Population Considerations for Rural Oral Health Programs
It is important for rural programs providing oral health services to consider the unique characteristics of the
population being served. Specific populations may require different approaches or strategies for delivering oral
health services. Some rural oral health programs have conducted community health needs assessments to identify their
For more information about how social determinants of health (SDOH) impact populations with unique needs, see
the SDOH in Rural Communities Toolkit.
Rural America's population has a larger proportion of adults over the age of 65 than the nation as a whole.
Older adults are less likely to have insurance coverage that includes access to dental services, and traditional
Medicare does not cover routine dental care. As people age, their overall health tends to decline and their
level of physical functioning decreases. Chronic conditions like diabetes or heart disease can worsen oral
health and vice versa. Additionally, conditions associated with aging, like arthritis or cognitive impairment,
can make oral hygiene difficult. Despite improvements in recent decades, tooth decay remains the most prevalent
chronic disease among older adults and approximately 1 in 6 adults aged 65 or older
have no teeth.
Tooth decay is one of the most common chronic diseases among children. Approximately 20% of children aged 5-11
years and 13% of children aged 12-19 years have at least one untreated decayed tooth. A 2021 study, The Oral Health Status of America's Rural Children: An
Opportunity for Policy Change, found that rural children were less likely than urban children to have
received a fluoride treatment (46.6% versus 52.5%) and less likely to have received a dental sealant (19.5%
Tooth decay can have serious and negative impacts on a child's overall health and wellbeing, including problems
eating, speaking, and learning. Untreated tooth decay may make it harder for children to eat nutritious foods
and may cause children to miss more days of school and receive lower grades than children who have access to
Indian Health Survey found that twice as many American Indian and Alaska Native (AI/AN) adults have
untreated tooth decay compared to the general population. AI/AN adults are more likely to have severe gum
disease and missing teeth compared to the general population.
Despite significant declines in tooth decay among young AI/AN children, tooth decay remains the most common
health problem among AI/AN children ages five and younger. AI/AN children ages 0-5 years have the highest level
of tooth decay among all other population groups in the United States — almost four times higher than
white, non-Hispanic children. AI/AN children ages 6-9 also have higher rates of untreated tooth decay compared
to children of other racial/ethnic populations.
Pregnant people are susceptible to a range of oral health conditions including cavities, gum disease, and
gingivitis. Changing hormone levels during pregnancy can directly impact gum health in pregnant people. It is
important that pregnant people receive adequate nutrition, healthcare, and dental exams and cleanings during
pregnancy to avoid oral diseases.
For more information about maternal health, see RHIhub's Rural Maternal
People with Developmental Disabilities
Developmental disabilities typically develop during childhood and last throughout a person's lifetime.
Developmental disabilities impact all racial and ethnic groups and people at all income levels. Common
disabilities include: autism spectrum disorder, attention deficit hyperactivity disorders, blindness or vision
impairment, hearing loss, cerebral palsy, and intellectual disabilities.
People with developmental
disabilities experience more dental disease than those without disabilities. They also face barriers
accessing appropriate care. They may need additional accommodations to attend appointments or face challenges
related to daily oral hygiene. People with intellectual and developmental disabilities may depend on a
caregiver's help to access appointments, assist with oral hygiene, and manage their care coordination. Providers
should be aware of any additional accommodations that may be needed so they can create an accessible environment
for all patients.
People with Substance Use Disorders
Alcohol, methamphetamine, and opioid use disorders are more prevalent in rural locations compared to urban
areas. Oral health problems vary by substance used. Methamphetamines and opioids can cause dry mouth and a
reduction in saliva production, in turn causing gum disease and tooth decay. The use of methamphetamines can
induce tooth grinding and clenching, causing damage to teeth and facial pain. Drug use can also lead to poor
oral hygiene and poor nutritional habits, which contribute to additional oral health problems. Long-term use of
alcohol predisposes individuals to gum disease and oropharyngeal cancers.
For in-depth information on rural substance use disorders as well as the treatment of opioid use disorder, see
the Prevention & Treatment of Substance Use Disorders in Rural
Communities Toolkit and the Rural Medication for Opioid Use Disorder
People Who Use Tobacco
Nationwide, rural residence is associated with higher rates of smoking and other tobacco use. Cigarettes and
other forms of tobacco can cause gum disease, oral cancer, and other oral health problems. Among adults aged
20-64 who smoke cigarettes, more than
40% have untreated tooth decay. Among adults aged 65 and older who smoke cigarettes, about 43% have lost
all of their teeth.
Dental professionals may consider using culturally sensitive cessation strategies, including motivational interviewing in their clinic
to assist patients with quitting tobacco use.
For more information about tobacco use in rural communities, see the Rural Tobacco
Control and Prevention Toolkit.
People with Lower Incomes
In the United States, about 40% of
adults with lower incomes or without health insurance have untreated tooth decay. Adults with lower
incomes or who are uninsured are one to four times more likely to have untreated tooth decay than those with
higher incomes or private insurance. Children from households with lower incomes are about twice as likely to
have untreated cavities in both their primary and permanent teeth and are less likely to receive dental sealants
than are children from households with higher incomes.
People with lower incomes face challenges related to accessing oral healthcare. Individuals may need to take
time off from work or school to visit the dentist, may have difficulty finding transportation to dental care,
and may not have the resources like time and money for a dental visit. Rural employers are less likely to offer
dental insurance to employees. Even when patients are eligible for Medicaid, it can be difficult to find
providers who accept Medicaid.
People from Some Racial and Ethnic Minority Groups
Approximately twice as many African American adults and Hispanic/Latino adults have untreated tooth decay
compared to White adults. Among young children (aged 2 to 5 years), 33% of Hispanic or Latino children and 28%
of African American children have had cavities in their primary teeth, compared with 18% of White children.
Among adolescents aged 12 to 19 years, approximately 70% of Hispanic or Latino children have had cavities in
their permanent teeth, compared with 54% of White children.
For additional information related to considerations for people from racial and ethnic minority groups, see the
Implementation Considerations for Social
Determinants of Health (SDOH) Programs Serving Racial and Ethnic Minority Populations and Tribal
Communities in the SDOH Toolkit.
Resources to Learn More
Best Practice Approaches
A collection of evidence-based public health strategies for state, territorial, and community dental programs
supporting program planning, development, implementation, and evaluation. Relevant topics include oral
healthcare for people with special needs, perinatal oral health, and oral health for older adults.
Organization(s): Association of State and Territorial Dental Directors (ASTDD)
Access to Dental Care in Medicaid: Targeted Programs for Four Populations
Describes several strategies used by states to address the oral health needs of children, pregnant women, people
with developmental disabilities, and people living in rural areas.
Author(s): Snyder, A.
Organization(s): National Academy for State Health Policy (NASHP)
Use and Cessation
Collection of well-documented information and data about the impact of tobacco and nicotine on oral health and
proven methods of treating tobacco dependence.
Organization(s): American Dental Association (ADA)
Tribal Oral Health Initiative
Offers resources and publications relative to the Tribal Oral Health Initiative with a focus on dental therapy.
Provides several reports with data derived from the analysis of Indian Health Service (IHS) Oral Health Surveys.
Organization(s): National Indian Health Board (NIHB)