Closing the Oral Health Care Gap for Rural Populations

Rural populations face many barriers when it comes to accessing oral health care, including cost, transportation, distance, and availability of providers. Right now, 70 million people who live in the US, or one in five people, live in “dental deserts” — areas where no or very few dentists practice.

Marcia Brand, former strategic advisor for CareQuest Institute, knows the struggles that these populations face well, through her own personal and professional experience.

Growing up as a child of Appalachia in West Virginia, an area disproportionately impacted by oral health disparities, Brand has seen firsthand the obstacles in accessing care. She was struck by the desperation of people seeking this critical form of care in her volunteer work for the Mission of Mercy project in Virginia, which provides free dental care to those most in need in Appalachia.

“Mission of Mercy would be set up at county fairgrounds, and people would sleep in their cars to make sure they were in line first thing in the morning to get dental care because it’d been so long,” says Brand. “In the middle of the fairgrounds, you’d see a couple thousand patients, and we heard so many stories: people who have been in pain every day for six months; people who requested all of their teeth to be pulled so they never had to deal with the pain again.”

Barriers to Oral Health Care for Rural Populations

According to Brand and her experience, the main barrier for rural communities is the lack of oral health providers. A close second is the fact that many people in rural communities lack dental insurance and cannot pay for dental services out of pocket.

Further compounding these issues is that states with larger rural populations have historically not included comprehensive adult dental coverage in their state Medicaid programs, such as Alabama and Mississippi. There are also often many older people in rural communities, and Medicare only covers limited oral health services.

Rural veterans also face major barriers to oral health care. They are less likely to qualify for coverage and pay higher out-of-pocket costs for dental care compared with urban veterans. They are also more likely to rate their dental health as “poor” and to need dentures than their city-dwelling counterparts.

In some cases, the barriers that rural populations face are generational and the result of a lack of not just resources but also education.

“In a number of these communities, younger people see their grandparents and parents with poor oral health or losing teeth and just accept it as part of the aging process,” says Brand. “My grandparents didn’t have their teeth in their 20s, and even my mother didn’t have anterior teeth very early on in her life, and that was not unusual where she grew up.”

Finding Solutions to Expand Access

As Brand’s career progressed — from teaching dental hygiene to working in the US Senate — she dedicated herself to improving rural oral health. She served in various leadership roles at the Health Resources and Services Administration (HRSA), an agency within the US Department of Health and Human Services that works to improve access to health care services for people who are uninsured, isolated, or medically vulnerable. As director of HRSA’s Federal Office of Rural Health Policy, she was able to directly serve and represent the community she came from.

When she joined the DentaQuest Partnership for Oral Health Advancement, which later became part of CareQuest Institute, Brand was able to bring her perspective and experience working on rural oral health to the organization and help drive solutions through oral health philanthropy.

Brand worked with CareQuest Institute through its grantmaking efforts to support various organizations that focus on improving rural oral health, including the National Rural Health Association (NRHA).

The NRHA provides leadership on rural health issues through education, communication, and advocacy. NRHA has more than 18,000 members, over 40 state-based affiliates, and funding from CareQuest Institute that has made a major impact.

“The investment that CareQuest Institute made in NRHA let them stand up a significant oral health initiative that gave them the capacity to work across their membership and also with states,” says Brand. “NRHA is the strongest advocate we have when it comes to rural health, and the grant from CareQuest Institute was the biggest investment they had ever received for oral health.”

With Brand’s guidance, CareQuest Institute has also been one of the most significant supporters of the creation and exploration of new ways to get oral health services to people and connecting them to care — including supporting teledentistry, mobile dentistry, and dental therapy.

These new innovations have proved effective for rural populations. For example, teledentistry is more often used by individuals living in rural areas (13%) compared to those living in suburban (10%) or urban (6%) locations, and studies show that dental therapists can provide more cost-efficient care in rural areas.

CareQuest Institute has also supported the work of the National Interprofessional Initiative on Oral Health (NIIOH), whose sole purpose is to integrate oral health into primary care. Brand, who ran the organization at one point, stresses that because many rural populations don’t have access to dental care, it’s even more important that primary care providers assume some responsibility for oral health in those areas, and they can often do this with just a quick check.

“Doctors look in your ears, eyes, nose, and even in your mouth at your throat, but they aren’t trained to look at your teeth and gums, which would take an extra 30 seconds to identify problems and make a referral to a dentist,” says Brand.

Community health centers like Federally Qualified Health Centers (FQHCs) are a critical model in these areas because dental and primary providers are often colocated at these places, making medical-dental integration easier.

While there is certainly more work to do to increase access to dental care for rural populations, investments in work being done on the ground to close this gap and in innovative new solutions are moving the needle.

For Brand, she goes back to her days volunteering at Mission of Mercy to explain the progress she’s seen.

“What was really remarkable was that over the course of the years, the line for extractions got shorter, and the line for restorative care got longer. So, it was clear that we really began to effectively address some of the most acute needs within those populations.”