Each workday morning, Dr. Dwayne Albritton leaves his home in the greater Birmingham area and heads to his general dentistry office. Three days a week, the office is a few miles away. Two days of his work week, however, his office is 60 miles away in a different county.
Mondays, Tuesdays and Thursdays, Albritton drives a few minutes to his office in Vestavia. Wednesdays and Fridays, he travels over an hour through the countryside to his office in rural Rockford. Melding the needs of the two practices is something he’s done for 22 years. He is the only dentist office in Rockford, population 447 and the county seat of Coosa County.
Rockford is just one example of the growing concern that dental and public health experts have as they try to address an alarming shortage of dentists in Alabama’s small rural towns.
Albritton is no stranger to small towns. The town where he grew up in Massachusetts had fewer than 10,000 people. The atmosphere in Rockford reminds him of childhood. “There is a need for a dentist in Rockford,” Albritton says. “I love it down there.” But people graduating from dental school now usually skip small towns and set up shop in larger places.
Alabama health care planners look at patterns showing where dentists live and work and their current age.
Planners say new dentists often leave school owing $250,000-$300,000 or more in dental school debt. The debt is a major reason dentists choose a larger city practices.
“Sometimes it is the travel time, the schools, other family needs,” Albritton says. “If there were incentives to a new dentist to go to a rural area, it would be great.”
Recruitment a challenge for rural towns
The way Albritton acquired his Rockford dental office shows the challenge that small rural Alabama communities face when trying to recruit dentists. The town’s only dentist had been killed in a car accident. The dentist’s family had tried for some time to find a buyer for the practice with no success.
Albritton sold another small dental practice in Ashville to a colleague and bought the one in Rockford, where he is able to treat patients with typical dental needs, some with dental insurance, some children with Medicaid, others who pay with cash. He sees more adults needing teeth pulled in the rural practice, and some rural patients may wait longer between dental visits if funds are tight or transportation is a problem.
Dr. Stuart Lockwood, a retired state dental officer and epidemiologist with the Alabama Department of Public Health, grew up in Union Springs and opened his first dental practice there.
Lockwood then specialized in public health epidemiology, at the U.S. Centers for Disease Control and Prevention in Washington, D.C. before returning to Alabama. As an epidemiologist, Lockwood looks at causes of disease and injury and then seeks ways to stop problems that can have negative impact on health.
Lockwood studies the ages of Alabama dentists and where they locate their offices and compares that data with parts of the state that have the greatest dentist shortages. Lockwood then can determine where the provider gaps are and help predict future needs. He gets his figures by studying the Dental Care Health Professional Shortage Areas (HPSAs) of the U.S. Department of Health and Human Services.
Longer waits ahead without help
Lockwood said planners believe if current patterns in dental care availability remain, rural Alabamians in the future will face longer waits for dental appointments and travel greater distances to get to the dentist. He is working with The Alabama Dental Association, providers and other advocates who want the Legislature to fund dental school tuition scholarships.
Dr. Zack Studstill, dental association executive director, said the scholarships would fund four $45,000-per-year ongoing tuition scholarships for qualified dental students who agree to practice in a small Alabama town. Studstill said if new dentists can be drawn to rural communities in exchange for tuition help, some will love life there.
“Small-town Alabama is such a good life. Small-town Alabama deserves good health care,” says Studstill, who grew up in Andalusia. The dental organizations and other providers helped secure passage of a tuition scholarship in the 2016 session of the Legislature, but the scholarship funding was cut in budget negotiations. As of press time, a tuition scholarship bill, SB144, was under consideration again in the 2019 legislative session.
A taste of small-town practice
Students at the state’s only dental school, at the University of Alabama School of Dentistry in Birmingham, get a taste of what a dental practice would be like during placements at community health programs.
The dental school partners with 14 community health centers across the state, including some that have dental care for patients, says Dr. Conan Davis, assistant dean for community collaborations.
Davis says the dental school credentials health center dentists to serve as adjunct faculty to mentor students. He also teaches a class in community dentistry that teaches students to be advocates for their patients. Davis called the class a way to give students “a broader view of the world beyond people just like them.”
Others view of Alabama’s dental needs
Dr. Richard Simpson, a pediatric dentist in private practice in Tuscaloosa, is chair of the Oral Health Coalition of Alabama.
Simpson said more than 90 percent of Alabama children have oral health coverage either through dental insurance, All Kids, Medicaid or other programs that provide care for children. He hopes that children who receive regular care now will not have the dental problems that adults without dental care now have.
State Dental Director Tommy Johnson was in private practice in Mobile before he came to the Alabama Department of Public Health a year ago.
Johnson said Alabama provides coverage for children’s dental care, but adults, especially if they are low-income and live in rural areas, have challenges finding and paying for dental care. Transportation can be a problem.
Alabama does not pay for dental care for adults on Medicaid, so adults with income well below the poverty level often end up having problem teeth pulled as a result. But Alabama Medicaid Director Danny Rush said the program does have some non-emergency transportation funding to help patients get to a doctor’s office.
Alabama rural health advocate Dale Quinney is a retired director of the Alabama Rural Health Association. Quinney questions whether dental hygienists could clean and check teeth for problems in rural areas and use telehealth to connect with a dentist who could check for problems.
Johnson said the public health department already uses telehealth, and designs and builds programs to communicate with public health clinics around the state.
“I would like very much to be able to incorporate tele-dentistry in public health at some point, but the Alabama Dental Practice Act requires direct supervision of dental treatment by a dentist,” Johnson says.
The dental association’s Studstill said current Alabama law requires that a dentist be in the same location as a hygienist or other dental professional doing cleaning or other preventive or diagnostic treatment.
Studstill said the requirement is a patient safety issue in case a patient has problems with bleeding or other medical issue needing quick response of a dentist. The law is one that he said the dental association and the Board of Dental Examiners support.
But along with the telehealth tools that the Department of Public Health has, Studstill said the dental school is developing telehealth capabilities to help dentists practicing in small towns consult with specialists who are usually in larger city settings.
Bradley W. Edmonds, executive director of the Alabama Board of Dental Examiners, says the board is aware that there are concerns about access to dental care in rural areas. He said the board earlier this year voted to allow dental hygienists with additional training to administer local anesthesia by injection, something he said is a step toward better access to care.