Lacking money, insurance or dentists, oral health takes a back seat, and rural is barely on the bus

A dentist works at a Remote Area Medical Clinic in Wise, Va.
(Associated Press photo by Steve Helber)

Dental disease is the largest unmet health need in the U.S. among both children and adults, according to the Pew Children’s Dental Campaign. The worst-off are the poor, the young, the old, and those in rural America, reports Margot Sanger-Katz in the National Journal.

Dental disease is among the most common reasons that children miss school. It’s the most common medical reason that soldiers can’t deploy. It is a leading cause of emergency-room visits in several states. For proponents of a freer health care market, who want patients to be motivated by financial incentives to shop around and avoid “unnecessary” care, the dental system offers a glimpse of how such a system might work. And research shows that poor oral health can lead to disease elsewhere in the body.

In a world of medical priorities, dentistry takes a back seat to most, and In a world of health care, and rural America sometimes appears to not even be on the bus. The net result, writes Sanger-Katz, is that the United States faces a shortage of dentists that is particularly acute in poor, rural regions. "Huge pockets of the country have few (or no) providers. The federal government counts 4,503 mostly rural regions where more than 3,000 people share one dentist," she notes, "making it tough for many residents to find someone to fix their teeth."

Sanger-Katz continues, "For more than 100 years, dentistry has run on a separate -- and more laissez-fair -- track than the rest of medicine. Dentists have their own schools and treat patients in their own offices; fewer laws and regulations govern the field. Insurance plans typically demand high co-pays and limit their payouts for invasive procedures. About half of all dental expenses are paid out of pocket, compared with less than 10 percent of costs in the overall medical system. This is the free market. And, in some ways, it has worked: People do not drive up insurance rates by seeking frivolous procedures. Patients tend to shop around for care, and prices vary according to local economies. The rate of dental inflation, although higher than the rate for the economy overall, is lower than the rate in medicine, which is typically several points above the growth rate of the gross domestic product. (You don’t hear policymakers complain about the burden of “runaway” dental costs.)

“It’s very much a free market, with a greater spread between the haves and have-nots,” said Burton Edelstein, a professor of dentistry at Columbia University and the founder of the Children’s Dental Health Project. "Dental insurance is much less widespread than medical insurance; 130 million Americans lacked dental coverage in 2009, but only 50 million lacked medical coverage," Sanger Katz-writes. "And with most payouts capped at $1,000 to $2,000 per year, insurance can’t cover much beyond basic services. Medicare does not pay for dental care at all, so 70 percent of seniors lack any dental coverage, according to an Institute of Medicine report. Medicaid also fails to provide meaningful dental access for many of its beneficiaries: The program pays dentists so poorly for treatment that only about 20 percent of them see Medicaid patients." Meanwhile, seven of 61 dental schools closed in the last 30 years, meaning 2,000 fewer dentists every year, a 33 percent drop in supply, just as an older generation of dentists started retiring.

The result is a crisis. And, in a few lucky rural towns, the result looks like this: A mobile van outfitted with a volunteer dentist comes to a rural elementary school and offers free check-ups but no fillings. Or, better yet, a volunteer army of dentists, dental students and oral surgeons in a region volunteer for a two-day event at a vast arena where everyone is welcome to camp overnight for a place in line for care. Some of the dental expertise and hospitality is donated by Ronald McDonald House, or Remote Area Medical out of Knoxville, Tenn., or local community health centers. And while are limited in their ability to do much more than prevention, others can offer real dental care but no follow-up. The result is often a brutal kind of dentistry that involves, at best, mass extraction, some advice about what not to drink and explanations about how oral health is connected to overall health.

Dr. Nikki Stone is a dentist who works in Hazard, Ky., in one of the those federally qualified community-run clinics. A native of the Kentucky mountains, she knew that children in Eastern Kentucky weren’t getting enough dental care, but she was still "staggered by the prevalence of dental disease when she began examining them in 2004," Sanger-Katz notes. "Large numbers of the kids had never seen a dentist. Half had untreated tooth decay, and nearly 20 percent had urgent needs -- more than six cavities or an active abscess. She and her staff 'cried a lot,' she recalls. Crisscrossing four counties in her van, she painted fluoride on all the teeth and sent notes home with the children who needed immediate attention. In the early years, only 8 percent of those youngsters with urgent problems got the care they needed. The job was like fighting a forest fire on a mountain, she says. 'I felt like I was standing here on the line of the fire with a squirt gun.'

There seems little hope for any change soon in rural America, even if the federal health-reform law survives. "It deems dental coverage an essential part of any health plan for children, but regulators have yet to spell out what insurers must cover to meet that definition," Sanger-Katz writes. "The law expands existing loan-repayment funds for dentists who relocate to underserved areas, but it offers no expansion of dental coverage for adults and doesn’t try to integrate dental health into the larger health care system." (Read more)

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.

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.

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."

Study suggests dental therapists are good option for underserved areas

A new study funded by the W. K. Kellogg Foundation reveals dental therapists in an Alaskan pilot program provide safe, competent and appropriate dental care. "The two-year, intensive evaluation is the first independent evaluation of its scale to assess care provided by dental therapists practicing in the United States," the Kellogg Foundation writes.  "It confirms what numerous prior studies of dental therapists practicing in other countries have already shown: that dental therapists provide safe care for underserved populations."

Dental therapists have been providing dental care to remote Alaska Native villages since 2006. "These findings clearly indicate to me that alternative providers such as dental therapists can successfully provide good, quality dental care in areas where people can’t gain access to dentists," Sterling K. Speirn, the W.K. Kellogg Foundation’s president and chief executive officer, said in a news release. "Other states and tribal areas should explore the dental therapist model as a way to expand the reach of dentists, and in the process, help millions of people get the dental care they so desperately need." The study observed dental therapists in five communities and evaluated the experience of hundreds of patients and relied on examination standards used for assessing clinical competency for board certification of U.S. dental school graduates.

The report concluded "dental therapists are technically competent to perform the procedures within their scope of work and are doing so safely and appropriately, they are consistently working under the general supervision of dentists, they are successfully treating cavities and helping to relieve pain for people who often had to wait months or travel hours to seek treatment, patient satisfaction with their care is very high and they are well-accepted in tribal villages," the Kellogg Foundation writes. The study was conducted by RTI International and was funded in part by the Rasmuson Foundation and the Bethel Community Services Foundation. (Read more)

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 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."

New level of dental professionals – therapists – could provide care to Medicaid-eligible kids, save a bundle

Research at the University of Connecticut suggests that adding a new kind of health professional – dental therapists – to clinics designated as Federally Qualified Health Centers could significantly expand the availability of care for millions of American children, many of them in rural areas. (Pew Center for the States photo)

The white paper from the Pew Center on the States notes that, "in particular, by including dental therapists as providers in school-based programs operated by FQHCs, the researchers estimated states could provide access to care for 6.7 million Medicaid-eligible children, nationwide." The analysis also suggests that this significant increase in access could be realized for a cost of approximately $1.8 billion, or just one half of 1 percent of combined state and federal 2009 Medicaid spending. To read the full Pew report, go here. 

Nationwide, 830,000 emergency room visits in 2009 were due to preventable dental problems, according to the center. Most of the children lacking care don't have insurance, live in areas without enough dentists or can't find doctors who accept Medicaid. Problems accessing dentists could grow in 2014, when 5 million more children are expected to get dental insurance under the federal health reform law.

Despite the undisputed need, not everyone is behind the concept. The American Dental Association argues that dental therapists lack the training and education needed to perform irreversible surgical procedures and to identify patients' other medical problems, writes Anna Gorman in the Los Angeles Times. Shelly Gehshan, director of the Children's Dental Campaign, said the therapists would be properly educated and would help close vast gaps in care that can lead to costly emergency room visits for dental problems.

In 2005, Alaska became the first state to try out the new dental-care model, when therapists began treating native populations. Minnesota authorized the new tier of practitioner in 2009, and the first graduates of dental therapy programs began practicing last year.

Despite Medicaid, rural kids often lack dental care

One of the greatest threats to the health of rural children is the lack of attention to their teeth and gums. Judy J. Owens of Kentucky writes for the Daily Yonder, "Lack of dental care, common among low-income and Medicaid-eligible adults and children, often results in severe or persistent pain, inability to eat, swollen faces, and increased susceptibility to other medical conditions." (New York Times photo by Stephen Crowley: A student in Barbourville, Ky., gets ready for a free exam through Kids First Dental, a mobile clinic.)

Poor dental health is a problem that plagues much of rural America. "In a rural state such as Kentucky, for example, dental decay is the No. 1 infectious disease in children. Dental pain is the number one excuse for public school absences." Medicaid provides dental insurance to all children who are eligible for the program, but many rural children grow up without dental care because adults don't take advantage of the benefit and many if not most rural dentists don't accept Medicaid patients, citing low reimbursement rates. (Sometimes we wonder if there are other reasons.)

"Many children grow up in homes where the adults do not have regular dental treatment, and so the children are not taken to the dentist," writes Owens. "A survey in North Carolina found that on average, only 20 percent of Medicaid recipients visited the dentist in 1998." There are signs of progress, however. This year Kentucky passed a law requiring children to have their teeth examined before beginning school. Early care is seen as the best form of prevention of poor dental health. While the law hasn't taken effect, other efforts have failed to make a dent in the rural dental health problem. "Despite years of advancement, including the establishment of two colleges of dentistry and an impressive water fluoridation program," Owens writes, "Kentucky is a national leader in toothlessness." (Read more)

Dentist shortages in rural places contribute to rise in emergency-room visits for tooth trouble

The number of emergency-room visits for patients seeking dental treatment has increased, mostly because of problems that could have been prevented with regular dental visits, according to the Pew Center on the States. Most cases are in rural areas, which have a shortage of dentists. Nationwide, the number of ER dental visits increased 16 percent from 2006 to 2009, and the center suggests the trend is continuing. (New York Times photo by Stephen Crowley: A student in Barbourville, Ky., gets ready for a free exam through Kids First Dental, a mobile clinic.)

Visiting the ER for dental treatment can be 10 times more expensive than preventive care. Many visits involve the same patients seeking more care because emergency rooms aren't staffed by dentists. Doctors can offer pain relief, but not much more, and many patients can't afford follow-up treatment or can't find a dentist. "Emergency rooms are really the canary in the coal mine. If people are showing up in the ER for dental care, then we’ve got big holes in the delivery of care," said Shelly Gehshan, director of Pew’s child-dentistry campaign. "It’s just like pouring money down a hole."

The center analyzed information from 24 states, the federal Agency for Healthcare Research and Quality and dental care studies. It found that in 2009, 56 percent of children with Medicaid didn't receive dental care, ER visits for dental care increased by almost 60 percent in South Carolina, and there were 55,000 dental-related ER visits in Tennessee hospitals. Part of the problem is that few dentists participate in Medicaid programs, The Associated Press reports. The center is working with states to develop dental hygienists training programs and train non-dentists to treat cavities and other uncomplicated procedures. (Read more)

Fewer dentists are practicing in rural America, but some states are trying to change that

The number of dentists in rural Nebraska keeps shrinking, and there is little interest among new dentists in setting up practice in the state's rural areas. States like Nebraska, Kentucky and Kansas are trying to lure more dentists to rural areas through incentive programs or by educating the area's youth about the benefits of becoming a dentist and practicing close to home. (Kansas Health Institute photo by Ann Williamson: Dental patients waiting at the Kansas Mission of Mercy Dental Clinic in Manhattan. The free clinics treat thousands who otherwise might not have access to dental care.)

Twenty of Nebraska's 93 counties don't have a dentist, and 31 counties only have one or two, the Fremont Tribune reports. Even worse, 39 percent of the state's dentists are nearing retirement, and there is little interest among recent college graduates in setting up practices in rural areas. Kim McFarland of the University of Nebraska told the Tribune she estimates that of the 45 new dentists entering practice in the state each year, only five or six go to rural areas.

Nebraska has an incentive program that gives a dental-school graduate up to $20,000 a year in tuition reimbursement for workign in underserved rural areas, the Tribune reports. But McFarland said students often graduate with $200,000 or more in debt. She told the Tribune, "We just need to make sure we're recruiting dental students from rural areas and giving them incentives to practice in rural areas." That won't be easy, because the state's two dental schools, at the University of Nebraska and Creighton University — are operating at capacity, McFarland said. (Read more)

Grants in Kentucky and Kansas are helping to raise awareness about the need for dentists in rural areas. Morehead State University received approval this week from the Appalachian Regional Commission for a $400,000 grant to initiate the Appalachian Rural Dental Education Partnership Program, MSU reports. Matching resources from Morehead and the University of Kentucky, which is partnering with Morehead in the program, brings the total to $514,437. 

"The program will increase awareness and support for dental careers among kindergarten through 12th-grade students in Eastern Kentucky; establish a new undergraduate predental curriculum at MSU with links to the UK dental school; and improve oral health conditions at MSU and in the surrounding region," MSU reports. "The strategic will ultimately improve access to dental professionals in underserved areas such as Appalachian Kentucky's distressed counties." (Read more)

In Kansas, in response to a 2011 report that 57,000 people in the state live at least 30 minutes from the nearest dentist, it was announced this week that "the DentaQuest Foundation has given a $100,000 grant to Oral Health Kansas to develop a plan for improving access to dental care," Jim McLean reports for the Kansas Health Institute. "The nonprofit group will work with several other Kansas oral health organizations to craft the plan and submit to the foundation for a  possible two-year implementation grant." (Read more)

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."

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.”

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.

Medicaid dental coverage is first to go when states can't tighten eligibility rules; has big rural impact

Many states have cut optional benefits for poor adults enrolled in Medicaid, rather than tighten eligibility requirements at a time when more people need the program, and dental services are often first to go. The problem likely won't improve under President Obama's health-care overhaul because it requires dental coverage just for children. The cuts probably affect rural residents disproportionately since many rural places are facing dentist shortages, according to the Pew Center on the States.

In about half the states, Medicaid dental care now covers only pain relief and emergencies, according to a recent Kaiser Commission on Medicaid and the Uninsured report. Other states cover preventative exams and cleaning, but not fillings and root canals, Abby Goodnough of The New York Times reports. Some states are also cutting vision, chiropractic and podiatry coverage, and requiring co-payments for prescription drugs. (Times photo by Gretchen Ertl)

Many adults on Medicaid are turning to community health centers for dental care. In Massachusetts, which has long been a state with very generous Medicaid, community clinics received 22,000 new dental patients in the first six months after dental coverage was dropped. And in states where Medicaid still covers dental care, "finding dentists who accept Medicaid can be next to impossible," Goodnough writes, because reimbursements have also been cut and dentists have dropped out of the program or refuse to join. (Read more)

As dentists' fees rise faster than inflation, more people leave cavities untreated

For many Americans, perhaps the only thing more dreaded than a trip to the dentist is getting the bill afterward. The costs of dentists' fees have risen faster than inflation in recent years, and more than 100 million Americans remain without dental insurance, reports The New York Times. Add those two factors to a lack of dentists in many rural areas, and it's not hard to see why the number of Americans with untreated cavities is on the rise after decades of progress in dental health. (Times charts)

Figures from the Centers for Disease Control and Prevention show that in 2003 and 2004, 27 percent of children and 29 percent of adults did not receive treatment for their cavities, the highest such figures since the late 1980s, writes Alex Berenson. The average American spends $600 annually on dental care, of which about half is covered by insurance. That's not the case for poor families whose Medicaid coverage is not accepted by most dentists. In most places, Medicaid won't cover basic care, and dentists prefer the steady income of patients that pay cash or have private insurance.

“Most dentists consider themselves to be in the business of dentistry rather than the practice of dentistry,” said Dr. David A. Nash, a professor of pediatric dentistry at the University of Kentucky. “I’m a cynic about my profession, but the data are there. It’s embarrassing.”

To combat a growing shortage of dentists, especially in rural America, many want dental hygienists and dental therapists to be allowed to provide basic care such as drilling and filling cavities. State dental boards and the American Dental Association have lobbied against such plans and won. Dental therapists are technicians without the general medical training of dentists, and they practice in more than 5o nations, including parts of Western Europe.

Bills would require dental exams for school kids in Ky. and W.Va., the 2 states with worst oral health

To attack oral-health problems where they begin, a bill in the Kentucky legislature "would require all children entering public school to have their teeth checked" by a dentist, reports Sarah Vos of the Lexington Herald- Leader. (Photo by H-L's David Perry shows Dr. Wendy Humphrey, left, dental clinic director at the Family Care Center in Lexington, listening as Alexus Wilkinson explains that her mouth was still numb after she got two crowns)

"Kentucky has some of the worst oral health in the nation," Vos writes. "The state ranks number two in the nation for toothlessness among adults, and number one in toothlessness among adults of working age. The teeth of Kentucky's children are not much healthier. Approximately 42 percent of kids ages 2 to 4 have active cavities. At any given point, some 4,500 3-year-olds, or 8 percent of the population, have a tooth ache, said Julie McKee, the state dental director."

The Kentucky Association of School Administrators "says the bill could have the unintended effect of preventing kids from going to school," Vos writes, but Mike Porter, executive director of the Kentucky Dental Association, told her, "Dental disease, dental pain is one of the number one reasons kids are missing school."

The dentists' group is backing the bill, but dentists are skeptical if not opposed to an alternative that would allow the exams to be conducted by dental technicians or hygenists. The sponsor of House Bill 186, Rep. Tom Burch, D-Louisville, is open to that idea. The bill will be heard soon in the House Health and Welfare Committee, which he chairs. (Read more) A similar bill is pending in West Virginia, which regularly vies with Kentucky to avoid the distinction of state with worst oral health.

Poor oral health in children isn't just from too much sugary food; education, income and environment play a role

CDC photo

While brushing your teeth is important to maintaining good oral health, dental-health experts say it's not the only thing responsible for poor oral health, especially when it comes to children in Appalachia, where sugar is usually blamed.

"It’s a common misconception that consuming sugary foods and beverages is the only cause of tooth decay. While that is undoubtedly a problem, there’s much more to good oral health," Daniel W. McNeil and Mary L Marazita write for The Conversation, a site for journalistic writing by academics. "It includes consistent brushing and flossing; eating healthy foods, like fresh fruits and vegetables; avoiding tobacco products; and wearing mouth guards while playing certain sports. Regular visits for dental care are also critical, as they provide an opportunity for cleanings and preventive care." 

McNeil and Marazita, who run the University of Pittsburgh's Center for Oral Health Research in Appalachia, say the region's poor oral health stems from a combination of factors beyond tooth brushing and other personal hygiene.

Poor oral health, they write, is more common among "people who have less formal education or lower incomes, marginalized ethnic and racial groups and those living in more rural areas, such as Appalachia," which has one of the highest rates of oral health problems in the nation. And among these groups, oral health issues tend to show up at younger ages. 

Other than education, behavioral and social influences, reasons for poor oral health can include genetic influences that dictate a preference for sweet foods, mouth bacteria that can lead to oral diseases, environmental factors such as air quality, access to healthy foods, the cost of dental care, access to transportation to and from the dentist, access to school-based programs, water quality and whether one lives in a community with fluoridated water, which can keep cavities from forming.

McNeil and Marazita note that cavities are the most common chronic disease in children, despite being preventable and that "more than 40% of children have tooth decay when they start kindergarten. . . . Dental problems in kids can lead to missed school, pain and embarrassment about visible decay, and missing or crooked teeth." 

They write that parental and caregiver role modeling can greatly influence children's oral health habits. Examples include drinking water instead of sugary beverages, eating a healthy diet, practicing good dental hygiene habits and expressing a positive attitude about going to the dentist. 

The article offers several other suggestions to improve oral health, saying one of the best things parents or caregivers can do is to take their child to the dentist.  

"The American Academy of Pediatric Dentistry and other professional health organizations recommend that children see an oral health care provider before age 1 or at the emergence of the first tooth," they write. "Access to dental treatment, especially preventive care, has been shown to improve oral health in families and their communities."

McNeil and Marazita also call for system-level changes that ensure routine dental care is affordable and accessible to everyone. They also call for integrating oral health practices into schools and educational programs, saying this will benefit all children regardless of their family's socioeconomic status.

Annual free clinic in southwest Va. highlights big gap in dental-care system for adults

A lack of affordable dental care has long been a problem in rural America, and while health-care reform addresses that shortage for children, it makes little mention of adult dental care. At the annual Remote Area Medical clinic in Wise, Va., most of the 2,347 people who showed up for free care wanted to see a dentist even though a wide range of other medical exames, tests and screenings were offered, Mary Otto reports for The Washington Post. "You still have this big huge hole for adults," dentist Terry Dickinson, who runs the state dental association and volunteers at the clinic, run by Knoxville-based RAM, told Otto.

Public and private dental insurance can be hard to find, even after the passage of health care reform, Otto writes. Some can afford to pay for dental care out of pocket, but for many, like those at the Wise clinic, that is not an option. "For the financially stretched, dental work can take a back seat to other needs, such as food, fuel and housing," Otto reports. (Post photo by Michael S. Williamson of crowd gathered outside gates before opening of clinic)

"It's rugged dentistry," North Carolina dentist Brittany Semones told Otto. "It's rewarding. We get a lot of hugs." Blacksburg, Va., dentist William Huff said, "I came here because people need help desperately. A lot of people are hopeless. Their teeth are beyond what we can restore." While pulling teeth is considered a last resort, it's the grim reality for many of the Wise clinic patients. "We cannot leave these people in pain." Huff told Otto. (Read more)

Farmers are less likely to have dental insurance

Farmers have always recognized the impact medical costs can have on their finances, but a new study by The Access Project found that dental care accounts for more than 25 percent of those medical costs.

Among farmers and ranchers, 42 percent had dental insurance, compared to the national average of 60 percent. "The researchers also found that when factoring in the estimated costs of dental premiums, having dental insurance did not result in a major reduction in average costs," writes Lynda Waddington for The Iowa Independent. "It did, however, make dental expenses more predictable, made it less likely that people delayed care and made it less likely that health care costs contributed to financial problems."

"A lot of attention has been paid to the high cost of prescription drugs," said Carol Pryor, the report's primary author and The Access Project's policy director. "We hope this report grabs the attention of the policymakers since it shows that average dental costs can consume an even greater part of the family’s budget." (Read more; read the report)