ECU dental students work with a patient. (Photo credit: ECU photos)

This story was originally published by North Carolina Health News.

Millions of rural residents have not seen a dentist in over a year, a recent CDC report reveals.

In 2019, before the coronavirus pandemic forced dentists to shut down, 42 percent of adults in rural areas did not receive dental care, according to the survey. In urban areas, roughly a third of adults did not see a dentist that year.

In both groups, people of color and low-income residents were less likely to have seen a dentist in 2019. These disparities were wider in rural areas, where issues such as transportation barriers, dentist and dental hygienist shortages and lack of health insurance are more common. The coronavirus pandemic has likely exacerbated the need, especially for low-income patients, the report says.

“The things that really went by the wayside [with the pandemic] are the maintenance, the routine exams and the cleanings — things that keep people healthy,” said Katherine Jowers, who oversees oral health programs at the Asheville-based Mountain Area Health Education Center. “ … We’re still dealing with very old treatment plans for patients we haven’t seen in two years. Nothing was on fire so they didn’t come, and now all of their plans are completely disrupted and we have to start from scratch.”

Since cavities and other dental problems don’t resolve on their own, what might have been small areas of decay that could have been addressed with a filling have likely advanced to more extensive decay that requires a root canal or even extraction.

Lower-income patients are already predisposed to forgoing preventative dental treatment because of cost, especially if they aren’t in pain, said Anahita Shaya, a dentist at the Brunswick County Health Department.

“People are having to choose between the necessities of life,” she added. “If they’re having to pay for fillings and a cleaning out of their pocket and that’s against having to pay their electric bill or mortgage or rent, [preventative dental care] is not always at the top of the list.”

Dr. Anahita Shaya is a dentist at the Pender County Health Department. (Photo credit: Pender County Health Department)

Oral health is an important part of overall wellness and if left untreated, tooth decay can lead to a whole host of other complications. Cavities have been linked to heart disease, pneumonia and sepsis, for example. Pregnant women with poor oral health have been found to have a higher risk of premature births and other complications.

Shaya sees some of these complications in her own practice, with patients turning to the emergency department for dental abscesses.

The same is true for communities nationwide. Dental abscesses accounted for 3.5 million visits between 2008 and 2014 and cost a collective $3.4 billion, research shows. Uninsured people and Medicaid beneficiaries accounted for the bulk of these emergency visits.

Though receiving antibiotics at the ER can cost $1,000 or more out of pocket, Blake Gutierrez, a dentist at MAHEC, said patients go there because they don’t think there are other options. In most cases, however, emergency departments can’t fully address a dental issue. At most, emergency providers can administer antibiotics and painkillers, but without dental treatment, the source of infection remains and can flare up again.

Even after an ER visit, patients may still be hesitant to seek dental care because of cost. Care Credit, a company that provides financing for dental and other health procedures, estimates that an extraction, the cheapest option for advanced tooth decay, can cost anywhere from $130 to $500, depending on the complexity of the extraction. Root canals, another common treatment, can cost $1,000 or more.

Scarce North Carolina providers

Rural North Carolinians have another significant challenge to deal with when seeking care: lack of dentists. Most dental providers congregate in urban areas, according to data from the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Some rural counties, including Hyde, Tyrrell and Gates, did not have an active dentist in 2019, the data shows.

Greg Chadwick, dean of the East Carolina University School of Dental Medicine, keeps close tabs on that data. By his calculation, the state has roughly 5,600 active dentists, and most of them — over 4,500 — work in cities. The remaining 1,400 serve North Carolina’s 80 or so rural counties.

study published this year by the American Dental Association notes North Carolina has about 54 dentists per 100,000 residents, behind the national average of about 61 dentists per 100,000. Based on a 2015 analysis generated by the federal Health Resources and Services Administration, North Carolina is likely to remain a state with not enough dentists to meet the demand into the future.

That math alone makes it so patients in rural areas have to travel farther for care, he added, something that many residents struggle with. The only way to address these disparities is to make dental care more accessible, perhaps by coupling it with primary care as many community health centers do across the state.

These health centers aren’t always enough. MAHEC’s dental clinic, for instance, has a two-month wait for a cleaning and general exam. Another provider, CommWell Health – a community health center with locations in Sampson and surrounding counties – has seen a similar trend.

Time, said MAHEC’s Jowers, isn’t on rural patients’ side, especially since the pandemic delayed care for so many of them.

Data, graphic courtesy: Sheps Center for Health Services Research, UNC-Chapel Hill

“You’re not addressing needs that were minor needs two years ago,” she said. “[Dentistry] is the type of health care where if you don’t address the problem, it doesn’t get better by itself.”