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National Rural Health Association Calls for Solution to the Crisis in Oral Health Care Services in Rural America

The National Rural Health Association calls upon policymakers and the rural health community to address the growing crisis in access to oral health care services in rural America.

Oral health is becoming recognized as a critical unmet need, particularly in rural America.

  • Eleven percent of rural residents have never seen a dentist.
  • Even after controlling for population density and income, non-metropolitan counties have lower dentist to population ratios.
    • 61-62 dentists per 100,000 population in large metro areas
    • 29 dentists per 100,000 population in the most rural counties

  • Rural persons are more likely to have lost all their teeth than their non-rural counterparts; in fact non-elderly adults (i.e., 18-64 years of age) are nearly twice as likely to be edentulous if they are rural residents.
  • Rural adults are significantly more likely than non-rural adults to have untreated dental decay (32.6% v. 25.7%)

The barriers to improving oral health in rural areas include the shortage of dentists practicing in rural areas; uninsured or underinsured low-income households with gaps in coverage from government-sponsored health insurance; the lack of coordinated school-based or community oral health education pro-grams; and geographic barriers encountered by residence in remote, isolated areas. The factors which prevent rural Americans from getting the oral health care that is necessary for good overall health fall into two main categories: factors that limit the number of professionals currently available to provide care, or "provider issues"; and factors which impede people from getting care, or "consumer issues."

A severe lack of dentists limits access to oral health care services for rural Americans. Rural areas are proportionately older, sicker and have lower-incomes than urban/suburban populations. Rural areas are simply not able to compete with the salaries that are available in urban or suburban settings.

Because rural people have lower incomes on average, more of them are dependent on Medicaid or the Children's Health Insurance Program for insurance coverage. Dentists overall often do not take Medicaid or CHIP patients, which creates a barrier to access for people dependent on these government assistance programs.

Policy Recommendations

  • Reimbursement rates for dentists in Medicaid and state SCHIP programs should be raised to more approximate private health insurance rates. This should be accompanied by more simplified provider contracts which reduce dentists' administrative burdens and promote ease in enrollment. States can promote a more streamlined reimbursement process for rural practitioners through use of dental billing codes and claim forms developed by the American Dental Association (ADA).

  • Efforts should also be undertaken for all states to designate eligible dental HPSAs, and identify stable communities that can support dental services and are in the greatest need.

  • In collaboration with Professional dental organizations, dental health institutions, and oral health advocates including the NRHA, states should pass standardized state oral health legislation including reciprocity credential standardization. Reciprocity in dental licensure is a state-sanctioned process that enables professional mobility and the interstate transfer of occupational rights. Several states have been active in promoting and adopting such legislation as an incentive to dentists wishing to relocate or expand service areas.

  • States should also pass legislation to encourage contracting with private providers to oversee Medicaid-funded dental services. This results in a seamless system minimizing the extensive paperwork normally associated with government-sponsored insurance.

  • Due to the shortage of dentists in rural areas, increased provisions are needed for both school/community-based and primary care dental programs with an emphasis on prevention. States should consider increased implementation of dental sealants in Medicaid, SCHIP, and locally sponsored oral health care programs. Dental sealants are an underused but effective means of protecting the teeth of young children. These plastic coatings are applied to the grooves in the chewing surfaces of teeth to discourage the formation of decay-causing plaque. Sealant application is a non-invasive procedure that, in addition to dentists, can be administered by trained dental hygienists. Dental sealant and varnish usage has been shown to be effective in communities with and without fluoridated water.

  • States should increase designation of Registered Dental Hygienist in Alternative Practice (RDHAP) or general supervision status for qualified dental hygienists providing preventive care, prophylaxis, and education in HPSA designated areas. These designations permit more independent practice in other settings like hospitals, public health facilities, schools, and nursing homes. Skilled hygienists may also encourage flexible practice hours during evenings and weekends to treat working people who may skip dental care rather than miss time from work. This flexibility can afford continuity of care when a dentist is ill or unavailable.


  • Efforts must be made to attract more dentists to rural areas through financial incentives such as student loan forgiveness, equipment purchasing grants and loans, assistance in establishing clinic facilities, and programs providing specialized training.

  • In addressing shortage area needs, support of ongoing funding for the National Health Service Corps is essential to the placement of dentists in these areas, as well as support for provisions advocated by NRHA to give NHSC clinicians flexibility to serve part-time, which could make the program more attractive to dentists considering serving underserved areas. Reauthorization of the NHSC is essential to the continued vitality of the program.

  • Increase funding for and reauthorize the Rural Health Outreach and Network Development Grant Program, which encourages partnerships among health care providers and other community service organizations, as well as the Community Access Program, which supports integration of health care services in a community.

  • Maintain funding for programs in the Bureau of Health Professions in the Health Resources and Services Administration. Dentistry programs within the Bureau of Health Professions encourage dental students to serve in underserved areas and facilitate training and collaboration among providers serving underserved areas.

  • The federal government as well as the states should encourage public oral health education, including education about the benefits of water fluoridation.

  • The federal government as well as the states should encourage the use of culturally sensitive educational materials.

National Rural Health Association
December 9, 2002