Adding dental care to regular checkups is helping people with little access to dentists get needed care and referrals

Dr. Braun, left, and dental hygienist Valerie Cuzella work in tandem
to add dental care to regular medical checkups. (KFF photo)

As the number of dentists who serve low-income and Medicaid patients dwindles, primary care providers such as pediatrician Patricia Braun and her team are stretching their skills to include dental care, reports Kate Ruder of KFF Health News. "Braun is part of a trend across the United States to integrate oral health into medical checkups for children, pregnant women, and others who cannot afford or do not have easy access to dentists."

Private and federal money has financed more options for medical providers to deliver dental care during routine medical checkups. Braun and her colleagues launched their integration with help from a five-year, $6 million federal grant. The collective group "has helped train 250 primary care providers in oral health in Colorado, Montana, Wyoming, and Arizona," Ruder writes. "Similar projects are being funded by the federal Health Resources and Services Administration’s Maternal and Child Health Bureau in Illinois, Michigan, Virginia, and New York. . . . Embedded dental hygienists become part of their practice."

Ruder reports, "Having doctors, nurses, and physician assistants who assess oral health, make referrals, and apply fluoride at community health centers is critical for the many children who lack access to dental care, said Tara Callaghan, director of operations for the Montana Primary Care Association, which represents 14 federally qualified health centers and five Urban Indian organizations."

In big, more rural and sparsely populated states, having a primary doctor address dental needs is ideal. "Because of Montana’s large geographic area and small population, recruiting dental professionals is difficult, Callaghan said. Some counties don’t have a single dentist who takes Medicaid," Ruder reports. "Montana ranks near the bottom for residents having access to fluoridated water, which can prevent cavities and strengthen teeth."

To address its lack of dentists, "Colorado enacted a law to alleviate workforce shortages by allowing dental therapists — midlevel providers who do preventive and restorative care — to practice," Ruder reports. "But Colorado does not have any schools to train or accredit them."

Dental care for low-income rural residents often out of reach

Dr. Jessica Meeske of Hastings, Neb., works on a patient.
(Photo by Laura Beahm, Flatwater Free Press)

Toothaches can cause a lot of pain and make eating difficult, so it's important to see a dentist as soon as possible. But what if no dentist in your area will accept you as a patient--even if you have state Medicaid insurance? You suffer and search for options even hundreds of miles away, which is what many rural residents in Nebraska are doing, reports Destiny Herbers of Flatwater Free Press.

Arline Morris desperately needs oral care, but she lives in Stratton, Neb., more than 200 miles from any dentist that will take her Medicaid insurance, Herbers explains. "She can’t eat much and struggles daily with constant pain while taking medication that makes her teeth even more fragile. . . . She’s been offered appointments at Omaha and Lincoln. . . . [But] It’s an eight-hour round trip, plus hours of dental work. . . John Morris, Arline’s husband and sole caretaker, spends his days calling around for help, working around the spotty cell phone signal at their home. He’s talked to more than 50 dentists’ offices with no luck."

Over the past five years, "the total number of dental providers reimbursed after treating at least one Medicaid-eligible patient dropped by 37%," Herbers writes. "The problem is especially pronounced in western Nebraska. Only two dozen dentists west of Kearney have been paid for treating a Medicaid patient this year. Forty-three Nebraska counties, many in the state’s western half, have zero dentists helping low-income Nebraskans."

Why does Nebraska have low-income dental deserts? "Because it doesn’t pay," Herber reports. "State government reimbursements for this dental work have fallen 'far below market levels,' said Dr. Jessica Meeske of Hastings. They fail to cover the overhead costs of most procedures, leading to what Meeske calls a 'crisis level' with large numbers of patients unable to get care. . . . Meeske, a pediatric dentist at Pediatric Dental Specialists of Greater Nebraska, said her clinic turns away 15 families a day because they are 'overloaded and booked out.'"

Nebraska isn't the only state with dental Medicaid woes. The Rural Blog spoke to Gabriella Fryer in Orono, Maine; she and her husband, Cody, have three children ages 3 to 9, all of whom qualify for "Mainecare," the state's Medicaid program. Fryer described their experience: "There are very, very few dentists that accept Medicaid, even for kids, and ones that do have such [long] waitlists that you never get seen. A dental hygienist comes to schools, and that's the only way kids get seen and get referred to a dentist for cavities and whatnot." Fryer noted she and Cody opted to pay out-of-pocket to see a private-practice dental hygienist for preventative care, hoping to avoid dental problems in the first place. She adds, "That's not an option for everyone. . . . Mainecare says it "offers" dental care--but not really."

Florida is another state where low-income rural residents have limited dental care options because few dental school graduates choose to live in those areas, reports Lauren Peace of the Tampa Bay Times. "With fewer patients in mostly poorer rural communities, graduates flock to private practices elsewhere, seeking financial stability. . . . . Because Medicaid reimbursements for dental care are paltry, even in urban areas, most dentists opt not to serve Medicaid patients."

Dental deserts widen the gap in care for rural Americans; a look at Florida highlights reasons for the continued disparity

Implants, dentures, etc. (Photo by Jonathan Borba, Unsplash)

"Tooth decay is the most common chronic disease in children and adults in the United States," says the U.S. Office of Disease Prevention. While most dental diseases are preventable or treatable, even the most basic care is often not accessible for rural Americans. Reasons for care disparities range from the dental hygienist shortage to non-existent dental insurance and low Medicaid reimbursements to transportation limitations. Florida is an example of a state that has been unable to overcome these challenges,  reports Lauren Peace of the Tampa Bay Times.

"Every day, Adrienne Grimmett and her colleagues at Evara Health, a not-for-profit which serves Medicaid and uninsured patients in the Tampa Bay region, see stories of inequity in their patient's teeth, gums, and palates," Peace writes. "Marked in painful abscesses, dangerous infections, and missing molars are tales of unequal access to care. . . . All these ailments — which keep patients out of work. . . . and children out of school because they can't concentrate with rotting roots — are preventable. Annual dental checks are essential to overall health. But of the 67 counties in Florida, experts say, only one has enough dentists to treat all patients [and] Lafayette County, in north Florida, doesn't have a single one."

Grimmett, Evara's director of dental services, told Peace, "It's a social injustice. You will never be totally well if you don't have oral health." Peace reports, "About 6 million Floridians live in dental deserts, according to data from the Department of Health and Human Services. That's the largest state population living without basic dental care in the U.S. . . . Vulnerable and marginalized communities — already prone to higher rates of chronic disease and limited access to health care — are left behind in these dental deserts."

The U.S. does not have a dentist shortage; however, "The majority of [dental] graduates aren't practicing in underserved communities. . . . The issue is uneven distribution, said Joe Anne Hart, who's worked for the Florida Dental Association for nearly two decades. . . . And often, she added, there's a financial reason why dentists choose to practice in more affluent regions: student loan debt. . . .With fewer patients in mostly poorer rural communities, graduates flock to private practices elsewhere, seeking financial stability. . . . . Because Medicaid reimbursements for dental care are paltry, even in urban areas, most dentists opt not to serve Medicaid patients."

Even when a rural citizen has a dentist, the cost of the treatment can make it "unattainable." Peace spoke with 40-year-old Lisa Lambros from New Port Richey, pop. 17,000, who drive "90 minutes to Tampa for appointments at the county health department. She lost her teeth due to cancer three years ago and desperately needs dentures but hasn't been able to afford them. She feels bad for her kids, embarrassed when they bring friends home to meet her." Lambros told her, "I had perfect teeth until I got sick. Now people treat me differently. They look at me like I'm a bad person." Peace adds, "Lambros lives with daily pain that could be relieved with dental care."

Frank Catalanotto is a founding member of Floridians for Dental Access. "His organization is a partnership between nonprofits, individual dentists and medical centers working to improve health access in the state. . . He's motivated to close disparities," Peace reports. "Catalanotto stressed that teeth don't fix themselves. . . . Some minor ailments, such as colds and viral infections, can simply run their course. A minor dental ailment, he said, does no such thing. Oral disease is progressive and ongoing and ultimately leads to severe infections."

CDC: Three of seven rural adults went without dental care before pandemic, especially men, non-whites and the poor

Dental visits in 2019 by adults aged 18 to 64 (CDC chart)

Dentists were forced to shut down during the early months of the pandemic, leaving Americans unable to get appointments for routine dental care. But even before the pandemic, nearly half of rural adults went without it, according to the Centers for Disease Control and Prevention.

In 2019, the CDC says, 42.4 percent of people aged 18 to 64 in nonmetropolitan counties did not visit a dentist that year, compared to 33.3% of metropolitan residents. Rural residents who did see a dentist were more likely to go there for more serious treatment, such as oral surgery. 

Some groups were less likely to visit the dentist in both rural and urban populations, though the disparities were wider in rural areas: men, non-white residents, and the poor. Rural disparities were likely wider because of transportation problems, dentist shortages, and lack of overall health care. 

The report matters because dental care is correlated with overall physical health, and regular preventative care can keep small dental problems such as cavities from becoming large, expensive problems that threaten health and require more invasive treatment.

Local governments, citizens solve problems as D.C. dithers

While nationwide debate over many issues remains deeply polarized, local governments are quietly finding common ground—and solutions—on a wide range of issues, Washington Bureau Chief Gerald Seib reports for The Wall Street Journal.

For example, "While national politicians lapsed into finger-pointing over shortages of masks and surgical gowns during the pandemic, two businesswomen in Morganton, N.C., organized a network of small textile companies in the area to begin producing half a million masks and surgical gowns for the region’s doctors, hospitals, businesses and citizens," Seib reports. 

"In the early days it was like Rosie the Riveter," Sara Chester, one of the businesswomen, told Seib. "Everybody wanted to do their part."

"There are potentially big lessons in such small steps," Seib reports. "At a time of deepening national divisions and political tribalism, many Americans have decided to rely less on Washington to deal with problems and have turned for answers to local institutions, state governments, business leaders, their own communities and one another."

"States of Innovation," a new series of case studies from the Pew Charitable Trusts, highlights examples of state governments tackling problems, including "laws passed in more than a dozen states to deal with a shortage of dentists in rural areas by authorizing dental therapists to provide more services," Seib reports.

Evangelical doctor group begs churches to stop holding services

"As coronavirus cases spike, a national group that represents thousands of evangelical Christian doctors and other healthcare providers is asking churches to stop holding services in person," Sarah McCammon reports for NPR.

Leaders of the Christian Medical & Dental Associations, who claim 20,000 members, said that Christians who hold large gatherings may "appear to care only about our individual freedoms and don't care that we may be contributing to others getting this illness because of our selfishness."

According to several studies, most health-care workers infected with the coronavirus got it out in the community, not at work, the statement says. That includes church services.

Dr. Jeff Barrows, CMDA's senior vice president for bioethics and public policy, told McCammon that Christians are commanded to love their neighbors as themselves, and that avoiding in-person gatherings is one of the "most tangible" ways to do that right now.

"Barrows said he's particularly concerned about the risk of asymptomatic carriers of the virus spreading it to vulnerable people with weaker immune systems," McCammon reports. He also said that CMDA members who work in hospitals and emergency rooms are warning that the pandemic has stressed the medical system to its breaking point.

"Polling indicates that political conservatives are more skeptical of the need for social distancing, a category that overlaps substantially with white evangelicals," McCannon writes. "According to a survey in May, white evangelicals – the largest religious group in the country by some measures – also expressed more reluctance than most other groups toward the idea of being vaccinated against covid-19."

Study shows disparities that hurt rural children's health

Though rural living offers some benefits to health, such as increased community cohesion, many of the approximately 1 million infants and toddlers living in the rural U.S. face challenges that can hurt their health and stymie their development, Jessie Laurore, Gayane Baziyants, and Sarah Daily report for Child Trends.

The brief relies on national- and state-level data compiled by the State of Babies Yearbook 2020, which in turn gets its data from national data sets such as the U.S. Census Bureau's American Community Survey and the National Survey of Children's Health. Click here for state-level data about race, poverty, family structure, rurality, and more for infants and toddlers in each state.

Some key takeaways from the Child Trends report:

• Rural ares have higher infant mortality and preterm birth rates.
• Low birth weight is a significant challenge in rural areas for some states, more so than in urban areas.
• Rural infants are less likely to be breastfed. 
• Rural mothers are less likely receive timely prenatal care and more likely to give birth outside of the hospital. 
• Rural infants and toddlers are less likely to receive preventative medical or dental care and less likely to receive recommended vaccines.
• Rural infants and toddlers in low-income families are less likely to have health insurance than their urban counterparts.

The report recommends that lawmakers identify any existing barriers that rural families may face in enrolling their children in their state's Children's Health Insurance Program. CHIP covers families that make too much to qualify for Medicaid but don't earn enough to afford private health insurance. Medicaid and CHIP, which cover more than one-third of children in the U.S., can help ensure more children in rural areas can access health care, but rural families are less likely to be enrolled in CHIP.

The report also advocates options like mobile health clinics and telemedicine to increase rural access to health care. It also recommends promoting timely vaccinations for rural children and finding ways to pay for it using existing programs.

They also recommend that states identify whether there are gaps in how existing in-home visiting support programs serve rural children and families and, if so, find ways to bridge that gap.

Finally, the report recommends that states work to increase rural prenatal care by working with community hospitals, doulas, birthing centers, and mobile health clinics.

States increasingly allowing dental therapists to practice, which can help bring more dental care to rural areas

It can be difficult to find adequate dental care in rural areas, since there usually aren't enough dentists and many rural residents lack money and/or dental insurance. One solution, adopted by dozens of countries, is to let dental therapists to practice in rural areas. Roughly speaking, the therapists are to dentists what nurse practitioners are to doctors. But in the U.S, dentists and their powerful lobbies have argued for years that dental therapists should not be allowed to set up shop in rural areas.

"Therapists can fill teeth, attach temporary crowns, and extract loose or diseased teeth, leaving more complicated procedures like root canals and reconstruction to dentists," Marina Villeneuve reports for The Associated Press. "But many dentists argue therapists lack the education and experience needed even to pull teeth."

In the U.S. right now, dental therapists practice in four states, "on certain reservations and schools in Oregon through a pilot program; on reservations in Washington and Alaska; and for over 10 years in Minnesota, where they must work under the supervision of a dentist," Villeneuve reports.

But more states have passed, or are in the process of passing, laws to authorize dental therapists. Arizona, Maine and Vermont have passed such laws; Connecticut, Michigan, Nevada and New Mexico did so since December, and Idaho and Montana's governors signed laws this spring that allow dental therapists to operate on reservations. "Legislation failed in North Dakota and Florida this spring. Bills are pending in Kansas, Massachusetts and Wisconsin, as well as Washington, where therapists could be authorized to practice outside reservations," Villeneuve reports.

The American Dental Association and its state chapters spend more than $3 million a year on lobbying, some of it in opposition to dental-therapy laws. ADA chapters in Connecticut and Massachusetts supported legislation in those states that satisfied their concerns about safety. "The Massachusetts proposal, not yet law, would require therapists to attain a master's degree and temporarily work under a dentist's supervision," Villeneuve reports.

Education could be an obstacle to increasing the ranks of dental therapists. Some start out as hygienists, who usually have a two-year associate's degree. And though some advocates say dental therapists should only need the same education level as a hygienists, many opponents say therapists need more training. However, only Alaska and Minnesota have dental therapy educational programs, and Minnesota's program is the only one that offers a master's degree—an expensive proposition for prospective therapists, Villeneuve reports. Vermont is creating a dental therapy program at Vermont Technical College set to launch in the fall of 2021. The program, funded with the help of a $400,000 federal grant, will have distance-learning options.

Study: Rural dentists show awareness of opioid epidemic in their prescribing, and are in good positions to fight it

While rural and non-rural dentists prescribe about the same number of pain pills, rural dentists do so more often in combination with ibuprofen or acetaminophen and at lower dosage rates. So says a new study, which also found that rural dentists are more likely to have suspected their patients of drug abuse -- and not prescribed opioids to them as a result of that suspicion.

AARP photo illustration

The study, published in The Journal of Rural Health, pointed out that rural dentists are in a great position to help combat the opioid crisis, largely because rural communities have been hit so hard by the opioid epidemic and because dentists prescribe about 12 percent of annual opioid prescriptions.

"Recognizing and engaging rural dentists as leaders in addressing opioid misuse will be an important step toward reducing the fatal impacts of this epidemic among rural communities," the researchers write. "Rural dentists encountering this epidemic can implement screening for opioid misuse and abuse, as well as provide a referral for treatment."

The researchers delivered an online survey to dentists in the National Dental Practice-Based Research Network to measure both rural and non-rural dentists' pain management practices, their perceptions of the scope of the problem and the perceived adequacy of their training around preventing the misuse and abuse of opioids.

The survey excluded those who did not provide an email address, and those who practiced exclusively in orthodontics, oral pathology or pediatric dentistry, because those types of practices rarely prescribe opioids. Of the 822 dentists who completed the survey, 91 were in a rural practice and 731 were not; 11.1% of them were in an area that is short of health professionals. Rural practice was defined as those with a ZIP code with more than 50% of its population living in a non-metropolitan county or in a rural census tract. (Many metro counties have rural census tracts.)

"Rural dentists were significantly more likely to prescribe opioids in combination with a recommendation to use ibuprofen or acetaminophen for pain management, and were significantly less likely to prescribe six to seven days' supply of opioids," the researchers report. They also found that only one-third of the dentists said their training to prevent misuse or abuse of opioids was "sufficient and up to date." Rural dentists appeared slightly less likely to say that. The rest said their training was either sufficient, but out of date; insufficient; or that they had received no such training.

The researchers said the American Dental Association's new policy was a great support for dentists because it sets limitations for opioid dosage and duration for acute pain, elevates the significance of mandatory continuing education for prescribing opioids and other controlled substances, and provides a recommendation for dentists to use state prescription-drug monitoring programs.

The journal article concludes, "Dentists should employ recommended risk-mitigation strategies broadly, as a substantial segment of dental patients report at least some non-medical use of their pain medications, and recent substance abuse—including problematic alcohol use or illicit drug use—has been reported by approximately one in five dental patients."

The article acknowledged several limitations to the study: Self-reported data is retrospective in nature, making it subject to potential bias; no objective prescribing data was collected; a patients may live in a different ZIP code (perhaps an urban one) than the dentist; and the study did not differentiate between the complexity of procedures as potential reasons for the dentists' prescribing practices.

The corresponding author of the study report is Dr. Jenna McCauley of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina.

Rural America has too few dentists, partly because it has too few patients or Medicaid programs that can pay

Dr. Lynnel Beauchesne's clinic in Preston County, West Virginia,
at lower right. (Photos by Ricky Carioti for The Washington Post)

Efforts to recruit dentists to rural towns, and expand state scope-of-practice laws to allow basic services to be delivered by dental therapists, have long been regarded as two of the best ways to improve oral health in rural America, where 43 percent of residents lack access to dental care. But because the care is so expensive, those efforts may sometimes be counterproductive, Anne Kim, domestic policy director at the Progressive Policy Institute, writes for The Washington Post.

"People don’t go to the dentist if they can’t afford to, no matter how many dentists there are," Kim writes, citing Richard Meckstroth, chair of the department of dental practice and rural health at West Virginia University. "Recruiting more providers into shortage areas can compound the problem, said Meckstroth, putting local dentists into tougher financial straits by increasing competition for a relatively small pool of paying patients. The dentists who arrive under loan forgiveness programs also tend to leave after their two-year obligation is up, what Meckstroth calls a 'revolving door' that deprives patients of continuity of care."

Beauchesne and 15-month-old daughter, Landyn, in the office

And in states like West Virginia, where poverty is widespread and Medicaid doesn't cover adult dental care except for extractions or infection treatment, even dentists can have it tough. Kim's object example is Dr. Lynnel Beauchesne of Preston County, who "keeps prices barely above costs. The office charges $90 for a cleaning, an exam and bitewing X-rays — about half the national average fee and a third of what many big-city dentists would charge for the same services."  Beauchesne tols her, “I try to keep my prices in the realm of what people can afford and so they will want to come. I don’t want people to come just for extractions. I want them to come for cleanings and to keep the teeth they have.” The closest dentist is 30 miles away.

"Poor oral health has an impact beyond mere toothache," Kim reminds us. "A landmark 2000 report by the U.S. surgeon general found that oral health is intimately linked to people’s overall physical health and is often associated with serious systemic conditions such as diabetes and heart disease, as well as the likelihood of complications in pregnancy. Nevertheless, some 74 million Americans had no dental coverage in 2016, according to the National Association of Dental Plans, putting the dentally uninsured rate at nearly four times the rate for the medically uninsured." A 2014 report from the American Dental Association said nearly 20 percent of adults under 65 "said they’d foregone needed dental care in the past 12 months, with the most common reason being “they couldn't afford it.”

Which brings us back to recruiting dentists. "Patients’ inability to afford care is one reason younger dentists — many facing up to $250,000 in school debt — are reluctant to settle in rural areas and why dentists like Beauchesne find themselves working hard to keep their doors open," Kim writes, adding, "The dental-care crisis in rural America is closely linked to the broader economic challenges in the parts of the country that have not yet caught up in this recovery." As Meckstroth told her, “How you improve access in rural America is to get people jobs.”

Kentucky's (and nation's?) oldest working dentist dies at 97

Dr. J.M. Stephenson

Julius Middleton Stephenson, who was Kentucky's oldest working dentist, and may have been the oldest in the nation, died May 5 in Bowling Green. He practiced in the Cumberland River town of Burkesville, population 1,500.

Stephenson worked in his office as recently as March. He was a fixture at the state high school basketball tournament well into his 90s, and was secretary-treasurer of the South Central Kentucky Dental Society for 40 years. His son and daughter, who survive, are both dentists.

His funeral service will be held at 2 p.m. Wednesday at Burkesville First United Methodist Church with burial in Burkesville Cemetery with military honors. Flowers are welcome, but donations are encouraged to Lindsey Wilson College in Columbia, Ky.

Full disclosure: In his youth, the writer of this post was a patient of Dr. Stephenson.

Dentistry program trains students to serve in rural areas

Dr. Art DiMarco with RIDE students (RIDE photo)

It's hard to find medical professionals to practice in rural areas, and dentistry is no exception. So the University of Washington School of Dentistry has created a program to train future dentists to serve in rural areas, Kay Miller Temple reports for the Rural Health Information Hub. Other universities near rural areas could copy its model.

The Regional Initiatives in Dental Education program has an impressive success rate: over 70 percent of its graduates have been placed in rural or underserved areas of Washington, Oregon, California and Texas. The 4-year program is modeled on--and designed to integrate with--the university's WWAMI program (so named for the states Washington, Wyoming, Alaska, Montana, and Idaho), which trains medical students to serve as primary care physicians throughout the Pacific Northwest, especially in rural areas. RIDE dental students and WWAMI medical students both spend their first year at Spokane's Eastern Washington University campus. Second- and third-year RIDE students train in Seattle, and fourth-year students spend four months working with community health center dentists. The training is meant to create a "super-generalist" who can capably serve in rural areas.

Dr. Art DiMarco, the program's director at Eastern Washington University, said the program was different from other rural placement programs from the start. Other programs relied on loan forgiveness to lure students, which DiMarco said helped, but didn't attract as many students as they needed. The RIDE program's founding director, Dr. Wendy Mouradian, looked instead to the WWAMI program. She says the four keys to both programs that ensure its success rate are:

1. Have faith in the students' desire to provide care to rural/underserved populations and reward this interest early.
2. Ensure comprehensive training for rural practice.
3. Provide mentoring and post-graduation support.
4. Structure education for a "cohort effect". i.e., the students support each other so that everyone shows up every day and does their best work.

Read more about the RIDE program here.

Rich-poor divide in oral health forces low-income folks to choose extraction over costly repairs

The rich-poor divide is causing many impoverished rural residents to forgo dental health care, or resort to having teeth pulled rather than pay for costly fixes, Mary Jordan and Kevin Sullivan report for The Washington Post. The rate of Americans who have lost all their natural teeth is higher in rural areas in every age group, and 20 percent of all Americans over 65 do not have a single real tooth remaining. (CDC graphic: National Health Survey 2010-12 results of of people who have lost all their natural teeth)

Toothless rates among those 65 and older are especially high in the South. According to Kaiser Family Foundation data from 2014, 33.6 percent of West Virginia residents 65 and older have had all their natural teeth extracted. Second is Kentucky, at 23.9 percent, followed by Mississippi and Oklahoma (22.5), Tennessee (22.4), Alabama (22.2), Arkansas (22) and Louisiana (20.5). (CDC graphic: Where people 65 and older have lost all their teeth, by region)

More than 50 million Americans "live in areas officially designated by the federal government as Dental Health Professional Shortage Areas," reports the Post. "A great many of them are working poor. In these rural areas, even the water can work against people." Many people rely on well water that is not fluoridated, which helps reduce tooth decay. The Centers for Disease Control and Prevention says 25 percent of Americans are not connected to a fluoridated water system. Another problem in rural areas is a shortage of dentists.

While rich people can afford the luxuries of the best oral health care, poor people often resort to standing in line at free clinics, reports the Post. "High-end cosmetic dentistry is soaring, and better-off Americans spend well over $1 billion each year just to make their teeth a few shades whiter. Millions of others rely on charity clinics and hospital emergency rooms to treat painful and neglected teeth." The problem is that emergency rooms are not typically equipped to fix dental problems. That means they prescribe painkillers, which can lead to addiction, which destroys teeth, and dry mouth, which leads to more cavities.

Dental therapists in Minnesota leading to increased care in rural and underserved areas

Kassie Scott works as a dental therapist in
Minnesota (Times photo by Dave Schwarz)

Minnesota's goal to increase dental care to rural and underserved areas is beginning to pay off, but still lacks enough qualified workers, Stephanie Dickrell reports for the St. Cloud Times. In 2009 the Minnesota Legislature authorized the licensing of dental therapists "to expand access to dental care to more state residents, especially those with low incomes or who live in rural areas where dentists may be rare." Minnesota "has some of the lowest reimbursement rates for pediatric dental care services in the nation. As a result, dentists say they can't afford to treat any or many Medical Assistance patients."

The first class of dental therapists, who "perform routine dental work, including fillings, while the dentist concentrates on more complicated cases," graduated in 2011, Dickrell reports. "A 2016 study by the University of Minnesota found that dental therapists saw up to 90 percent of uninsured patients or patients on public assistance."

Having dental therapists is also leading to shorter waiting times for appointments, Dickrell writes. A study in 2014 by the Minnesota Department of Health, "showed that almost one-third of all patients saw a reduction in wait times to get an appointment, especially in rural areas. Time with a provider increased by 10 minutes."

Using dental therapists is also saving money, Dickrell reports. Sarah Wovcha, executive director of Children's Dental Service, a nonprofit clinic that treats low-income, uninsured and diverse kids and pregnant women, said "while a dentist might make an average of $75 an hour for a filling, a dental therapist would make half that for the same work." Wovcha said that leads to weekly savings of $1,200 and annual savings of $62,400, "or the cost of another full-time dental therapist."

One problem is that Minnesota only has two programs to train dental therapists, producing about 20 graduates per year, Dickrell writes. The health department said there are currently about 70 licensed dental therapists in Minnesota, which accounts for only 1 percent of the state's dental workforce.

Soft drinks are by far the No. 1 item purchased by households with food stamps, USDA finds

Households that use the federal Supplemental Nutrition Assistance Program, or SNAP – formerly known as food stamps – are a fifth more likely to have more sweetened beverages in their homes than households not in SNAP. A study by the U.S. Department of Agriculture revealed that the top items bought with food stamps are soft drinks, which are high in sugar and have been blamed for increasing childhood obesity, which is more prevalent among rural children.

This is the first Agriculture Department study to reveal "purchasing habits under the program in detail," Jen Fifield reports for Stateline. "The report, along with the election of President Donald Trump, who may be more inclined to tighten welfare rules, has reignited a long-standing debate on whether the government should allow people to use food stamps to buy unhealthy food."

The study found no huge differences between households with or without SNAP when it came to purchasing most food products like fluid milk, ground beef and bagged snacks. But "expenditure proportions on soft drinks were slightly higher for SNAP households compared to non-SNAP households," making it the No. 1 purchase for SNAP holders. Soft-drink packages of 12 to 18 cans ranked $164.6 million, followed by 2-liter bottles ($70.9 million), and 20-24 pack cans ($39.7 million). Those categories plus two others for soft drinks added up to 38.6 percent of SNAP expenditures; in non-SNAP households, the soft-drink total was 31.7 percent.

The study report said the data came from "a leading grocery retailer" during the 2011 fiscal year. The study analyzed the spending habits of about 3 million SNAP households; the report notes that purchases made at other SNAP-authorized stores were not included.

Studies have suggested that the consumption of sugar-sweetened beverages lead not only to tooth decay and weight gain, but also to type 2 diabetes, elevated cholesterol and nonalcoholic fatty liver disease in children. Nutrition educators want to ban the purchase of junk food through the SNAP program, but advocates such as the Food Research and Action Center say banning certain products from SNAP would be too complicated and costly, Fifeild writes. "FRAC and similar groups that fight to end hunger, along with organizations representing merchants, are fervently opposed to restrictions, saying that along with being burdensome to implement, they are also unlikely to change eating habits."

Nutritionists want to ban use of food stamps for junk food

Nutrition educators want the federal Supplemental Nutrition Assistance Program, or SNAP—formerly known as food stamps—to ban the purchase of junk food through the program, Jen Fifield reports for Stateline.

According to a 2016 report from the Department of Agriculture, the top items bought with food stamps are soft drinks, which are high in sugar and have been blamed on increasing childhood obesity, which is more prevalent among rural children. Studies have suggested a link between the consumption of sugar-sweetened beverages and dental caries, weight gain, type 2 diabetes, dyslipidemia and nonalcoholic fatty liver disease in children.

The USDA report found that "23 cents of every food stamp dollar is used to buy candy, desserts, salty snacks, sugar and sweetened beverages," Fifield writes. "The report, along with the election of President Donald Trump, who may be more inclined to tighten welfare rules, has reignited a long-standing debate on whether the government should allow people to use food stamps to buy unhealthy food."

"Lawmakers in at least five states—Arkansas, Florida, Mississippi, New Mexico and Tennessee—introduced bills this year to ask the USDA for permission to ban the purchase of certain kinds of food or drinks, such as candy and soda, with food stamps," Fifield writes. "Since the USDA administers the program, states can’t create their own restrictions. But the department can give a state permission to conduct a pilot to test new ideas—something it has so far been unwilling to do."

"Many public health and medical officials have supported the idea of restrictions on junk food for years, saying the program was meant to supplement nutrition but is instead feeding into the country’s unhealthy habits and worsening the obesity epidemic," Fifield writes. "The idea sounds appealing to people who don’t know much about nutrition or how the program works, said Ellen Vollinger, legal director for the Food Research and Action Center, a nonprofit that aims to reduce hunger. The proposals often fail, she said, once lawmakers find out how costly and complicated they would be to implement, including how to determine which food items should be restricted and how to create a database and keep it updated as new products come out. FRAC and similar groups that fight to end hunger, along with organizations representing merchants, are fervently opposed to restrictions, saying that along with being burdensome to implement, they are also unlikely to change eating habits."

Five-part series takes a look at Central Appalachia

Oxycontin/Stacy Kranitz photo

Vice, a print magazine and website focused on arts, culture and news, this week published a five-part series on Central Appalachia called "Ain't No Grave." The series "focused on the effects of the declining coal industry, systemic problems with the health-care system, the struggle against the obliteration of mountains due to strip mining, the drug epidemic, and the history and meaning of the terms 'redneck' and 'hillbilly'," Stacy Kranitz reports for Vice. She said those involved in the series didn't want to focus on "mass media's view of Central Appalachia as a poverty-ridden region," but didn't want to ignore those traits either.

One story, "A Portrait of Coal Town on the Brink of Death," is a first-person narrative of Boone County, West Virginia. "Handley's Funeral Home buried most of my family," Jacob Knabb writes. "The stone structure sits on a corner lot near the terminus of Phipps Avenue, a couple miles downriver from my parents' house in Madison, W.Va., and right across the street from the old Bank of Danville building. The funeral business is one of the few that remain viable here in Danville—these days home to a smattering of churches and fast-food joints, a shocking number of for-sale signs, and not much else. But there are always going to be bodies to bury, grieving families to comfort, and so Handley's remains, its logo emblazoned on the menus a few blocks up Phipps at the Park Avenue Restaurant, on the fence at the Little League Ballpark in Madison, and on the press box perched above the football field where the Scott Skyhawks play."

Another story, "The Hard Times, Struggles, and Hopes of Addicts in Appalachia," looks at opiate addiction. "The opiate epidemic in Beckley, W.Va., is something that reveals itself quickly and casually—on the side of the road, in the parking lot at Walmart, in line at Taco Bell," writes Juliet Escoria, a Beckley resident. "Burnt bits of aluminum foil, paper packets that once held heroin. People nodding out, buying drugs on playgrounds, smoking heroin on the side of a busy road. It's worse on hot days, immediately after snowstorms, and especially on the first of the month, when paychecks and government benefits come through."

Other stories include: "What It Means to Be a 'Redneck' or a 'Hillbilly'"; "How Environmental Activists Are Fighting Back Against Pollution and Big Business in Appalachia"; and "Inside a Life-Saving Rural Clinic in Appalachia".

Rural Iowa had 13% fewer dental practices in 2013 than in 1997; average age of dentists increasing

The average age of dentists in Iowa continues to increase, while the number of dentists in the state's rural areas continue to decline, statistics that need to be addressed to prevent a serious dentist shortage in the future, says a study by researchers with the University of Iowa Public Policy Center, Hayley Bruce reports for Iowa Now. From 1997 to 2013 the number of dentists in the state 55 or older increased from 23 percent to 42 percent. During the same time the number of dentists practicing in rural areas decreased from 49 percent to 36 percent. One-third of the state's dentists practice in three metro counties that account for 27 percent of the state's population. (University of Iowa map: Number of private-practice dentists in each county in 2013)

The study also shows that oral health in Iowa has shifted from solo practices to group practices, "with the proportion of Iowa dentists who work in solo practice declining from 59 percent in 1997 to 43 percent in 2013," Bruce writes. Raymond Kuthy, University of Iowa professor of preventive and community dentistry, told Bruce, “These changing demographics are likely to impact overall practice patterns, as well as the geographic distribution of Iowa’s dentists. People who go into group practice tend to wind up in larger communities because it provides them with a larger patient pool, better emergency coverage in the dentist’s absence, and the ability to vary their work hours." (Read more)

Rural N.D. lacks dentists; ADA's chief economist says some rural residents don't see a need for care

While a 2014 report from the Center for Rural Health highlights a serious shortage of dentists in North Dakota's rural, under-served and Native American communities, some health professionals deny there is a problem or blame rural residents for lack of care, John Hageman reports for the Grand Forks Herald. The report found that 67 percent of all North Dakota dentists practiced in the state's four most-populated counties, where about 52 percent of the state's people live. That meant that in 2014, 12 of the 53 counties did not have a dentist, nine had only one and nine had two (data were unavailable for five counties). North Dakota ranks 48th in population but 19th in land area, making it difficult for many rural residents to travel to see a dentist.

Rob Lauf, a dentist in Mayville in rural Traill County, just outside Grand Forks, said he doesn't consider the eastern part of the state to have a dental shortage, Hageman writes. Lauf told him, "Either way, you have to have a full schedule. There are some counties that don't have a dentist, but they also don't have the population to support a dentist." The eastern part of the state includes two rural counties adjacent to Grand Forks and Traill counties—Nelson and Steele—that do not have a dentist, according to the Center for Rural Health report. (Center for Rural Health map: Dentists in North Dakota in 2014)

At the same time, an "American Dental Association survey showed that less than 10 percent of general and specialist dentists in North Dakota reported they are not busy enough and could see more patients in 2013, which was the lowest percentage of the 36 states included on the survey and well below the national average of roughly 35 percent," Hageman writes. Marko Vujicic, chief economist with the American Dental Association, "said the main reasons people don't seek dental care are cost and 'a perceived lack of need' rather than an inability to get a dental appointment scheduled."

North Dakota, which lacks a state dental school, has tried to recruit recent college graduates with loan repayment programs, Hageman writes. Legislation proposed last year allowing certified advanced dental hygienists to perform some procedures now done by dentists, a move designed to increase dental care needs in rural and Native Americans, was opposed by the North Dakota Dental Association and ultimately did not become law.

Dental therapists are the key to improving oral health in underserved rural areas, advocates say

Dental therapists could be the solution for improving oral health in rural areas, Pew Charitable Trust's oral health advocates Julie Stitzel and Rebecca Singer Cohen report for Stateline. Of the 4,438 areas designated as having dental health professional shortages, 60 percent are in rural areas. The oral health deficiency is compounded by rural residents being more likely than urban ones to be poor, lack dental insurance, have poor water supplies and often have long distances to travel to the dentist.

Another problem is that only about one-third of dentists accept Medicaid or other public insurance, Stitzel and Cohen write. As a result, many patients skip dentists and go to the emergency room with oral care concerns. "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."

Midlevel dental providers—or dental therapists—are the solution, Stitzel and Cohen write. These professionals "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."

Minnesota was the first state to authorize dental therapists in 2008, with a therapist opening a private practice in rural Montevideo, Stitzel and Cohen write. "In the therapist's first year, new patients increased by 38 percent," and the therapist served 500 more Medicaid patients and made an additional $24,000 in profit. The American Dental Association has publicly criticized dental therapists, saying a in February statement: "The supply of dentists is adequate to serve America’s needs," and ADA "remains firmly opposed to allowing non-dentists to perform surgical procedures."