Dental access in Alabama is shrinking, what you need to know

BIRMINGHAM, Ala. (WBRC) - Alabama dentists say the state is on the verge of a workforce crisis.

According to CDC data, nearly half of Alabama counties have less than 10 dentists, some have none. Those taking the hardest hit are patients in rural communities who drive hours for dental care.

It’s a situation that will get worse without swift action and innovation. We explain the problem and possible solutions in this installment of Bridging the Great Health Divide.

Access to dental care in Alabama

One-third of Alabama’s dentists are 60 years old or older. At least half of those practice in rural Alabama, which means the majority of rural dentists are eyeing retirement.

“We are facing a real significant crisis right now,” stated Dr. Stephen Mitchell, a dentist who serves as the director of UAB’s Civitan-Sparks Clinics. “We are seeing over eighty percent of Alabama dentists operating within the thirteen counties that are urban. That’s leaving only twenty percent servicing the forty percent of Alabama citizens in our rural counties.”

Alabama has the lowest dentist per population ratio in the country, when considering a dentist per 100,000 people Alabama is 51st in the nation.

Few are on track to fill this void, especially in rural areas.

“Even if they would like to do that they can’t afford it,” explained Dr. Richard Simpson, a practicing pediatric dentist. “The average dentist graduating from dental school nationally has over $300,000 in debt. They need immediate income, so they are gravitating toward the large metropolitan areas, not the rural communities and to existing practices.”

In fact, nearly half of the dentists that graduate from UAB leave for other states with higher insurance reimbursement rates or they go into specialty programs.

“The last several years, the average is out of a graduating class of fifty-five from our dental school, four go into rural area or small town each year,” added Simpson.

Dentists who serve rural patients already see the impact.

Mitchell has offered free school dental screenings for more than twenty years. The amount of tooth decay in Jefferson County students of all socio-economic backgrounds has rapidly decreased over the years.

“When we step as little as forty-five minutes outside of Jefferson County and get into some of our surrounding areas we start seeing children with much more significant levels of disease,” Mitchell explained. “We did a screening last week toward the Oneonta, Blount County area and what we saw there were many children with at least some level of disease and then a good number of children with things that we had to mark ‘this is urgent, you’ve got to get in and get help.’”

Simpson is a pediatric dentist in Tuscaloosa who serves children from 17 counties. Since the shutdown, Simpson’s seeing children with far more tooth decay and an ever-increasing number of new patients whose dentists retired as a result of COVID or stopped seeing Medicaid-eligible patients.

“Sometimes we have patients that are driving two hours to get to our office,” responded Simpson. “That’s a burden on the family; working parents have to take off an entire day of work to get their child to the dentist because there’s no one in the area to see them.”

Almost all health-related issues in Alabama are underpinned by lack of insurance coverage. Those in rural areas have less access to private health insurance. The reimbursement rates for government-funded insurance is often not enough for dentists to keep their doors open in rural areas.

“Eighty percent of [tooth] decay is in twenty percent of children,” Simpson said. “We see similar scenarios in adults because of lower socio-economic status. In rural areas with decreased access to care, we see a higher disease rate. Studies show that in schools that have at least seventy-five percent of students on free or reduced lunch, those students have twice the amount of decay as children in other communities.”

Insurance further complicates care for children with poor oral care.

Children who aren’t on private insurance receive dental care through CHIP, the federal Medicaid program managed by Blue Cross Blue Shield in Alabama or through the state’s Medicaid program.

In the past, dentists would admit children with severe oral issues and treat them under general anesthesia. Over the last few weeks, financially-strapped rural hospitals have decreased or cancelled dentists’ operating room access. While those with CHIP are covered, hospitals don’t break even with Medicaid patients.

“So they’re both federal and state programs, one set of kids can go and one set can’t,” added Simpson. So it’s a real access issue.”

Simpson was in the operating room with twelve to sixteen patients a month, now it’s two to three.

“We have nowhere to send them and the waiting list at Children’s Hospital for young children that need this care or special needs kids is almost a year,” Simpson admitted. “So when they do the exam of kids that are in pain and have significant disease state, by the time they’re actually seen is ten to twelve months later.”

Mitchell sees patients with developmental delays in the Birmingham-area, he’s also limited by insurance.

“When I see them very often the only way to humanely treat them is to be able to get them into a hospital operating room, put them to sleep and try to do their work under general anesthesia”, he explained. “In the state of Alabama, that becomes an office that is increasingly becoming an almost impossible goal to access.”

His patients with special needs often have Medicaid, however when they turn 21 years old that coverage ends, no matter their condition.

“Once that ends, there’s very little ability to get anybody to an operating room,” Mitchell acknowledged.

Solutions for dental access

Both Mitchell and Simpson are advocating for better access to good insurance across the board. This would not only help patients maintain better overall health, it would also allow more dentists to reach underserved communities.

That could come by employers offering private dental insurance and expanding Medicaid in Alabama with a dental plan. Simpson added that states that have expanded Medicaid with dental coverage have seen a significant decline in those who are going to the emergency department with dental issues. Patients who are forced to visit an ER for preventable dental problems due to lack of access to care account for nearly $2 billion dollars a year.

“If we expanded Medicaid and included dental benefits, we would actually see a rise not only in dental patients but probably a decline in other types of disease and problems, because oral health is so integral to overall health,” stated Simpson.

Patients who see a dentist regularly and engage in prevention measures avoid costly and sometimes painful dental problems.

There is a new initiative called the 1st Look Program which trains pediatricians to do risk assessments with children under the age of three and engage in preventative dental measures like applying fluoride. 120 pediatricians are currently participating.

“I just spoke with over one hundred and twenty practices in northeast Alabama, that are very strongly interested now in working on getting trained in the 1st Look Program,” Simpson said.

Aside from prevention measures, additional work is being done to offer tele-dentistry and mobile dentistry in Alabama to reach underserved communities.

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