Policy Brief by Conan Davis, DMD and Stuart Lockwood, DMD, MPH

Text-only version below. To access the fully formatted version click here: AL_Dentistry_Policy_Brief_3.pdf

 

A Nationwide Trend Appears in Alabama

Life is changing in small-town and rural America. People are leaving their small towns in favor of living in larger cities. Some of the reasons driving this change include the search for better employment opportunities, potentially better schools, and better entertainment options as seen in the media.

This is happening in Alabama as well. This trend is affecting many sectors of life in small-town Alabama, and thoughtful leaders in the state are beginning to confer and strategize about how to address this trend and to reverse it (Tomberlin, 2019, 2020; Washington, 2019).

Trend Affects Access to Dental Care

One of the issues small-town Alabama is facing and that is even beginning to happen in larger Alabama towns is the loss of access to dentists. Many of the smaller towns and counties with smaller populations have older dentists. Younger dentists are not taking their place when these older dentists retire, as was the case in times past. Researchers studying this issue have recognized that unless a change is made soon to challenge this trend, residents of small towns in Alabama will be facing a crisis in access to dentists in the very near future.

Distribution of Dentists in Alabama

Alabama currently ranks 51st in US dentist-to-population ratios, with 4.1 per 10,000 according to a ranking by the American Dental Association in 2018 (M. Vujicic, personal communication, January 2018). Additionally, the federal government identifies 65 of Alabama’s 67 counties as being dental professional shortage areas due to a number of factors (The Alabama Office of Primary Care and Rural Health, 2017).

Alabama has only one county without a dentist, Greene County. However, approximately 80 percent of all dentists practicing in Alabama practice in the 13 most urban counties. The remaining 20 percent practice in the 54 non-urban counties of Alabama, many of these smaller counties with only 1 to 3 dentists. This translates into about 1 dentist for every 1,800 people in the urban areas versus 1 dentist for every 4,100 people in the non-urban areas—a significant difference. Jefferson County alone (at 543 dentists) has more dentists than all 54 non-urban counties combined (at 455 dentists). This is clearly seen on the interactive web map of the dentists in Alabama, shown in Figure 1.

Aging Dentists Are Not Being Replaced

Another factor identified by research on the dental workforce of Alabama is that many dentists (33.3%) are over age 60 (as noted in January 2017 with data from the American Dental Association). One of the reasons for this larger number of older dentists was a federal grant program in the 1970s and 1980s that rewarded dental schools nationwide for increasing their enrollment. When that program ended, the number of students in each class dropped from around 75 to 55, resulting in a group of around 170 dentists from this era who are now retiring but are not being replaced. Currently, more than 50% of the dentists in 25 of our 67 counties are over age 60. At the same time, more than half of all Alabama counties currently have no dentist or only 1 dentist under age 40.

In 2017, a briefing paper developed for the University of Alabama School of Dentistry Alumni Association magazine charted the growth or loss of dental care vs growth or loss of population of every county in Alabama from 2003-2017. Revealingly, this research showed that 23 of Alabama’s 67 counties lost general or pediatric dentists from 2003 to 2017; further, there was a net gain of only 183 general and pediatric dentists in the state during this period (Davis & Lockwood, 2017).

Many Dental Graduates Stay in Jefferson County or Leave the State Altogether

Over time the graduates of the University of Alabama at Birmingham (UAB) School of Dentistry have not been choosing to practice in small-town and rural Alabama. Since 1990, an average of only about 4 dentists per class of 55 have chosen to practice in Alabama’s most rural 41 counties. There have been a few exceptions with larger numbers but not many. An average of 8.5 dentists per class of 57 have chosen to practice in one of the 54 non-urban counties of Alabama. Twenty-five percent of the 2017 class alone, however, chose to stay and practice in Jefferson County. Another disturbing fact is that approximately 40% of Alabama’s dental graduates are choosing not to practice in Alabama at all (data from Board of Dental Examiners of Alabama, 2019 ). This is reflected in their lack of Alabama licensure maintenance a few years after graduation.

Gender Plays a Role in Dentist Distribution in State

Another factor influencing the migration from dental school to the rural areas and small towns of Alabama is gender. Recent classes of dental students have increasingly had larger percentages of female students. In fact, the last several classes accepted to UAB School of Dentistry have approached or exceeded 50% female. At the same time, however, few female graduates choose to practice in smaller towns and rural areas, contributing to the lower number of dental graduates overall choosing to practice in those areas. Currently, 80% of Alabama’s 499 female dentists practice in only 9 urban counties. Only 16.7% of female dentists practice in the 41 most rural counties.

Facing the Facts, Addressing the Problem

These are the facts Alabama is facing at present. Where will dental care be 10 to 15 years from now if the current trends do not change? Will dental care only be accessible for those who happen to live in one of the state’s 13 urban counties? This is not an acceptable situation, but there is now some hope for the future. One might wonder what has been done thus far to address the problem.

The authors, both former state dental directors with the Alabama Department of Public Health, have examined the teeth of thousands of children in Alabama to assess the state of dental decay and to make referrals to local dentists. We have seen many children with excellent dental care and many without any need for treatment. However, we have also seen the evidence of neglected dental needs in many children. An even larger concern is the lack of access afforded to low-income adults with no dental insurance and no public dental coverage in Alabama.

After many years of studying the issues underlying the widening gap between urban and non-urban dental care access, we brought together leaders from the UAB School of Dentistry and the Alabama Dental Association to develop a partnership. This partnership worked to develop a strategy to correct the disparities found in access to a dentist in the more rural areas of the state.

Offering Incentives to Practice in Rural Areas Is Effective

Through this partnership we applied for and were awarded a federal grant to accomplish several goals. One was to take the available data on dental practices in Alabama and, with the help of the UAB School of Public Health, develop an interactive web map (Figure 1) of the location of each dental practice in Alabama that includes demographics of each county, areas with Medicaid disparities, and population projections to help contextualize the distribution of Dentists throughout Alabama. The grant also provided funding for dental student rotation experiences in rural areas, allowing students to see dental practice life in these areas. Additionally, the grant provided significant financial awards to a few graduating dentists each year who would agree both to practice in a rural area and to see a certain percentage of Medicaid patients for a specified number of years. Graduating dental students can have significant school debt; this incentive was designed to assist them with that debt and help them establish a practice. The grants were planned to help “plant” dental offices in 9 rural areas needing a dentist. Nine such practices were planted through this grant program, and they have successfully continued in those areas to this day. It is clear that financial incentives can help direct dentists to choose to practice in rural areas. Our medical colleagues have known this for many years and are well funded for this approach, but until recently, dental care providers were not.

Many dental leaders in Alabama worked together on legislative language presented to the state legislature and the governor’s office for consideration of a similar state-based financial incentive program for new dentists willing to locate in a rural area. The legislation for this incentive program passed but took a few years for funding to be approved. This year adequate funding was approved by the state to fund the first year of a new tuition-based dental scholarship program for dental students willing to agree to practice in rural and underserved areas of the state for a defined number of years. We are very pleased that this first year of funding has finally been approved and hope this approach will encourage young dentists to choose a smaller town or rural areas to practice dentistry.

Sitting on the Edge of a Crisis; Collaboration Is Key

In conclusion, our data demonstrate that Alabama has been sitting on the edge of a crisis in access to dental care in Alabama. Some of the root causes of the current situation have been identified. Concrete solutions are developing to rectify this trend and reverse it. However, the dental community cannot accomplish this on its own. The engagement and involvement of leaders from many sectors of life in Alabama is critical: leaders of small towns, leaders in the state house and the legislature, leaders in insurance and education, as well as leaders in the medical community must join in this effort. It will take the involvement and combined efforts of many interested and engaged individuals and groups for these young practitioners to be successful and to effect a change for the better in rural areas. Collectively, we can increase access to dental care. In the process, we will be able to assist the efforts of others seeking to improve life in our small towns and rural areas.

References

Davis, A. C. & Lockwood, S. A. (2017). Practicing dentist trends in Alabama: Comparing data from 2003 to 2017. Dent Alumni, Fall 2017, 10. https://www.uab.edu/dentistry/home/images/documents/publications/dent-alumni/Fall_2017_DentAlumni.pdf

The Alabama Office of Primary Care and Rural Health. (2017). Dental Health Professional Shortage Areas. https://www.alabamapublichealth.gov/ruralhealth/assets/dentalhpsamap-oct2017.pdf

Tomberlin, M. (2019, August 6). Alabama putting added horsepower behind rural economic development efforts. Yellowhammer News. https://yellowhammernews.com/alabama-medical-practices-hit-hard-by-covid-19/

Tomberlin, M. (2020, January 29). Rural Alabama is getting much-needed attention from economic developers. Alabama NewsCenter. https://alabamanewscenter.com/2020/01/29/rural-alabama-is-getting-much-needed-attention-from-economic-developers/

Washington, D. (2019, November 4). Officials: Rural Alabama important to state’s economic growth. Alabama NewsCenter. https://alabamanewscenter.com/2019/11/04/officials-rural-alabama-important-to-states-economic-growth/