Improving Dental Care Access in Rural America

  • November 18, 2015
  • By Rebecca Singer Cohen and Julie Stitzel
Dental health aide therapist© The Pew Charitable Trusts

Dental health aide therapist Rochelle Ferry consults with supervising dentist Dr. Mark Kelso at the Norton Sound Health Corporation (NSHC) dental clinic in Nome, Alaska (population nearly 3,800). Norton Sound Health Corporation’s hub houses a hospital and a dental clinic, and offers a range of outpatient services. NSHC also has satellite clinics in 15 surrounding villages, ranging in size from 150 to 750 residents.

This piece was updated Nov. 19, 2015, to correct the number of Medicaid patients served.

Julie Stitzel directs Pew’s children’s dental policy program, leading research and advocacy efforts to improve access to dental care for children.

Rebecca Singer Cohen, a senior associate at The Pew Charitable Trusts, oversees oral health policy research projects.

Rural communities face serious challenges to oral health, resulting in a high incidence of cavities and other dental problems. Compared to people in urban settings, rural residents are poorer and less likely to have dental insurance.  Their communities are less likely to have fluoridated water, and they often have to travel long distances to find a dentist.

Many rural communities are considered dental shortage areas: 60 percent of the 4,438 total designated dental health professional shortage areas nationally were located in non-metropolitan areas in 2012. In fact, every state is expected to face a dental shortage over the next 10 years, according to the Health Resources and Services Administration, part of the U.S. Department of Health and Human Services.

Searching for Care

Only about one-third of dentists accept Medicaid or other public insurance. When patients do not have access to a dentist, their oral health care needs often go unaddressed until the pain becomes so severe they seek relief in an emergency room. Even then, patients typically only receive pain medication and antibiotics to address symptoms and infections, but the cause is left unaddressed since these settings often do not have the providers or equipment to fully treat oral health issues. For those in rural areas, emergency care falls to critical access hospitals, which are already overburdened and underfunded.

Dental care in emergency rooms and hospitals is expensive and inefficient. In 2012, there were more than two million dental-related visits to hospital emergency rooms—most of them for preventable conditions that could have been addressed earlier in a dental office. The cost for this care was about $1.6 billion.

Solutions in States

One way dentists could increase access to care in rural areas would be to expand their teams to include midlevel dental providers. These professionals, often called dental therapists, have a proven ability to deliver cost-effective and high-quality preventive and routine restorative care—such as filling cavities, placing temporary crowns, and extracting loose teeth—to a variety of underserved populations. The growth of dental therapy in recent years mirrors the rise of physician assistants and nurse practitioners in the mid-1960s during a time of physician shortages in rural areas and in primary care.

Many rural communities benefit from programs that lower costs and improve health by utilizing telemedicine, such as in Mississippi and Alaska. Using telehealth technology to share patient records and consult on treatment plans, dentists could extend care and send their dental therapists and other providers directly to community settings such as assisted living facilities, schools, and senior centers. This strategy can be used to provide dental care to rural populations that would otherwise not receive it.

Rural dental practices in several states are already expanding their dental teams and the amount of care they provide to underserved populations in their communities through midlevel professionals and telehealth technology. For example:

  • Alaska: Sixty-three percent of Alaska Native children have had tooth decay, according to a 2010-2011 survey. As a result of the urgent need to address the access problems that affected many rural residents, dental health aide therapists have provided care in rural tribal clinics since 2004. Telehealth technology supports these providers and connects them with their supervising dentists who are in hub locations. Since dental health aide therapists began working in the region, more than 40,000 Alaska Native people living in 81 previously unserved or underserved rural communities have regular access to dental care.
  • Maine: The state authorized dental therapists in 2014 to perform both preventive and routine restorative dental care. Fifteen of Maine's 16 counties have dentist shortage areas, making it hard for 180,000 residents to find care. As this legislation is implemented, it is expected to help bring care to the state’s rural and other underserved communities.
  • Minnesota: Minnesota became the first state to authorize dental therapy in 2008. A 2014 Pew study examined how dental therapy was used in a rural private practice in Montevideo, MN to increase access to care among underserved populations. In the therapist's first year, new patients increased by 38 percent, and the practice served 500 Medicaid patients, and made an additional $24,000 in profit.

Dental therapy is a growing profession in the United States, as evidenced by the national standards recently implemented by the Commission on Dental Accreditation, the accrediting body for all dental education programs in the country. As more states consider allowing dentists to hire these providers, these standards are expected to encourage the growth of training programs  to prepare dental therapists to help dentists bring critically-needed care to rural communities.

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