Finding New Ways to Meet Oral Health Needs in Rural Areas

by Candi Helseth

Teddy Tooth

Teddy Tooth, mascot for the Early Smiles oral health program, has become a familiar figure in Storm Lake, Iowa, where he visits local schools and marches in parades.

Nationwide dentist shortages are prompting rural providers to look for new ways to meet oral health needs. Residents with Maine-Dartmouth Family Medicine Residency (MDFMR) have added dental clinics to their patient care regimen. In Storm Lake, Iowa, school and home health nurses are giving oral exams and fluoride treatments to children as part of a broader-based program known as Early Smiles.

Poor oral health, particularly among low-income people, is gaining attention as a significant health care problem, according to the July 2008 Issue Brief, Community Efforts to Expand Dental Services for Low-Income People. According to the report, “Key barriers to dental services include low rates of dental insurance coverage, limited dental benefits available through public insurance programs, and a lack of dentists willing to serve low-income patients.”

The programs in Maine and Iowa rely on primary resources outside of dental offices to improve oral health care.

Dr. William Alto, a MDFMR faculty member and family medicine physician at the MDFMR Fairfield clinic, routinely did oral exams and tooth extractions while working overseas for 12 years. Frustrated by the lack of oral care he saw patients receiving in Maine, he initiated an oral health program at MDFMR in 2003. Dartmouth’s family medicine residents do oral exams, apply fluoride, lance abscesses, pull teeth and make referrals to dentists and oral surgeons when necessary.

“In the last six years, we’ve seen more than 2,300 patients for oral health needs,” Alto said. “Our residents have found cancers, lesions and other oral health problems that need medical care. We encourage our residents to do an oral exam with every medical exam.”

A $50,000 grant from Maine Health Access Foundation provided funding for an oral surgeon to train residents in primary dental care. Two dentists travel twice a month to Dartmouth’s clinics in Augusta and Fairfield to oversee residents at work and provide consultations.

Stacy Kepner

Stacy Kepner, a hygienist with the Early Smiles program, screens a young patient at a local child care center.

“Just last week at our dental clinic, we had eight patients scheduled one afternoon,” Alto said. “Three had simple tooth extractions that were done by different residents. One extraction that was more technically difficult they asked me to do. Four we had to refer to oral surgeons. Most of these patients don’t have a dentist.”

Dr. Alto said most patients are low-income and are either uninsured or on Medicare or Medicaid. With Maine’s dentist shortage even higher than the national average, many dentists don’t accept new patients or take patients that are unable to pay. So Dartmouth’s program is filling a critical gap. The Maine Dental Association supports the program and, working with the Maine Medical Association Board of Licensure, developed a written agreement outlining the standard of care for patients.

“Improving oral health also improves patients’ overall health,” Dr. Alto asserted. “There are associations between periodontal disease and diabetes, coronary artery disease and even premature birth.”

Making Oral Health Fun

Rural Iowans are having fun while they learn how to care for their teeth and prevent cavities. The Early Smiles program, begun in 2007, is aimed at children but has positively impacted parents and community members who have also begun practicing better oral care, according to Veronica McFadden, Early Smiles project director.

Teddy Tooth is a familiar figure at parades and events, handing out sage advice on tooth care. A tote bag that includes oral health games (fashioned after the popular board game Candy Land), educational puppet shows on nutrition and proper oral care, puzzles, books with bright visuals, catchy songs on the benefits of flossing and other tools with an oral health care theme are used by teachers, school nurses, Head Start instructors and day care providers to educate and inspire children to take good care of their teeth.

School nurses and home health nurses have also been trained to do oral exams and apply fluorides to prevent decay. A monthly newsletter, Teeth Tips for Parents, encourages healthy oral habits at home.

“We’ve had such positive responses from the community and the increased awareness has really helped our outreach,” McFadden said. “We worked with the university (Buena Vista University at Storm Lake) to create oral health puppet plays that university students wrote. They’re educational and funny, and the humor in them appeals to the adults too. The community likes them so much that I’ve gotten donations to expand the plays to other topics. We’ve even been asked to bring them to places like the Latino Festival. We’ll go wherever we can get our message out.”

Program materials are in English and Spanish; three of the counties have large Spanish-speaking populations. The first year, Early Smiles targeted day care centers and preschools, providing dental hygienists who went to those locations to do screenings, fluoride treatments and sealants. The second year, Head Start and public health nurses were brought onboard to do screenings and treatments in the elementary schools.

“When we began looking at this program, we were seeing a lot of early decay—even in preschools—and young children who had never gone to a dentist,” McFadden said. “There were no dentists in some areas and in others, dentists weren’t taking more patients. We knew we had to address the problem.”

Early Smiles focuses on infants through eight-year-olds in 12 rural counties. A HRSA Rural Outreach grant provided initial funding. Grant funding ends this year, and 30 community partners are working together to continue the program. Area community health centers are taking over administration of Early Smiles. McFadden praised the community partnerships, saying that their buy-in assures the program’s continuation and the local support will strengthen participation.

In its first three years, Early Smiles provided exams and preventive treatment for approximately 5,400 children and had nearly 130,000 “unduplicated encounters,” which McFadden said refers to the program’s educational outreaches.

Preventive care and education efforts are relatively low-cost compared to the cost of treating future dental problems, according to the Community Efforts study. These programs in Maine and Iowa are among others nationwide using community resources to fill dental care gaps in innovative ways.

For more information on Maine-Dartmouth Family Medicine Residency, visit their website: . For more information on organizations and projects dedicated to improving oral health in Maine, visit the Maine Oral Health Coalition website:

For more information on Early Smiles, contact: Veronica McFadden, Early Smiles Project Director 620 Michigan Street, Suite 5 Storm Lake, IA 50588 Phone: 712-213-9287 Fax: 712-732-1471 Email: Website:

Other Innovative Rural Dental Programs

  • Cavity Free at Three – This Colorado program provides education and training to health care providers from a variety of disciplines (including family doctors, pediatricians, nurses, physician assistants, public health practitioners, dentists, and dental hygienists) on how to incorporate oral health risk assessment, parent education and fluoride varnish applications into regular services for young children.
  • Dakota Smiles Mobile Dental Program – Since its inception, Delta Dental’s mobile dental program has provided more than $3.4 million of dental care to more than 8,000 children in 50 different South Dakota communities.

For more information on these and other dental initiatives and programs, see:

Research on Rural Oral Health

  • Crisis in Rural Dentistry April 2009 WWAMI Rural Health Research Center This report discusses the need for intensified recruitment efforts to increase dental access and improve oral health in rural areas. It proposes potential solutions that may increase the rural oral health care workforce.
  • Dental Health and Access to Care Among Rural Children: A National and State Portrait March 2008   South Carolina Rural Health Research Center   Although children’s dental health in the United States has improved over recent decades, a subset of children continues to suffer dental disease severe enough to constitute a public health problem. This Chartbook examines dental health status, use of preventive services, and dental insurance among rural and urban children. The Chartbook provides information specific to rural children, and in particular rural minority children, not available in similar detail from other sources. This information can be used at the state level for program planning and assessment.
    For additional reports and publications on rural dental health, see the RHIhub’s Oral Health in Rural Communities Topic Guide – Documents list.

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