By Becky Bennett
A common joke frustratingly familiar to any transplanted West Virginian is that poor, rural people are missing teeth. There’s even a label applied to people in Appalachia: They’re said to have “Mountain Dew mouth.”
The stereotype contains seeds of truth: Pew Trusts and many other organizations report that low-income rural residents, poor children, people with disabilities, people of color and the elderly are more likely to suffer from tooth decay and gum disease and are less likely to see a dentist than urban, white and wealthier people.
The National Conference of State Legislature notes that rural residents are twice as likely to lose their adult teeth as urban residents.
The rural stereotype is cruel—first, because it’s meant to imply backwardness, ignorance and stupidity, and second, because poor dental health is not the fault of rural people, but of fixable inadequacies of the health care system.
Like other types of rural neglect, our society and governments have chosen to ignore rural dental care needs, through a variety of mechanisms, including:
- Fewer dentists practicing in rural areas.
- Few dentists (39% nationwide) accepting Medicaid coverage due to inadequate reimbursement,
- Lack of thorough dental coverage in most state Medicaid programs—a handy target for budget cuts (ask ex-Gov. Tom Corbett),
- Lack of dental coverage for seniors under Medicare.
- Unaffordable cost for the uninsured, and
- Lack of water fluoridation in rural communities due to its expense.
These problems add up to a lack of access to care, compounded by rural isolation and lack of transportation.
Data clearly show the human toll, for instance, the rural news website, The Daily Yonder reports that in rural Kentucky, dental pain is the top reason given for school absence, and dental decay is the top infectious disease among children.
Beyond statistics, you can see the toll for yourself, if you’re looking and listening. As I waited in line at a convenience store recently, the man ahead of me purchased a bottle of ibuprofen and an ointment for toothache pain. The clerk remarked that he was her second customer that day with a toothache. She advised him to go to Aspen Dental and have the tooth pulled. She’d had them pull four of her teeth, she said.
Having teeth pulled is often the remedy of choice for rural people because it costs much less and minimizes time away from work or need for child care and transportation compared to restorative treatments requiring multiple visits. An extraction may cost $500, while a root canal costs up to $2,000.
Those lacking access to dental care may turn to emergency rooms when pain becomes unbearable. The Center for Health Care Strategies cited $2.7 billion in dental-related emergency room visits over a three-year period. Thirty percent of the visits were by people on Medicaid while over 40% were by people without insurance.
Beyond the stereotype of rural people lacking teeth, dental problems are a clear marker of being lower class and poor, so they carry a large element of shame. Aspen Dental taps into this shame with ads in which working-class people relate how embarrassed they were by dental problems before getting treatment. (Aspen doesn’t accept Medicaid payment, according to its website.)
Of course, people’s habits and behaviors exacerbate rural dental problems: These include a lack of oral health literacy, no family history of regular dental checkups, and drinking sugary drinks and using chewing tobacco.
But the solutions, if we were willing to spend more public money in rural areas, are easy to identify: Increase Medicaid reimbursement to dentists, expand Medicare to cover dental care, expand incentives for dentists and hygienists to work in rural areas, fund mobile dentistry programs, and integrate dental care with primary care.
Two other key solutions are:
- Support fluoridation in rural communities. Fluoridated water helps prevent cavities, but it costs much more to add fluoridation to small community water supplies than to large ones. Plus, many rural residents get their water from unfluoridated private wells and springs.
- Expand the use of “dental therapists.” These mid-level professionals provide preventive and restorative care, including fillings and extractions, in underserved areas. While the American Dental Association has objected to the position, a handful of states have authorized dental therapists.
Anyone who’s experienced dental issues knows how painful they can be—stereotypes without action add yet another level.
Becky Bennett lives in south-central Pennsylvania and is a freelance writer and editor. She was editor of the Public Opinion newspaper in Chambersburg for 18 years and a journalist for over 40 years. “Across the Divide” examines rural perspectives on issues facing Pennsylvania and the nation. Email her at email@example.com.