In a May 2000 report, U.S. Surgeon General Dr. David Satcher described the "silent epidemic" that was causing “needless pain and suffering, complications that devastate overall health and well-being, and financial and social costs that diminish the quality of life and burden American society.”1
The report was titled, “Oral Health in America: A Report of the U.S. Surgeon General."
Compared to 50 years ago, most middle-aged and younger Americans expect to retain all their teeth throughout the entirety of their life and expect any oral health problems to be relatively minor.
However, not all Americans have the same access to oral health care. Poor children, the elderly and members of certain racial and ethnic minority groups are most vulnerable to this lack of oral health care access.
74 million Americans had no dental coverage in 2016, a rate that is nearly four times the rate of Americans with no healthcare coverage.2 Rural communities and communities with high populations of people who identify as American Indian or Alaskan Native have felt firsthand the oral health challenges that living in a dental desert brings. Today about 43 percent of rural Americans lack access to dental care. Minor oral health problems quickly become major, and they bring constant challenges to a person's daily life.
Oral health is integral to general health. Routine dental care is the most important way to ensure oral health.
When people lack oral health care access, they often do not address their dental needs until the pain is unbearable and they go to the emergency room. However, emergency room doctors generally treat the symptoms, and pain medicine and antibiotics leave the dental cause unaddressed and likely to flare up again.3
By failing to provide all citizens reliable oral health care, we are allowing our most vulnerable citizens to suffer from entirely preventable health problems.
A dental desert is a Health Professional Shortage Area (HPSA) for oral health care. It is the prevalence of these areas, not an overall shortage of dentists, that cause limited access to care.4
HPSAs are made up of three kinds of designations: geographic area, population, or facility.
Dental HPSAs are scored on a scale of 0-26, with 26 indicating the greatest shortage and 0 indicates very low shortage, although scores of 0 are rare. The criteria for scoring are: the population-to-provider ratio, the percent of population below the Federal poverty level, the travel time/distance to the nearest dental provider, and local water fluoridation.
The dental shortage score?, as represented at the county level, was calculated through normalizing the number of dental Health Professional Shortage Areas (HPSAs) within each county and their scores by the population of that county.
Counties with higher dental shortage scores have the greatest number of HPSAs per 100,000 people and the worst (and highest) HPSA scores. Thus, their residents live within the worst dental deserts and have the worst access to dental health care. Counties with lower dental shortage scores have fewer HPSAs per 100,000 people and better (and lower) HPSA scores. Dental deserts in these counties are less severe and their residents have better access to dental health care.
A typical student leaves dental school more than $250,000 in debt, and that number is going up. As these new dentists decide where to open up a practice, finding a way to pay off that debt is important from the start.
For that reason, more dentists are choosing to locate in prosperous urban and suburban communities, instead of rural areas and poorer neighborhoods in urban communities with high Medicaid rates.
Medicaid provides dentists with low return rates, so two-thirds of dentists won't accept it. Those that do are most often clinic-style providers, which allows them to "cost shift and spread their financial risk across many patients."5 Most new dentists locate in places where they can make a profit, and that has created a huge maldistribution of dentists that continues to get worse.6
The state of West Virginia, among the poorest and most rural in the country, is feeling this maldistribution especially hard. In 2014 and 2015, nearly half of West Virginian counties had less than six practicing dentists, only half of adult West Virginians had visited a dentist in the previous year, and more than one-fifth hadn’t visited a dentist in five years.7
In the nearly 20 years since Dr. Satcher's report was released, the U.S. government has developed no new national policies to address oral health care. But some states and organizations are attempting to take the lead.
In Alaska, where many tribal communities are extremely remote, tooth decay is widespread. More than 4 out of 5 Alaska Native third graders experience tooth decay, compared to less than half of white third graders.8
In 2002, in an effort to increase dental access for even the most remote communities, a consortium of Alaska Native tribes began sending groups to students to New Zealand to train them as dental therapists.
Although they must work under the supervision of a licensed dentist, dental therapists, or Dental Health Aide Therapists are able to provide patient and community-based preventative dental services, as well as basic restorations and simple extractions.9 Dental therapists can provide the routine dental care that residents in dental deserts so desperately need.
Alaska pioneered access to dental care for its Native communities when it became the first U.S. state to allow dental therapists and develop its own training program.
The Alaska Dental Therapy Educational Program began in 2013, training students from Pacific Northwest tribes to become dental therapists for their own rural communities. It is now a model of success for improving rural access to oral health care around the world.
Since dental therapists began working in Alaska, more than 40,000 Alaska Natives in 81 previous unserved or underserved rural communities have regular access to dental care.2
Washington, Oregon, Arizona, and New Mexico now have their own dental therapist programs, while dental therapists are also authorized in Maine, Minnesota, Michigan, and Vermont.10
Rural communities in states like Mississippi and Alaska are utilizing telemedicine to share patient records and consult on treatment plans. This extends the reach and care of dental therapists and helps bring dental providers directly to rural community settings, even if the dentist does not physically travel to the community.
Some rural health clinics or healthcare campuses offer dental services, and many are run as non-profit organizations. Mobile and pop-up dental clinics are also appearing around the country, where dentists volunteer to provide free dental care. These clinics often have limited resources, but they do allow residents who live in nearby communities to access dental care they wouldn't have otherwise.
There are some federal programs, like the Health Service Corps, which offers up to $50,000 in loan assistance to dentists who commit to working two years in a designated HPSA.8 Most of the dentists who participate in this program only remain in the HPSA for the length of the program and relocate soon afterwards.
Even when Americans in rural communities with a dental care provider, many cannot afford to pay for care, forcing them to forgo dental care in favor of health care, housing, and other expenses.
For dental care to be truly accessible across all pockets of the country, preventative care must be affordable for all Americans, and there must be incentives for dentists to treat every patient, including those who have Medicaid or similar coverage.
That kind of change must come from deep within America's healthcare system, through federal policies that give all Americans, regardless of income level, race, ethnicity, or location, the opportunity to live a long and healthy life.
Photo from icethim on Flickr
"help" icon by Travis Avery from The Noun Project
The dental shortage score was calculated by multiplying each county's average dental HPSA score by the number of dental HPSAs per 100,000 people.
Note: Scoring by counties highlights the disparities for rural populations. The HPSA data can also be applied on a census tract level to show dental deserts at a neighborhood level within a single city.