Oral Health in Rural Communities
Adequate access to oral healthcare is a persistent rural health issue. Several factors have been well documented to contribute to the problems of accessing dental care in rural America. The National Advisory Committee on Rural Health and Human Services (2004) identified several factors that contribute to the problems of accessing dental care in rural America:
- Geographic isolation – There are fewer dental health professionals in rural areas resulting in people having to travel farther to obtain oral healthcare.
- Lack of adequate transportation – Public transportation systems are often non-existent, causing rural residents, particularly low-income residents, difficulty in traveling to a dentist.
- Rate of poverty is higher in nonmetro areas – Rural populations living in poverty most often do not have the ability to afford dental healthcare or purchase dental health insurance.
- Large elderly population – Rural America has a higher percentage of elderly population, which is less likely to have dental coverage, as they generally are not employed, and Medicare does not provide dental benefits.
- Acute provider shortages – A large majority of the nation's Dental Health Professional Shortage Areas are in rural America.
- Difficulty finding providers willing to treat Medicaid patients – Low reimbursement rates cause many dentists to not accept Medicaid or Children's Health Insurance Program (CHIP) patients.
- Lack of fluoridated community water supply – Rural communities often find fluoridated water systems to be cost prohibitive.
HRSA's Oral Health Initiative 2010 and the Southwest Rural Health Research Center's Rural Healthy People 2020 identify many of the same factors as significant barriers to accessing oral healthcare in rural America. In addition, a 2010 study published in the Journal of the American Dental Association found that employers in rural areas are less likely to offer dental insurance than those in more populated areas.
This guide highlights the resources that will support rural healthcare providers and others in promoting access of dental health services to rural adults and children.
Frequently Asked Questions
- What oral health disparities are present in rural America?
- What barriers do rural communities and populations face regarding oral healthcare?
- How do I start a dental health service in my local community?
- How have mobile oral health programs been used to increase access to dental care in rural communities?
- What emerging and alternative dental provider types have been used to provide dental care to rural populations?
- Are there any loan repayment programs for dental clinicians?
- Where can I find information about fluoridation in rural community water supplies?
- Who can I contact for information about oral health programs in my area?
What oral health disparities are present in rural America?
According to NRHA's 2013 policy paper, Rural America's Oral Health Care Needs, WWAMI's The Crisis in Rural Dentistry, and several other studies, rural residents have lower rates of dental care utilization and have higher rates of tooth decay and permanent tooth loss. For example:
- Rural children are less likely than urban children to have received any dental care in the previous year (23.4% versus 22.3%). (SCRHRC, 2012)
- Rural children were less likely to receive preventive dental care than urban children (29.3% versus 27.5%). (SCRHRC, 2012)
- Rural counties have higher percentages of people with partial edentulism when compared to urban (Urban, 38.4%, High Poverty Rural 51.3%, Other Rural, 45%).
- Counties with high rates of full edentulism are also rural (Urban, 4.3%, High-Poverty Rural 10.5%, Other Rural, 8.2%). (Mitchell, et al.)
According to the Pew Center's Dental Health Campaign, as reported in The Daily
Rural adults are significantly more likely than non-rural adults to have untreated dental decay (32.6 percent compared to 25.7 percent).
- Smoking is more prevalent in rural areas than in urban areas (22.0% in urban and up to 24.9% in small rural nonadjacent areas) and can cause significant oral health problems (Doescher, et al.)
Access to dental care is frequently cited as a cause of the dental health disparities that exist in rural
communities. Contributing factors to the shortage include:
- Limited slots in dental schools
- An unwillingness of providers to work in rural areas
- A large number of dentists retiring
- The growing trend of specialization in dental care
In addition, there are a number of unique challenges that limit access to dental services for many rural residents, including geographic and transportation barriers and a lower rate of dental insurance.
What barriers do rural communities and populations face regarding oral healthcare?
According to Pennsylvania Office of Rural Health Director Lisa Davis, as quoted in Dental Care in Rural Communities,
“People living in rural areas face a multitude of structural barriers when seeking dental care. These barriers, which include dentist availability, ability to pay, and transportation issues, contribute to minimal expectations for receiving dental care and cause people to undervalue dental care.”
The most common barriers that discourage rural residents to obtain dental care including:
- Provider availability
- Cost of dental care
- Lack of dental insurance
- Fewer dentists accept Medicaid
- Longer travel distances to dental care facilities
- Lack of transportation to obtain dental care
- Minimal awareness about the importance of oral health
The HRSA Data Warehouse interactive map of Dental Health Professional Shortage Areas (HPSA) identifies the total number and geographic location of dental HPSAs by state and county.
How do I start a dental health service in my local community?
Several resources are available that provide information on how to develop a rural dental health service:
- RHIhub's Funding & Opportunities by Topic: Oral Health includes both national and state funding programs that support projects that develop, enhance, and/or sustain dental health services in rural communities.
- RHIhub's Rural Oral Health Toolkit is designed to help a rural community implement an oral health program or service.
- Safety Net Dental Clinic Manual – Discusses aspects such as start-up costs, picking a location, construction, rules and regulations, mobile dental unit, and required staffing
- Expanding the Dental Team: Increasing Access to Care in Public Settings – Provides examples of midlevel dental therapists working to provide dental care to underserved populations
- Returning the Mouth to the Body: Integrating Oral Health & Primary Care – Describes how coordinating oral health and primary care services can address dental health disparities affecting vulnerable populations, including those in rural and underserved areas
- Organized Evidence-Based Care: Oral Health Integration – Provides resources and tools to support and prepare for the integration of oral healthcare services into a primary care setting
How have mobile oral health programs been used to increase access to dental care in rural communities?
Many successful mobile oral health programs have been developed and widely used in rural America. Mobile dental vans and other portable dental clinics have traveled to various rural population centers including schools to provide preventive care, x-rays, and other dental procedures. The Rural Health Information Hub Rural Oral Health Toolkit identifies the resources and best practices to help implement a rural Mobile Dental Services Model.
Across the nation there are examples of mobile oral health programs providing services to rural communities:
- Dakota Smiles Mobile Dental Program is a mobile dental program developed by Delta Dental of South Dakota that expands access to oral healthcare services to children in rural and urban areas of South Dakota.
- Miles of Smiles, Inc. provides a mobile dental unit to expand access to dental care for children in an 11 county region of southwest Missouri.
- Remote Area Medical® is an organization that offers free mobile health clinics to rural and underserved areas providing primary, dental and vision care.
- Tooth Tour is a mobile dental unit providing oral health education and preventive dental services to children in rural counties within west central Nebraska.
See Rural Project Examples: Oral health for additional model programs providing oral health services in rural locations.
What emerging and alternative dental provider types have been used to provide dental care to rural populations?
Alaska has been a leader in using alternative provider types to meet the needs of Alaska Natives in very remote villages. One alternative provider type is the Dental Health Aide Therapist (DHAT). DHATs are trained in Alaska in a two-year, post-high school competency-based primary care curriculum that incorporates preventive and clinical strategies. DHATs have been providing preventive and basic dental care to Alaska Natives since 2005. Program evaluations have shown that DHATs are technically competent and successfully treating patients under the general supervision of dentists. Additional information about Alaska's program is available from the Alaska Native Tribal Health Consortium.
The Swinomish Indian Tribal Community, a federally recognized Indian tribe in Washington State, has expanded their dental team to include a Dental Health Aide Therapist. Outside of Alaska, this is the first tribal community to train a student to become a Dental Health Aide Therapist.
In 2016, the Oregon Tribes Dental Health Aide Therapist Pilot Project was developed with the purpose of creating a new category of dental care providers and to provide dental therapy training to tribal members.
In 2009, Minnesota authorized dental therapists to practice in all of the states' underserved areas. Minnesota has three types of dental therapist programs: Oral Health Care Practitioner (OHCP) Master's degree program; Bachelor's and Master's level Dental Therapy degree; and Master's degree in Advanced Dental Therapy (currently under development.)
Maine (2014) and Vermont (2016) passed legislation authorizing dental therapists to practice in their state.
For further information on the above programs see:
- Dental Therapists: A Promising Practice for Frontier Communities
- CDC's Oral Health: Success Stories Workbook
- Working With Midlevel Providers: Dentists' Perspectives.
Are there any loan repayment programs for dental clinicians?
General practice dentists and registered clinical dental hygienists may qualify for the National Health Service Corps Loan Repayment Program. This is a federal program that is open to licensed dental health providers who are employed or have accepted employment at a National Health Service Corps approved site.
The Indian Health Service also has a loan repayment program for those who qualify.
For more information about loan repayment programs, see RHIhub's topic guide on Scholarships, Loans, and Loan Repayment for Rural Health Professions.
Where can I find information about fluoridation in rural community water supplies?
Community water fluoridation is consistently found to be one of the most effective means of preventing tooth decay. According to a 2001 article published in the Journal of Public Health Dentistry, every $1 spent on fluoridation saves $38 in treatment costs. However, it is proportionally much more expensive to fluoridate small community water supplies than large ones. This paper report that it is six times more costly per person to fluoridate water supplies with less than 5,000 people than those with greater than 20,000. In addition, most of the 12.6 percent of U.S. residents using private wells are located in rural areas. These wells are typically unfluoridated.
The Centers for Disease Control (CDC) Community Water Fluoridation website has information about water fluoridation, including maps, safety guidelines, and state statistics. The CDC's My Water's Fluoride website provides information on the fluoridation status of your community water supply. Also, Water Fluoridation and Dental Health Indicators in Rural and Urban Areas of the United States reports on the availability of fluoridated water in both rural and urban settings and compares fluoride availability to the dental health of adults and children.
Who can I contact for information about oral health programs in my area?
The Association of State and Territorial Dental Directors (ASTDD) maintains a directory of state oral health programs with contact information and a description of their programs.
Last Reviewed: 2/15/2017