State of Decay: Rural areas in America are at a tooth loss

West Monroe, Louisiana (InvestigateTV) - Every year, dentist Ronald Stratton puts about 50,000 miles on his car to help fight tooth decay in one of the neediest areas of the U.S.

Stratton is the only dentist in East Carroll Parish, Louisiana, where nearly half of its residents are poor.

By 7:30 a.m. each weekday, Stratton is driving his GMC Yukon gold to his dental clinic – an hour and half from his home.

“If I ever left, I think it would be very hard pressed to get another practicing dentist here,” Stratton said.

The lack of access to dental care plagues many parts of rural America.

Nationally, 229 counties in the U.S. didn’t have a single dentist in 2019, federal data shows.

The federal government has designated 476 counties as dental shortage areas, 107 of them are in the Appalachian and Delta regions, including East Carroll Parish.

That lack of access can lead to tooth loss and potentially other health problems such as heart disease.

“It’s truly a mirror of overall health,” said Daniel W. McNeil, clinical professor of Dental Practice and Rural Health at West Virginia University.

Across America, nearly 14% of senior citizens have lost all of their teeth. In the Appalachian and Delta regions, nearly every county exceeds the national average.

In East Carroll Parish, where Dr. Stratton practices, nearly 40% of senior citizens have lost all of their teeth, the fourth highest percentage in the nation.

For the past three decades, Stratton said he has extracted more than 40,000 teeth and has performed more root canals than he can recall. He sees about 8,000 patients a year.

When Stratton first started seeing patients in 1990, he never planned on staying in the parish because there were two other dentists in the area.

But then they left, leaving Stratton as the only provider. He said he had to stay for the sake of the residents.

In East Carroll Parish, the need for oral care is great.

It leads the nation with the lowest percentage of adults who have visited a dentist in the previous year – 33.9%.

Two of the four public drinking water sources in the parish do not have fluoridization, which helps prevent tooth decay.

And, because such a high percentage of the population lives in poverty, residents have to pay for a lot of oral health care out of pocket.

Medicaid, the insurance for the poor and people with disabilities, doesn’t cover some procedures or fully cover others.

In Louisiana, for example, it doesn’t cover the cost of root canals after the age of 21. It doesn’t pay for braces. And Medicaid reimbursements to dentists has been stagnant for decades, Stratton said.

Many of his Medicaid and uninsured patients cannot afford to go to an oral surgeon for tooth extractions, leaving the job to Stratton.

“In a lot of cases, these teeth need to go,” Stratton said. “I’m just happy I can take care of that problem for them.”

Filling the oral care need in the region

Stratton solved Margaret Sheppard’s problem.

After losing her teeth years ago, Sheppard received dentures for her top teeth through Medicaid.

But they never properly fit. With those teeth, she was in constant pain and couldn’t properly chew. Her dentist at the time couldn’t help.

She started searching for a new dentist and found Stratton 35 minutes from her home.

Within weeks, Sheppard, 72, had new dentures and a big smile.

“I had kind of given up,” Sheppard said. Her former dentist, “just couldn’t get it right.”

Now, she’s back to eating her favorite foods: hamburgers, neck bones and pig feet.

Sheppard knows that her tooth loss may have been prevented if she received regular oral care. Like millions of Americans, she avoided annual checkups.

According to the Centers for Disease Control and Prevention, about 40% of Americans between the ages of 18 and 64 forego an annual trip to the dentist.

In the Delta region, where Sheppard lives, more than half of adults haven’t been to a dentist in at least a year.

Sheppard said she never could find the time for dental visits. She had six children to raise and a job at a nursing home, where she worked 16-hour shifts.

That’s all changed now. She’s a regular at Dr. Stratton’s office.

“We ain’t letting him go,” she said. “He’s going to stay here.”

Oral health prevention begins with children

The key to a lifetime of healthy teeth can be a simple as setting aside time during the school day for children to brush their teeth.

And, researchers at the Center for Oral Health Research based at the University of Pittsburgh, said that one commitment could save taxpayers billions of dollars.

“Poor oral health in particular dental caries or cavities result in many hours of lost school time, loss of work…and it sets children on a trajectory to have poor oral health for their whole lives,” said Mary Marazita, director of the Center for Craniofacial and Dental Genetics at the University of Pittsburgh.

In 2001, Marazita and Daniel McNeil, a clinical professor of Dental Practice and Rural Health at West Virginia University, secured funding to study socioeconomic status and factors in children from Appalachia in their respective states. For the past two decades, they have followed children from womb to age six or so.

Their findings have shown that early prevention is the biggest driver in good oral health.

“Dental disease doesn’t require huge programs, but simple things that can easily be provided in a school setting,” Marazita said.

According to a 2017 report from the South Carolina Rural Health Research Center, rural children were less likely to receive preventive dental care than urban children and also were less likely to report having excellent or very good teeth.

Numerous barriers exist for rural residents, Marazita and McNeil said. Some may lack transportation or the time to take off from work. Some live in states such as Arkansas that lack a dental school, providing no local pipeline for dentists.

Many residents live in areas where there are too few dentists – and even fewer who will accept Medicaid because of the limited reimbursements make it difficult to run a business.

According to 2018 data from the American Dental Association approximately two-thirds of all dentists in the U.S. did not serve any publicly insure patients.

“We should have a system of reimbursement for oral health care providers that allows them to offer the best services for every patient,” McNeil said.

This past year, West Virginia passed a bill expanding dental coverage for adults under Medicaid, adding $1,000 in coverage for adults to receive additional dental care services.

For many families, this can mean finally addressing serious oral health problems.

Besides federal government programs, oral care prevention done at home and at school, fluoridation has helped with tooth decay.

“Over many decades, having fluoridated water has shown to be a major public health success in terms of prevention of cavities,” Marazita said.

But too many people now rely on bottled water, which doesn’t contain fluoride, to quench their thirst. Marazita calls bottled water “one of the triumphs of marketing.”

It’s also a win for cavities.

Lack of fluoridation in water systems

The CDC hailed the addition of fluoride to public drinking water sources as one of the top 10 public health achievements in the 20th century.

Even so, the water that at least 49 million U.S. residents consume – about 14% of the entire population - doesn’t contain the important cavity-fighting agent, CDC data shows.

“We know that in communities that have fluoride, they can see an average of 25% fewer cavities than communities that don’t,” said Tracy Boehmer, the CDC’s fluoridation engineer.

The CDC doesn’t require states to report the number of public drinking water systems that are fluoridated. But 32 states voluntarily send that information to the CDC, involving more than 33,000 water systems in the U.S.

Of those, more than 60% of them don’t add fluoride into the water.

In Louisiana, 88% of drinking water systems lack fluoridation. In California, it’s 89%. And in Alaska, it’s 95%.

“It can be cost prohibitive for a lot of smaller communities,” Boehmer said. “Mostly because just whatever that upfront cost might be but then also the operation and maintenance of the new equipment.”

To cater to those smaller communities, the CDC helped develop a fluoridation tablet that can be added to water systems that couldn’t afford to pay for it previously.

The system is being tested in White County, Georgia.

KC Industries, which developed the tablet, said that if the new water system is used in an area of 5,000 people, it would cost each person $1 a year to maintain fluoridation in the system.

Combined with the fluoride systems already in place and this new technology, the CDC believes it has the capacity of reaching 90 million people.

Such a move could help many people such as those served by Dr. Stratton in northeastern Louisiana, where dentists are few and far between.

“The people here have just been so good,” Stratton said. “But there’s a lot of need.”

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