Thinking About Health: States developing solutions to ‘dental deserts’ problems

Access to dental care is a serious and worsening health problem in rural America. But now many states are beginning to enact legislation that could ease the pain.

The federal government says 63 million Americans live in dental deserts — areas where few if any dentists practice — and that more than half of those who live in the deserts are in rural areas. Hundreds of counties throughout the United States have no dentist, meaning residents often have to drive long distances for dental care. (https://datawarehouse.hrsa.gov/topics/shortageAreas.aspx)

Nebraska is among the states with a severe shortage of dentists, at least in its rural areas. The state has designated more than half of its 93 counties as general dentistry shortage areas. In 2012, according to a study by the University of Nebraska Medical Center, 20 Nebraska counties did not have a single dentist. (https://www.unmc.edu/publichealth/chp/research/2013-access-to-oral-health-care-in-nebraska.pdf)

I first became aware of this “silent epidemic,” as former Surgeon General David Satcher called it, when I visited a pop-up medical clinic at the Wise County fairgrounds in rural Southwest Virginia 10 years ago. Thousands of people make a pilgrimage to Wise County during the last weekend of July every year for free medical and dental care, many of them driving from hundreds of miles away.

Stan Brock is the founder of Remote Areas Medical, the organization behind that event and many others like it across the country. He told me that regardless of the location, between 70 and 80 percent of those who come sign up first for dental care.

A primary reason behind the growing dental health care crisis in rural America is that, for financial reasons, most dentists set up their practices in prosperous and more heavily populated urban and suburban areas. Increasingly, new dentists leave school owing hundreds of thousands of dollars for their education. They can’t afford to practice in sparsely populated areas.

As the cost of becoming a dentist has increased, so has the cost of the care they provide. And because more than one of every three Americans has no dental insurance, going to the dentist has become unaffordable for many people.

Medicaid recipients in most states have dental coverage, but finding a dentist willing to treat them has become almost impossible in many places. Fewer than half of dentists treat Medicaid patients. In some areas fewer than 20 percent do, according to the American Dental Association website, ada.org.

Painful toothaches are a leading cause of missed school and work days, the ADA says. And decayed and missing teeth can also make finding a good-paying job more difficult.

Not only can untreated dental problems be painful, they can also lead to very serious, and in some cases, fatal conditions. Bacteria from abscesses can spread throughout the body and lead to heart disease and life-threatening infections. The same year I visited the Wise County clinic, the Washington Post and many other news organization reported the death of a 12-year-old Maryland boy who died when an infection that started in one of his teeth traveled to his brain.

To improve access to dental care, many states are turning to the use of midlevel dental practitioners called dental therapists. At least four states have laws authorizing the midlevels, and at least 11 more are considering legislation that would do so.

Similar to other midlevel professionals, like nurse practitioners and physician assistants, dental therapists have a limited scope of practice. Working as part of a dentist-led team, they provide education and preventive care as well as simple extractions and fillings. Patients requiring care beyond a dental therapist’s scope of practice are referred immediately to a dentist. In many states and countries, where they have been practicing for decades — since the 1920s in New Zealand — dental therapists can complete their schooling in two years, so the cost of their education is far less than that of a dentist.

Most dental therapists do not have to work in the same physical office as their supervisor. In the U.S. many of the dental therapists now practicing travel every week to schools and clinics in communities in dental deserts — more than 5,000 at last count — in both rural and urban areas.

While a broad coalition of patient and community groups advocate for dental therapists in state capitals from coast to coast, legislation to allow them to practice has been slowed in some places because of the influence of a single opponent, the American Dental Association. The ADA and affiliated state dental societies have lobbied against the bills, despite numerous studies in the U.S. and abroad that show dental therapists provide safe and effective care.

That opposition may wane in light of recent studies that show dental therapists can be a net positive to a dental practice’s bottom line. A study published by The Pew Charitable Trusts earlier this month found that a dental therapist can be a cost-efficient member of a rural dental clinic’s team. (http://www.pewtrusts.org/en/research-and-analysis/analysis/2018/03/12/dental-therapists-can-provide-cost-efficient-care-in-rural-areas)

The authors of the study said their findings “strongly suggest that other rural dental practices could benefit from adding dental therapists to their dental teams.”

Are you concerned about how individual states’ actions might affect the future of your dental care? Send me your questions, concerns and personal stories at Wendell@tarbell.com.

Wendell Potter is a former health insurance executive, author and founder of the journalism nonprofit Tarbell.org.