Structural Cavities in Rural Dental Health

[imgbelt img=US-teeth-map207.jpg] On the whole, the nation’s oral health has improved dramatically, but a shortage of dentists, lack of fluoridation, and poverty have put rural citizens at a dental disadvantage.


[imgcontainer left] [img:sealedteeth240.jpg] [source]Ohio Department of Health

Many cavities can be prevented with dental sealants (shown on tooth, far left). A few states already offer sealant programs in schools.

In 2000, the federal government issued the first-ever Surgeon General’s report on Oral Health, emphasizing disparities across the nation. It warned that dental disease in the U.S. constituted a “silent epidemic” with profound consequences for “affected populations.”

In rural America, the “silent” epidemic is in fact strident. In February of this year, The Pew Center for the States issued new evidence that poor dental health is especially severe among rural children and adults. The Pew Center’s Dental Health Campaign reports:

•    Total tooth loss among seniors increases as the population becomes more rural.
•    Rural residents are more likely to have lost all of their teeth as compared to their non-rural counterparts.
•    Rural adults are significantly more likely than non-rural adults to have untreated dental decay (32.6 percent compared to 25.7 percent).
•    In 2001, 67.1 percent of urban residents had visited the dentist in the past year as compared to 58.3 percent in rural areas.
•    The likelihood that a child will be insured for dental work declines steadily as the county of residence becomes more rural

Tennessee Today

A Remote Area Volunteer Medical Corps dentist treats a patient in Plaquemines Parish, Louisiana, 2012.

The outpouring of patients availing themselves of the Remote Area Medical Volunteer Corps (RAM) , which provides free medical and dental care, offers an unvarnished view of the dental needs in rural America. In October 2011, RAM visited Grundy, Virginia in rural southwest Virginia.  By 5 AM, hundreds stood in the freezing rain to see a dentist.  By the end of the weekend 900 teeth had been pulled.  In 2012, 17 such clinics are already planned by RAM, with similar numbers expected.

Why the discrepancies between rural and the rest of the nation?  The national media has tended to focus on emotional and superficial commentary related to soft drink consumption, and to an extent the images they project and the stories they tell are embedded in tragic fact.  But the whole nation is hooked on syrupy, caffeine-laced empty calories.  Although not always as visible, there are structural issues at work that explain a lot.

Access to Dental Care

There is a severe shortage of dentists in many rural areas.  The U.S. Department of Health and Human Services reports that at the end of 2011 there were 4,670 dental Health Professional Shortage Areas in the U.S.  Sixty-five percent of those were in non-metropolitan areas. Without strong incentives to bring dentists to rural communities, this situation may only get worse.  Nationally, rural areas had a higher percentage of general dentists age 56 or older than did urban areas (42% vs. 38%). In remote locations, 44%of dentists are age 56 or older.


4th year students hygienists from Southern Illinois University/Carbondale apply dental sealants on a patient. New programs that would permit non-dentists to practice some oral health care show promise for rural areas but have generally been opposed by the ADA.
One of the most innovative developments — and most controversial from the viewpoint of the American Dental Association — has been the creation of a new position: Dental Health Aide Therapist. The dental therapist is trained to provide basic restorative and preventive services, including fillings and extractions.  Advocates say that dental therapists will help people who can’t afford what dentists charge or who live in remote areas where no dentists have offices. The ADA argues that only dentists are qualified to extract or prepare teeth.  It should be noted that the Dental Health Aide Therapist position is modeled after a program begun in New Zealand in 1921 and now operates in over 50 countries.

The first experiment with using a dental therapists program in the United States was launched in Alaska in 2003 under the authority of the Alaska Native Tribal Health Consortium, a nonprofit health organization owned and managed by Alaska Native tribal governments and their regional health organizations.  The ADA unanimously passed a resolution supporting litigation, should it become necessary, to oppose dental therapists practicing in the Tribal health care system in Alaska. The  dentistry board also authorized an advertising campaign up to a $150,000 level “to educate Alaskan natives and others about the risks of allowing non-dentists to perform irreversible procedures.” In June 2007, a Superior Court judge for the State of Alaska ruled that Dental Health Aide Therapists have the right to provide dental treatment to Alaska Natives, including preventive and restorative care. The ADA dropped its lawsuit but continues to oppose the use of Dental Health Aides in restorative care.

Currently there are programs utilizing dental therapists only in Alaska and Minnesota. Oregon passed a bill last year that allows for a pilot program, and while planning is underway, the program has not yet begun. There is legislation to create dental therapist programs pending in Washington, Vermont, Kansas, New Hampshire, Maine, and California.

[imgcontainer left] [img:US-teeth-map207.jpg] [source]Daily Yonder

Thirty years ago, 40% of Americans over age 65 had none of their own teeth. Today, it’s 25%.
On average, Americans have seen significant improvements in oral health over the last 50 years but averages include all conditions along a continuum.  If we look at the continuum closely, we can begin to recognize gaps in health and well-being: low-income and rural citizens have less health insurance, are less likely to have flouridated water, receive less dental health care and experience more dental decay and tooth loss.

Dental costs amount to a small percentage of medical costs overall, but failure to deal with them can lead to serious — and very expensive — problems. It’s evident by now that private dental practice is not always financially viable in rural areas. This means that the dental health of rural Americans will have to be addressed by government or philanthropic forces. Even as extending medical care to the uninsured remains a contentious issue, is the nation ready to listen up and heal the “silent epidemic”?