Introduction
Health Centers Address Oral Health Disparities
While gains have been made over the last two decades, oral health disparities
persist among Americans from racially and ethnically minoritized populations and
those with lower household incomes (see Oral Health Facts).1,2,3 A major contributor
to these disparities is the shortage of accessible dental providers.4,5,6
As of June 2024, there were more than 6,860
communities across the United States federally designated as dental health professional shortage areas (DHPSAs).7
The largest number of shortages are in rural and low-income communities. Shortages also exist for publicly insured populations. Less than half of all dentists participate in state Medicaid programs making it challenging for people covered by
these programs to find care.8
Health centers, located in America’s
underserved communities, are community
driven healthcare organizations based in the
community-oriented primary care model. These organizations are committed to improving health by caring for the whole person. They accomplish this through the integration of oral health, behavioral health, and primary care services. With over two-thirds of the 32.5 million people receiving care in health centers being from diverse racial and ethnic groups, health centers are in the perfect position to address oral health disparities.
All health centers must provide preventive
dental services and 82 percent provide
comprehensive dental care to their
communities.9
A total of 1,359 federally qualified
health centers reported a shortage of dental
professional in the summer of 2024.9
Expanding access to dental care in health centers requires state-initiated strategies to train, secure, and maximize members of their dental care teams.
Who Is This Guide For?
We encourage health center leadership,
board members, and advocates to
consider the actions offered in this guide to inform your own tactics to leverage available resources for a more robust dental workforce in your community
Oral Health Disparities In America:
The Facts
Black and Hispanic children (age 2-5)
experience significantly higher rates of
tooth decay than White children (28%
and 33% compared to 18%).
Untreated tooth decay is nearly three
times higher among children (age 2-5)
from low-income households (17%)
than among those from higher income
households (6%).
Among working age adults (age 20-64),
Black Americans have nearly twice the
rate of untreated dental caries than
White Americans (40% versus 21%).
Among older adults (age 65 or older),
complete tooth loss is three times higher among those with lower incomes (34%) than those with higher incomes (11%).
1 Oral Health in America: A report of the Surgeon General (2000) https://www.nidcr.nih.gov/
sites/default/files/2017-10/hck1ocv.%40www.surgeon.fullrpt.pdf
2 Oral Health in America: Advances and Challenges (2021) https://www.nidcr.nih.gov/sites/
default/files/2021-12/Oral-Health-in-America-Advances-and-Challenges.pdf
3 https://stacks.cdc.gov/view/cdc/82756/cdc_82756_DS1.pdf
4 https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/
research/hpi/hpigraphic_0820_1.pdf
5 https://www.annualreviews.org/content/journals/10.1146/annurev-publhealth-040119-094318
6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7125002/
7 https://data.hrsa.gov/topics/health-workforce/shortage-areas
8 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10009318/
pdf/10.1177_10775587221108751.pdf
9 https://www.nachc.org/wp-content/uploads/2023/04/2024-Dental-Therapy-Resource-Guide.pdf
The Dental Workforce in Health Centers
Health center dental teams vary and can consist of a range of dental professionals
including dentists, dental therapists, dental hygienists, and dental assistants.
Each dental profession has unique requirements that define their contributions
to care including regulation (state licensing/certification), education, and scope
of practice. (Additional details can be found in the appendix.)
There are many complex factors contributing to the current shortage of dental professionals
nationally:
- Cost of education and limited community-based training opportunities.10
- Variations in occupational regulation within and across states.11
- Inconsistencies in reimbursement for adult dental services (see side bar).
Each of these factors impact the dental workforce pipeline and the sustainability of services in traditionally underserved communities.
The Cost of Education
The cost of education is a barrier for dental professions and impacts practice decisions post-graduation. Dentists have the highest educational debt of all health professions, with an average of nearly $300,000 in student loans. The estimated average educational cost for dental therapy may range from $84,000 to $138,000, and dental hygiene costs approximately $22,692 for an associate degree or $36,382 for a bachelor’s degree. Depending on the type of dental assisting training completed, the cost of training may range from $1,000 to several thousand dollars. Strategies to address the burden of educational costs are critical in making these occupations accessible, especially for those with lower incomes.
Community-based Training
Studies show that students are more likely to work where they train. Unlike medical and nursing students, dental and dental hygiene students have historically completed their clinical training at clinics located within universities or colleges. Community-based dental training has increased over the last decade with recognition of its importance among dental educators.
Regardless of the recent increase, dental professional education is still mainly provided within institutional clinics and not in community settings. This means most students are not exposed to different practice settings prior to graduation.
Expanding community-based training in health centers is critical to provide students with more experiences and raise awareness of the rewarding opportunities that exist for traditionally underserved patients.
Reimbursement Is Critical to Sustainable Dental Care in Underserved Communities
Federally Qualified Health Centers (FQHCs) are vital for uninsured, underinsured, and Medicaid beneficiaries as they are required by Section 330 grants to offer services to all, regardless of insurance or ability to pay.
Congress created the Prospective Payment System (PPS) and Alternative Payment Methodology (APM) to ensure that FQHCs are appropriately reimbursed for the care they provide.
Although only twenty-four (24) state Medicaid programs currently offer adult dental benefits, FQHCs are required by federal law to provide, at minimum, limited preventative dental services to all patients they serve.
It is critical for federal and state governments to invest in Medicaid coverage for dental care.
10 https://pubmed.ncbi.nlm.nih.gov/28765452/
11 https://onlinelibrary.wiley.com/doi/10.1111/jphd.12155
12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10503048/
13 https://www.leg.state.nv.us/App/NELIS/REL/80th2019/ExhibitDocument/OpenExhibitDocumentexhibitId=44283&fileDownloadName=0530SB366f_vanl.pdf
14 https://www.adea.org/godental/future_dental_hygienists/program_costs.aspx
State policy can significantly impact dental workforce development through strategies designed to train, secure, and maximize the dental workforce in health centers.
Health centers should be aware of state policies and strategies that exist and identify related opportunities for funding. Health centers can advocate for similar policies within their state. In this guide, you will find a description of state policies and strategies that can support the growth of programs to train, secure, and maximize opportunities for the dental workforce in health centers, including practical recommendations for health centers to “take action.” Eleven “Shining Star” case examples, presented at the end of the guide, illustrate how health centers across the nation have used a variety of the state policies and strategies featured in this guide to improve access to high-quality dental care for underserved patients.
For more information, download the complete Implementation Guide or the 11 Shining Stars case examples above, which illustrate how health centers across the nation have utilized various state policies and strategies from this guide to enhance access to care.
Authors
This report, including the concepts and research findings presented herein, was authored by Hannah Maxey, PhD, MPH, RDH, and Courtney Medlock, MPH, in partnership with NACHC and participating Community Health Centers, and with funding from CareQuest Institute for Oral Health. Dr. Maxey, Associate Professor of Family Medicine and Director of the Bowen Center for Health Workforce Research & Policy (Bowen Center) at Indiana University, is a state health workforce policy expert and advocate for community health centers. Courtney Medlock is a health policy consultant with nationally recognized expertise in the health workforce.
