to be treated? The oral effects of certain substance use is abuse. People know what they look like, and it's easy to judge. So I mean, I think, you know, giving them the confidence back in their smile to not be associated with that, to not have that stigma, because not a lot of people are ready to talk about that, you know, they're not ready to have that barrier. They don't want that, you know, used against them when they're trying to go to a job interview, they just want to be treated based on the skills that they have, just like they should be. And you know, we do a lot of restorations as many as we can, but in a lot of cases, they still require partials and dentures, but just having those tools to just kind of level the playing field for them. And that's just a part of the recovery piece that should just be there.

Aryana Misaghi

Oral health is a window to overall health. Problems with your teeth and gums can affect other parts of your body, and systemic diseases often manifest in the mouth as well. Autoimmune disorders like Sjogren's syndrome, HIV, and Crohn's disease may be first noticed based on oral symptoms. Mobile dental practices are a key part of the healthcare landscape in underserved communities.

Greta Nelson

In Boone County, we are across from Boone Memorial. So through that partnership, they're able to refer patients whether that be, you know, patients that are there for cardiac rehab or different types of rehab, or if they're in the ER, a lot of patients that they see, you know, they don't have any dental insurance.

Dr. Shah (to Patient)

Alright, that's it. Bite down.

Greta Nelson

This is not just a mobile unit that rolls into my community. They are people that truly care about me and care about my dental health and my overall well-being. And we create that safe space for those patients.

Greta Nelson (to Patient)

So no drinking through a straw, swishing any liquids and spitting, anything that creates a suction to make that blood clot form come out. Because it acts as a band-aid to aid in the healing. So when you lose that blood clot early, that's what gives you a dry socket. Okay, so bite on those gauzes for the next few minutes.

I'm gonna do some research and see if there's anything that I can do to maybe see if there's anything available that we can help with some of the costs of that. So let me do some homework first. Okay.

Patient (to Greta Nelson)

Thank you so much.

Greta Nelson (to Patient)

You're welcome. Sometimes there are things I just have to do some digging and see if there's anything available, we'll try to see what we can do.

Patient (to Greta)

I’m so grateful for everything.

Greta Nelson (to Patient)

You're certainly welcome. We were grateful for our patients. Okay, let me give you those extra gauzes, darlin’. Okay, everything I just told you, it's written down on this paper in the extra gauzes are in here in a baggie. Did you forget anything? Okay. Alright, you feeling okay?

Patient (to Greta Nelson)

I feel fine. Thank you. Thank you all so much.

Greta Nelson (to Patient)

Oh, you're welcome. We'll see you next time. Okay.

Greta Nelson

I'm gonna see what I can do, I'm gonna follow up on the papers, her husband is now edentulous. So no teeth. There are programs in our state like Donate a Denture, sometimes we're able to do things to get them taken care of. So I'm just going to do a little bit of digging, I mean, when somebody touches your heart sometimes... (chokes up).

You know, I think when someone feels like they're not entitled to care, and then suddenly you're someone who's showing up and just providing the care, and I'm not expecting, you know, anything in return. I'm just truly here because I want to be, and I give mom and dad a lot of credit too because, “Hey, this is important. Let's go to the dentist as a family and get this taken care of.” They're putting an emphasis on dental care for their daughters.

Aryana Misaghi

Greta sees dental education as an important part of her work. She is the chair of the West Virginia Oral Health Coalition, an advocacy program made up of dental providers, educators, and other health professionals from across the state. The group supports policies and programs like getting more communities in West Virginia to include the mineral fluoride in their water systems because fluoride helps to prevent tooth decay. Sometimes her work includes going over the very basics of oral hygiene with the public. Unlike a private dental practice, lots of patients that Greta sees in this public health setting, haven't had routine dental care.

Greta Nelson

First day, and on the mobile unit, 64-year-old male patient, and I'm really good about explaining what I'm going to be doing so through the process, you know, when I’m doing an oral cancer screening, what I'm looking for, when I'm scaling, why I'm doing that, you know, what polishing consists of. So I get to the very end of the appointment, and I pick up my dental floss, and I go to floss his teeth. And he says, "What is that?" And so at that moment, I realized he didn't know what dental floss was, no one had ever shown him how to use it. So something as basic, for most people, that's just part of your routine, whether it's not daily because people are not great flossers, but he had never, in 64 years, used dental floss. So that allowed me to set the tone and what public health is going to look like, what I needed to do as far as a dental educator, and really, it just changed my perspective on the program. You provide patients, you give patients the tools to be confident again, you give them the education that they need, their kids might not ever be your patient, but they go home and they share that education with their families. So hopefully, you know, they're not just coming to the dentist when they have a toothache, that they're prioritizing their dental health and they're coming in, especially in rural West Virginia, I have encountered patients that have what they refer to as a community toothbrush. So it's like a household toothbrush where everybody in the family will use the same dental products. They just don't have education, as far as, you know, transferring bacteria and how bad that is, and they can't afford going to the drugstore and buying four toothbrushes.

Aryana Misaghi

Every provider is important to the healthcare system, from the oral surgeon to the mid-level like Greta. Greta says she recognized where her limitations were in the field. But she also knew she had a lot to contribute.

Greta Nelson

I am so tender-hearted, you know, I would just, I would be the provider there just crying with you. You know, I knew that I did not want to work with sick people. But so, this is the way that I get to be in the healthcare field. I get to impact people's lives positively. And I don't take home a lot of the sadness and the baggage, because healthcare workers, they are a special breed of people because they are in the trenches, and they, you know, they deserve all the accolades that they get. But so, this is my way of being a part of a healthcare provider, without being in the hospitals and dealing with, you know, the terminal illnesses. I still get to be that educator, but in a different role.

Aryana Misaghi

Working at a free clinic requires providers to build trust with patients, ones who might not get routine dental care, who are coming in for an emergency situation, or who might not know the basics of dental hygiene. But the structure makes handling these challenges more manageable. Greta isn't dealing with insurance or wrestling with how to break it to a patient that their insurance won't cover a necessary procedure or service. She gets to focus squarely on their care.

Greta Nelson

I don't have to think about anything other than the patient and the patient's needs. And that's fantastic. And all of our dentists, that are local dentists and volunteers, I cannot say enough good things about the volunteers that come in here and take away time from their practices to volunteer their services. I mean, we could not operate at the capacity that we do without these guys. I absolutely think that the volunteers volunteer here because they take home what I take home every day, and I think they care about the patients. I think they care about the mission. My job is so rewarding. I could never see myself going and doing anything else. You know, I've found my home as far as where I want to be in my career. You provide patients, you give patients the tools to be confident again, you give them the education that they need. Their kids might not ever be your patient, but they go home and they share that education with their families. So you provide them so much more than just cleaning teeth. I get so much more from my patients than I ever give them.

Aryana Misaghi

Appalachian Care Chronicles is a production of the West Virginia Higher Education Policy Commission, Health Sciences Division.

Special thanks to the Claude Worthington Benedum Foundation and to West Virginia Health Right. For more information about educational opportunities related to healthcare in West Virginia, visit appcarepod.com. That's appcarepod.com.

I'm Aryana Misaghi, and you've been listening to Appalachian Care Chronicles.