Arkansas earned a last-place spot in America's Health Ranking with 55 percent of its residents visiting the dentist last year, compared to a national rate of 67.2 percent. The state is also last for dentists per capita and ranks 47th in percentage of loss of natural teeth.
The federal Affordable Care Act helped more than 65,000 Arkansans get health insurance, but dental care for adults was not part of the deal. Medicare provides no adult dental care, and the state's Medicaid system offers limited benefits for some enrollees.
More than 108 million people nationwide lack coverage for oral health
Dr. Dwight Duckworth, a Springdale dentist and president of the Arkansas State Dental Association, said most dentists have empty time to fit in more patients, but many issues -- cost, lack of insurance, fear or a previous bad experience -- keep people away.
Poor dental health has been connected to several other health conditions, including diabetes, stroke and heart disease, he said.
Julie Paradise, associate director of the Kaiser Commission on Medicaid and the Uninsured, said many things contribute to rankings.
"I think there is still limited understanding in the general population on the importance of oral health," she said. "This is especially true for people who have to pay out of pocket. Other health and general needs tend to take precedence."
Health officials said additional free services and increased competition from new, for-profit dental offices help, but are barely making a dent in the problem.
The state's medical school has expanded dental education programs and is examining opening a dental school that may help supply dentists to rural areas facing access issues.
Cost of care
Arlene Jones is a domestic violence survivor and single mother of four grown children. The 43-year-old moved to Fayetteville in 2002 after her then-husband broke her jaw in three places. She suffers from TMJ, a disorder where problems with the jaw and facial muscles cause pain and limit movement. Her ear drum is ruptured, pieces of teeth keep falling out of her mouth, she can't eat, and she suffers from depression.
She needs extractions, a root canal, cleaning and a partial denture. Pain keeps her from working, and she receives Social Security benefits. She is not eligible for any Medicaid coverage.
"When you don't have insurance, what are you supposed to do?" she said.
Out-of-pockets costs is the one barrier that keeps most low-income, uninsured people from getting the dental care they need.
FAIR Health, a nonprofit organization that maintains a health care claims database, shows the average price for a crown in Northwest Arkansas is about $1,060. Root canal prices can easily hit $1,200. Basic cleanings average $82.
A growing number of offices are posting rates online so customers have an idea on pricing going in.
Aspen Dental's website shows cleanings start at $60, extractions are $104 and crowns are $716. The site also features coupons such as 20 percent off general dentistry.
Dale Moore, regional manager for Dentures and Dental Services, said the firm works to have the lowest price and even offers a low-price guarantee. It will beat any competitor price by 10 percent. He said crowns are $695 at Dentures and Dental.
Many offices also offer some sort of financing packages through companies such as Care Credit that offer payment plans, often with no interest for a set amount of time.
Jones said she visited a chain dental office and left with an estimate of $4,300 to complete all her work. She said Arkansas Rehabilitative Services would pay $2,000, but she can't come up with the other half and did not qualify for any payment plans.
"Me getting my teeth fixed is not about cosmetics. It's about getting healthy," she said. "I want to enjoy life. I haven't been able to do that for a long time."
Community clinics
Many area community clinics offer dental care for free or on a sliding scale for low-income residents.
The Samaritan Center expanded its dental offerings at the Rogers office. The center stopped operating a medical clinic July 1 because the number of patients dwindled from 10 to 20 a night to just a handful since implementation of the Affordable Care Act, said Maxie Carpenter, director of operations.
"We just didn't see it as a wise use of our resources," he said. "Dental filled the vacuum."
The center hired Dr. Jill Self-Pike as staff dentist and Amy Gephart as dental clinic coordinator, allowing the clinic to expand hours and see more patients. It still has dentists who volunteer their time. Self-Pike was the clinic's first volunteer dentist in 2006.
Self-Pike said the center typically sees about six patients a day.
"We would love to see more, but we are seeing the worst mouths," she said. "Some of these people have never been to the dentist before."
The Samaritan Center pulled a tooth for Jones last week after she made her way on a short call list. An email she sent the clinic about her plight caught their attention.
"She said she had lost all hope," Self-Pike said.
Jones has been able to eat again since Self-Pike pulled the tooth, but she has to wait for another appointment to complete more work.
Washington Regional's Mobile Dental Clinic pulled a tooth for Jones last year. She said they couldn't do more work because she was going to need a partial denture. The Samaritan Center has a program that helps patients get dentures.
The hospital's mobile clinic began about 18 months ago and has seen about 1,500 patients.
"We have so many people who want to be seen," said Jamie Moore, the mobile clinic's dentist. A three-month waiting list means that many of its low-income, uninsured patients miss appointments, he said. Sometimes they forget about the appointment, and the clinic can't reach them. Othertimes, the pain lessens and they decide they don't need the care anymore.
The hospital started the dental clinic to help ease the crush of patients going to the emergency room for care. Washington Regional Medical Center had more than 900 emergency room admissions in 2010 because of poor dental care.
Using the emergency room for dental help is a national issue. The American Dental Association reports that dental emergency room visits nationwide doubled from 1.1 million in 2000 to 2.2 million in 2012.
Jones said said she's lost track of how many trips she's made to the emergency room for pain over the years, but said there have been times when it could be two or three times a week. Sometimes the pain would come from one of her rotting teeth, other times it might be from an ear infection caused by her ruptured ear drum.
Danita Mullins, interim director of Washington Regional's emergency department, said the mobile clinic provides an options for patients to follow up and get treatment once they have been seen in the emergency room.
Dentist offices
Northwest Arkansas also is seeing growth in for-profit dental offices. Several chain clinics have opened over the past year, including the recent opening of Aspen Dental in Rogers. The company is based in Syracuse, N.Y., and has more than 400 offices in 33 states. Michelle Titsworth, office manager for Aspen's Rogers office, said the company sees growth opportunities in the state and could have nine offices statewide in the future.
She said the office sees patients with and without insurance, but every new patient gets a free initial exam.
The American Dental Association's Health Policy Institute reports that dental firms with 20 or more employees increased market share between 2002 and 2012 and very large firms with 500 or more employees increased in annual receipts and number of establishments and employees.
Approximately 3 percent of dental offices in Arkansas were the largest size.
The institute says it expects the trend toward larger, multi-establishment dental practices to continue, driven by changes in the practice patterns of new dentists, a drive for efficiency and increased competition for patients.
Duckworth started his dental practice in Springdale in 1994, and he helped create Bold Dental a couple of years ago. The group has six offices across the area.
"We wanted to have some of the advantages of being bigger," he said. "A lot of the business aspects are handled by people well trained in those areas."
Moore said Northwest Arkansas was a natural place to expand Oklahoma-based Dentures and Dental Services. The company is opening its 35th store Monday in Ozark Center Point Place, just off Interstate 49 on Sunset Avenue in Springdale. The firm also owns Affordent General Dentistry, also opening Monday next door to Dentures and Dental. Together the Springdale offices have 25 employees.
Moore is regional manager and oversees offices in Springdale, Joplin, Mo., and Grove, Okla. The Grove office has seen patients from Northwest Arkansas for years, he said. Dentures and Dental has been around for about 40 years.
The goal is to do everything in one day and offer the lowest prices, he said.
Dental education
Paradise said improved dental education for both patients and practitioners will help more people get care.
"There is a small but growing number of states that are licensing new types of dental health professionals. In Maine there is one called dental health therapists and they can't do everything, but do many of the things people need," she said.
The University of Arkansas for Medical Sciences established the Center for Dental Education in 2012 as a hub for dental education programs at the school. The state does not have a dental school. The center's goal is to improve the oral health in the state through expanded access to dental care and establishing education programs to the increase the number of dental professionals in the state.
The school has a postgraduate dental residency program that started with two residents in July. They provide dental care at a clinic in Little Rock as part of the yearlong program, said Dr. Gene Jines, director of the Center for for Dental Education.
"The program helps graduated dentists transition to practice. They are treating more difficult issues than they would see in school and gain hospital experience," he said.
The hope is that some of those dentists will opt to stay in the state to practice, hopefully helping to fill the gap in some underserved areas, he said.
"There is definitely a distribution problem, especially in the Delta area,'' he said.
Dr. Stephanie Gardner, the school's provost and chief academic officer, said officials are in the early stages of looking at the feasibility of building a dental school in Arkansas. They are hiring a consultant who will help determine the costs, ideal location and whether it is feasible, she said.
"The biggest barriers are having the financial resources to get it off the ground," she said. "We don't know the numbers."
Arkansas ranks last in the nation in the number of dentists per capita. The American Dental Association reports there are 41.7 dentists in Arkansas per 100,000 people; the national average is 62 per 100,000.
Paradise said federal data shows about 41 percent of Arkansans' dental needs are being met, but there is much debate over whether there is a nationwide dentist shortage.
"What you see in dental access across the country is probably not a supply issue but a distribution issue. Dentists are not located in the areas that they are most needed," she said. "Dental decay is almost entirely preventable. We can solve this problem."
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