The regular preventive care of the teeth and gums is important in maintaining quality of life and overall
health, playing a role in controlling diseases such as diabetes and heart disease. Yet, rural communities often
lack adequate oral healthcare and subsequently miss out on the benefits of good oral health as well.
Several factors have been well documented as contributing to the oral health challenges of rural America:
Access to dental care – Many rural communities lack access to oral health providers
due to geographic isolation and workforce maldistribution.
Oral health literacy – A 2009
study found that health literacy is lower among rural populations. In terms of oral health, poor
health literacy can result in poor oral hygiene and difficulty in navigating the oral health system. In
addition, rural residents with low health literacy are more likely to consume sugar-sweetened beverages and
more prone to dental caries, according to a 2016
Fluoridation of water supplies – A higher proportion of homes in rural communities
are not served by community water systems and as a result cannot receive the preventive benefits of
optimally fluoridated water.
Tobacco use – Cigarette smoking is more prevalent in rural areas than in urban areas
(28.9% of adults in nonmetro areas vs. 17.2% of adults in large metro areas), as well as smokeless tobacco
use (7.5% of adults in nonmetro areas vs. 2.3% of adults in large metro areas), according to a 2021 SAMHSA report.
This guide highlights the resources that will support rural healthcare providers and others in promoting access
of oral health services to rural adults and children.
Frequently Asked Questions
What oral health disparities are present in rural America?
Oral health disparities in rural areas are due to factors such as workforce
shortages and dental health insurance coverage on top of the geographic and social factors that affect
the health outcomes of rural people broadly. Some of the specific oral health disparities in rural America are:
In 2019, 57.6% of adults age 18-64 living outside of a metropolitan statistical area (MSA) reported that
they had visited the dentist in the past year, compared to 66.7% of those living within an MSA, according
to Health, United States, 2020-2021.
According to a 2017
report from the South Carolina Rural Health Research Center, rural children were less likely (73% of
large rural, 75% of small rural) to receive preventive dental care than urban children (78%) in 2011-2012.
Rural children are also less likely to report having excellent or very good teeth.
A 2013 report shows rural counties have higher
percentages of people with partial edentulism, having had several teeth extracted, when compared to urban
(urban, 38.4%, high poverty rural 51.3%, other rural, 45%) and counties with high rates of full edentulism,
having all teeth missing, are also rural (urban, 4.3%, high poverty rural 10.5%, other rural, 8.2%).
Seniors in rural areas are less likely than their suburban or urban counterparts to have visited the dentist in
the past year and more likely to have all their teeth removed due to decay or gum disease, according to a 2018 report.
How has COVID-19 affected oral healthcare in rural communities?
During the early phase of COVID-19 pandemic, non-emergency dental care was largely curtailed across the country.
According to a 2020
report from the CDC, 76% of dental offices saw only emergency cases for the latter half of March 2020.
Although ADA guidance deferred to state and local government policies after mid-April 2020, there remained
concerns around COVID-19 transmission because dental care includes many “aerosol-generating procedures” that can
increase viral transmission, according to a 2020
report from the CDC.
A 2020 study found 38% of rural adults
reported delaying care due to COVID-19 as of June 2020, which is lower than the rate of urban adults but may be
a reflection about perceptions of the spread of the disease in relation to population density. These delays are
nevertheless significant because they add to the already existing barriers to oral health access in rural areas.
In some cases, the delay in care was avoided through the use of teledentistry. According to a 2022
report from the CareQuest Oral Health Institute, 5.9% of dental visits in the second half of 2020 were
done via teledentistry and 79% of those went on to have a follow up visit in 2021, most of which were conducted
in person. It also states that patients in rural areas (13%) were more likely to utilize telehealth services
than those in suburban (10%) or urban areas (6%). Although the use of teledentistry during the COVID-19
pandemic was limited, when utilized it maintained continuity of care and helped rural patients and their
dentists prioritize care.
As of 2022, there are no restrictions on oral healthcare other than the CDC’s standard vaccine and masking
recommendations, as well as specific
guidelines for medically-necessary procedures on patients who are, or are suspected to be, infected with
COVID-19. The extent and outcomes of delayed oral healthcare during the pandemic on rural populations have yet
to be examined fully.
For more information about the COVID-19 pandemic, see COVID-19.
What barriers do rural communities and populations face regarding oral healthcare?
In its 2004
report, the National Advisory Committee on Rural Health and Human Services identified several factors
that contribute to the problems of accessing dental care in rural America that still hold true today:
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
nonexistent, causing rural residents, particularly low-income residents, difficulty in traveling to a
Rate of poverty is higher in nonmetro areas – Rural populations living in poverty
often cannot afford dental healthcare or purchase dental health insurance.
Large older adult population – Rural America has a higher percentage of people age 65
and over, who are less likely to have dental coverage, as they generally are not employed, and Medicare does
not provide dental benefits.
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.
According to a 2021
report from the American Dental Association's Health Policy Institute, Medicaid only reimbursed
61.4% of the private insurance reimbursement rate on average for children and 53.3% for adults in 2020.
Acute provider shortages – Approximately 67% of the nation's Dental Health
Professional Shortage Areas are in rural America as of March 31, 2022. For the most current figures, see
HRSA's Designated Health Professional
Shortage Areas Statistics.
Lack of dental insurance – A 2010
study found that employers in rural areas are less likely to offer dental insurance than those in
more populated areas.
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:
What are some innovative solutions to address oral health in rural communities?
The lack of access to oral healthcare due to cost, insurance coverage, and other social determinants of health
in rural communities has spurred the creation of several innovative models to address this barrier. Oral
healthcare integration into primary care and mobile oral healthcare delivery are two prominent models that have
been deployed effectively in rural areas.
Oral Health Integration
Oral health integration refers to the integration of basic or preventive oral healthcare into primary care
settings in order to expand access to dental care for underserved populations. In the U.S. Department of Health
and Human Services' (HHS) Oral
Health Strategic Framework: 2014-2017, the integration of oral health and primary care was identified as
the number one goal in combating oral health disparities. Integration of services often includes co-location of
services. The model allows for improved communication and coordination between dental and primary care
Some integration models and resources:
Mobile Oral Health Programs
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 to provide preventive
care, x-rays, and other dental procedures. The Rural Oral Health Toolkit
identifies resources and best practices to help implement a rural Mobile Dental Services Model.
Rural providers have used existing healthcare technologies, practices, and methods to bring preventive oral
care to their communities, such as the use of school-based health centers, telemedicine, and community health
workers. Models for each are listed here, respectively:
See Models and Innovations: Oral health for additional model
programs providing oral health services in rural locations.
Do rural areas have sufficient dental health workforce?
Rural communities often suffer from a lack of oral health providers. According to the Health Resources and
Services Administration (HRSA), as of March 31, 2022, 4,633 of the nation's 6,927 Dental Health Professional
Shortage Areas (HPSAs) were located in rural or partially rural areas. For the most current figures, see HRSA's
Designated Health Professional Shortage
A 2015 report from the WWAMI
Rural Health Research Center breaks down the supply of dentists practicing in rural and urban areas in 2008.
There were 24.3 total practicing dentists for every 100,000 people in rural areas, whereas urban areas had 36.7
dentists per 100,000 people.
The shortage of dental professionals is frequently cited as a cause of the oral 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
The Rural Monitor article Washington
Program Trains Dental Super-Generalists to Serve Rural Communities describes a dental education program
that is addressing these factors by accepting students interested in rural practice and providing specialized
training to prepare them for rural practice.
Loan Repayment for Oral Health Careers
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 our topic guide on Scholarships, Loans, and Loan Repayment for Rural Health
What are dental therapists and how do they provide access to care for rural populations?
Dental therapy is the addition of midlevel providers to the dental healthcare system. Like physician assistants
in medicine, dental therapists are able to provide preventive and restorative care.
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.
Maine (2014), Vermont (2016), Arizona (2018), Michigan (2018), Washington (2019), Nevada (2019), Idaho (2019),
Montana (2019), Connecticut (2019) and New Mexico (2019) passed legislation authorizing dental therapists to
practice in their states, according to a 2021
PEW report. For further information on the above programs, see:
Dental therapists have been able to practice on tribal lands in Alaska since 2004, in one tribal nation in
Washington since 2016, and two tribes have been authorized under a state pilot project in Oregon since 2016.
Alaska has been a leader in using dental therapists — called Dental Health Aide Therapists (DHATs) in that
state — to meet the needs of Alaska Natives in very remote villages. 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. A 2018
study found that DHATs were linked to improved dental outcomes such as fewer extractions among children
and adults in Alaska Native communities in Alaska's Yukon-Kuskokwim Delta. Additional information about
Alaska's program is available from the Alaska Native Tribal Health
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.
Where can I find information about fluoridation of 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 2016 Journal of Public Health
Dentistry article, every $1 spent on fluoridation saves $38 in treatment costs in a community
with a population of 20,000+. However, it is proportionally more expensive to fluoridate small community water
supplies than large ones. For communities with fewer than 5,000 people, the ratio is $6 saved to every $1
spent. 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 and Prevention (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 local community water
supplies. 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.
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.