Rural Dentistry: Opportunities for the Next Millennium in Fixed and Mobile Practices

Many dentists assume that practice in California’s rural counties would be hindered by lower income potential, professional isolation, and lack of specialists for assistance. The evidence suggests otherwise, however. Income data shows that the population of many rural counties can well afford dental care. In addition, new uses of the Internet for teleconsulting and idea exchange has the potential for reducing isolation and providing access to specialized knowledge. Particularly for those practitioners who enjoy the rural lifestyle, such counties offer excellent potential for dental practice.

When one speaks of a rural community, images of bucolic expanses of pasture or farmland and small town squares filled with neighborly people spring to mind. Indeed, locating a dental practice in such an environment is appealing to many who are anxious to embrace the positives of a rural existence or perhaps flee the negatives of the big city. Reduced stress coupled with fewer lines and a dearth of bureaucracy can be a compelling enticement for practicing in rural settings.¹ Since this paper compares and contrasts practicing dentistry in these diverse locales, it is important at the outset to define how the terms "rural" and "urban" are used. Although typically in the United States, an area (e.g., village, town) having a population of greater than 2,500 is considered urban,² the authors here have chosen to use the term more loosely. For this paper, rural counties are defined as those that do not contain any towns with populations greater than 6,000.

Rural Population Growth

As is true of most idyllic images, there are downsides. Enticing dentists to open a practice in a setting where there are no or extremely few practitioners in the surrounding areas, as appealing as it may seem on the surface, can offer a number of unique considerations. The biggest might be the perception that California, the most populous state of the union, has no possibility of harboring such an alternative as a rural practice within its confines. Although much of the population of California is contained in large cities, it is the small rural counties where the biggest growth in population is expected to occur.

Consider, for example, the estimated growth between the years 2000 and 2010 as computed by the Demographic Research Unit of the state of California.³ Table 1 displays these rates as percentages. In the south, the urban counties are expected to have the following population increases: Los Angeles County, 14 percent; Orange County, 10 percent; and San Diego County, 17 percent. In the north, the urban counties of San Francisco, Alameda, and Marin are predicted to increase their populations by 3 percent, 9 percent, and 0 percent respectively over the same period. In the rural counties, the picture is much different. The estimated population increase in the next 10 years for Del Norte is 31 percent, Amador, 35 percent, and Calaveras, 49 percent, to mention only a few.

Table 1 County Population Estimates for 1998 and Percentage Change in California County Populations between 2000 and 2010 Based on Projections Performed in 1996
County	Population Estimate for 19985	% Change3	County	Population Estimate for 19985	% Change3
Alameda	1,400,322	9	Orange	2,721,701	10
Alpine	1,209	23	Placer	229,259	28
Amador	33,334	35	Plumas	20,370	11
Butte	194,597	19.5	Riverside	1,478,838	39
Calaveras	39,830	49	Sacramento	1,144,202	21
Colusa	18,572	26.5	San Benito	48,744	32
Contra Costa	918,200	14	San Bernardino	1,635,234	34
Del Norte	27,000	31	San Diego	2,780,592	17
El Dorado	158,502	25	San Francisco	745,774	3
Fresno	755,730	33	San Joaquin	550,445	27
Glenn	26,234	25.5	San Luis Obispo	234,366	18
Humboldt	122,262	10	San Mateo	700,765	8
Imperial	144,051	22	Santa Barbara	389,502	13
Inyo	18,125	17	Santa Clara	1,641,215	10
Kern	731,459	32	Santa Cruz	242,994	12
Kings	118,866	27	Shasta	164,349	19
Lake	55,147	29	Sierra	3,380	12
Lassen	33,285	13	Siskiyou	44,044	14
Los Angeles	9,213,533	14	Solano	377,415	18
Madera	114,748	30	Sonoma	433,304	14
Marin	236,770	0.005	Stanislaus	426,460	32
Mariposa	15,877	26	Sutter	76,976	40
Mendocino	83,734	21	Tehama	54,073	16
Merced	197,730	33	Trinity	13,117	15
Modoc	9,998	14	Tulare	355,240	27
Mono	10,288	27	Tuolumne	53,248	26
Monterey	365,605	19	Ventura	731,967	18
Napa	119,288	13	Yolo	153,849	26
Nevada	91,334	29	Yuba	60,067	28
3 Data derived from Interim County Population published by the California State Department of Finance 5 Data derived from County Population Estimates for July 1, 1998, published by the U.S. Census Bureau

Active Dental License Holders per County

Nor does one need to wait until the year 2010 to consider practicing in a rural location. In many areas, rural counties presently offer appealingly low numbers of dentists who hold active dental licenses in a particular locale (Table 2). Colusa County in north central California has only four licensed dentists; Alpine County has no active licensed dentists within its boundaries, whereas Sierra County has two.⁴ Admittedly, some of these counties have relatively small populations⁵ (Table 1); however, since growth projections are higher for the rural locations than the urban, these areas demonstrate increasing promise as desirable practice locations.

Individually, population statistics or the numbers of active licensed dentists don’t tell the entire story unless dentist-to-population ratios are computed. Such figures can be eye-opening (Table 2). For example, in Glenn County, the ratio of residents to active licensed dentists averages 4,833 residents per one dentist. Compare this to Los Angeles County, which has a ratio of 1,406 residents for each active licensed dentist, or San Francisco County which has a ratio of 686 per active licensed dentist.

Rural County Incomes

Some fail to consider the possibility of a rural practice, fearing that the income of those who live in the area will not support a dental practice. That may be true for some of the rural locales in California, but it is certainly not true of all. Over the years, utilization of dental services has been shown to be directly correlated with family income.⁶ The National Center for Health Statistics’ National Health Interview Survey reports that in the highest annual income group of $35,000 or greater, nearly three dental visits occurred every year. Those who had less than $10,000 in annual income visited the dental office at a rate of slightly more than once per year. Those with income levels between these two groups sought dental care at a level that fell between the two rates cited.

Since data supplying dental utilization rates for the individual counties in California is not available, median household incomes can be substituted as a proxy for dental care utilization (Table 3).⁷ It is clear that there is a wide range of incomes in the diverse rural counties of California. Examples of this variability as reported by the 1995 estimated median household incomes for counties are $25,124 for Modoc County and $31,012 for Sierra County. For comparisons, the median incomes for selected urban counties are: Los Angeles, $33,828; San Francisco, $37,854; and San Diego, $37,239.

Other economic data that are available to shed additional information on the economic status of each county include Denti-Cal eligibility rates.⁸ Sierra County has an 11 percent eligibility rate whereas Modoc County’s eligibility rate is 23 percent. (For comparison purposes, the eligibility rate for Denti-Cal in Los Angeles County is 14 percent.)

Given these statistics, particularly those that show the numbers of dentists per county, it is probably no surprise that the Office of Statewide Health Planning and Development has deemed that California has a maldistribution of dentists, with many rural areas sorely undersupplied. In 1996, the California Department of Health Services convened a forum to develop recommendations to increase access to dental care for residents of rural areas.⁹

Distribution of Dentists

What are some of the reasons this maldistribution of dentists exists in California in spite of the presence of five dental schools? National figures show that in 1998 graduates left dental school shouldering an average debt of $84,089 (with graduates of private schools owing $108,256).¹⁰ One might understand why these new graduates would not want to immediately open a private dental practice when start-up practice expenses can easily top $250,000.⁹ Since there are so few dentists in rural areas, finding a practice in which to associate or arrange a buy-out may prove difficult. Yet many recent graduates will also state that finding an associateship in a well-regarded office in an oversupplied urban area can also be a Herculean task. Stories of discomfort or downright unhappiness with current prospects or present employment arrangements abound in the experiences of those in their initial years of practice.

Rural Opportunities

What is often unappreciated is that in addition to private practice opportunities, there are numerous federally qualified health clinics and fee for service clinics located in rural areas with jobs currently going unfilled. The Web pages of the California Rural Health Policy Council, an organization established by the State of California, Health and Human Services Agency, to improve rural health (http://www.ruralhealth.ca.gov/ruraljob/jobsearch.htm) displayed 33 ads for health care practitioner positions in rural clinics. One-third of these ads were for single or multiple positions for dentists. Ads in community newspapers in adjacent counties can offer other possibilities. A review of the Oct. 9, 1999, Bakersfield Californian newspaper listed classified ads for dental clinics in San Luis Obispo County and in a rural Indian Health Service clinic.

Providing dental care in a salaried arrangement allows one to meet financial obligations while learning to build efficiencies gained with experience in care delivery without incurring additional debt. It also allows one to sample the experience of living in a rural setting without committing to a permanent relocation. Serendipitously, the contact with the local private practitioners through professional and personal interactions provides opportunities for the new dentist at the clinic in town to become known. Future offers from the local dentists for associateships in their offices as they modify their practices are much more likely to be extended to someone with whom a relationship has already been formed.

Impediments to Rural Practice

So, why aren’t dentists flocking to rural areas if there are jobs available? Are their reasons similar to those of physicians who indicate that they are disinclined to work in rural settings because of the lack of all-around activities, lower standards of living, few spousal career opportunities, and the inability to refer to and consult with local specialists.⁹

At an international meeting, one of the authors had an opportunity to interview two Canadian dentists who practiced far from the urban areas of their country. One was located in a town of 4,000 to 5,000 and the other in a town of 10,000 to 12,000. Although one was originally raised in a large city, both extolled the virtues of practicing in small towns. They liked being general dentists providing every type of dental service they felt comfortable performing. They liked treating families and noted that they have a lot of children in their practices. They enjoyed the absence of competition for their services. Neither seemed frustrated by the lack of specialists for referrals for they felt that the desires of their patients were for basic dental care that was well within their repertoires. Of course, specialists are not totally missing from the rural picture. In the larger Canadian town, the general dentist explained, a visiting periodontist was available on an as-needed basis, although most of the more common specialists’ practices (endodontics, periodontics, pediatric dentistry, orthodontics) are a distant 50 miles away. Professionals with knowledge in less common areas (Of course t (orofacial pain, oral medicine, infectious diseases, oncologists, etc) are likely to be even more distant. Although w(With the advent of online education and telehealth consulting options via the Internet, however, even this problem will be a thing of the past. Future models predict the end of the need and for a patients won’t have to take a full day and a 100-mile round trip to obtain geta specialist’s consult)). Neither dentist feels that he is enjoying a lesser quality of life. In fact, both love the outdoors and their proximity to hunting, fishing, and winter sports.

Since California dentists might not harbor the same attitudes as those of their Canadian counterparts, interviews of a handful of rural dentists in this state were arranged. Admittedly, their responses can hardly be considered to be obtained under a rigorous scientific protocol. However, this anecdotal information may help to shed light on the opportunities and pitfalls of rural dental practices in California. Similar questions were asked (by R.M.) of the California dentists as were asked of the Canadian interviewees.

The California dentists also praised previously cited attractions of small town life: the slower pace, closer community bonding, outdoor lifestyle, and positive experiences growing up in a small town. were all high on the list for our California interviewees. In addition, escape from big city crime was alsocited.

Urbanites perceive that the positive attributes of a small town atmosphere are unable to offset significant declines in the social and economic needs of the dentist and his or her family that occur whether the dentist becomes a salaried employee of a clinic or works as a private practitioner. On the economic side, the ads referred to on the Web site above posted salaries that compared favorably with many urban opportunities. In addition, during interviews it became clear that a number of these clinics provide incredible incentives to lure dentists to their areas, including substantial assistance in the repayment of education loans and generous continuing education benefits. Some clinics are so desperate for dentists that they are paying finder’s fees to the referral source for the successful referral of an employable dentist.

The dentists Iinterviewed were quite satisfied with their respective incomes. The consensus seemed to be that the income was less, but only slightly, and more than offset by factors such as the lower cost of living, minimal employee turnover, higher profitability, no arduous commutes to work, and so forth.

None of the dentists found spousal employment to be an issue, although one reported that the local hospital has problems recruiting physicians if the spouses have careers not typically found in small towns. In particular, those spouses of dentists who were teachers found positions in the local schools easier to secure than in the city.

What some dentists view as a positive -- the strong sense of community and accountability for each other -- others interpret as life under a microscope, with few professional or personal secrets. Or to put it in the words of one dentist "Since everybody knows you, . . .you have to leave town if you want to dance on the piano top with a lampshade on your head." Knowing everyone and everything about one’s patients, their friends, and their family can breed a familiarity that easily invites interruption at the grocery store, during a dinner out, or at other times when a break from providing professional services and opinions would usually be expected.¹

A personal style that thrives on such informality and familiarity is a prerequisite for success. On balance, the interviewees felt that the tradeoffs were well worth the occasional personal inconvenience that their visibility in the community causes.

Alternative Strategies for Care Delivery

From another reality of rural practice is that there are some communities any sites in California and elsewherethere are towns with too fewer inhabitants people than the two where our interviewees were located. In some cases towns may be too small to support a full-time dental practice. Alternatives to practicing in a fixed location changing the service delivery method may makepositively affect the feasibility of a rural practice. more feasible. Whereas in far-flung wilderness areas without adequate roads, the dentist may fly in with a team to provide dental care,¹ in California if a rural population is not large enough to sustain a practice, a mobile clinic operating from a nearby area where a practice is sustainable is an option. Using the mobile clinic during the better weather of the summer to reach more remote populations in mountainous terrain in a combined holiday/working getaway may be a practical and fun approach.

Yet, Mobile dental clinics are frequently downplayed as a strategy for reaching rural populations. They do require planning and organization to operate. Thirty-four years of experience operating theThe longest running mobile dental clinic program serving the residents of rural communities in California is the University of Southern California’s Mobile Dental Clinic has shown that repeatedly.. In its 34th year of existence,the The USC Mobile Clinic’s mission of the USC Mobile Clinic has not changed: to bring high quality dental care to members of low-income families in California who are unlikely to have access to or receive dental care iand n their current environs while at the same time to involveing dental and dental hygiene students in community dentistry and public health educational outreach programs. SWhat has changed is the scope of its operation. Since its beginning in 1965, the clinic has functioned operated continuously.. Initially prepared to Initially treatment was limited to mmanageing only the most serious dental problems to relieve pain and infection, i. It was not long before equipment was constructed so that routine dental care (restorations, extractions, and prophylaxes) could be provided. Each seven-day clinic now results in comprehensive care provided to 200 children. in addition to extractions and dental prophylaxes. Since its launch, then the USC Mobile Dental Clinic has provided care in more than 70rural communities in California to 75,000 children.

Increasingly, more and more of the communities theThe USC Mobile Dental Cclinic visits are in the rural counties of the state. today has out of necessity expanded its operation 10 fold. Each seven-day clinic now results in comprehensive care provided to 200 children. For years, because of the geographic expanse of the state, Previousclinical sites were limited to ruralcounties in southern and central California. have been expanded to additional clinics held in the northern counties of California. Within the past year, as aSuch expansion was result of identified shortages of dental care opportunities in the northern rural counties of California, the operation has been expanded into those areas as well..ose areas.

The USC Mobile Clinic has for some time been fully booked two years ahead by agencies and organizations and at times even individuals that contract with it for services year after year as the need for dental care in far-flung parts of the state seems endless.

Using the USC Mobile Dental Clinic as an example, the financing of a mobile clinic operation may readily be met by a variety of funding sources. In spite of its sponsorship by the dental school, since 1971 the mobile clinic has operated exclusively from contracts, grants, and private donations. The new northern California clinical venues are financed through a grant from Delta Dental. Frequent contributors and contractors include the Bureau of Migrant Education;, Sstate programs including Denti-Cal and Healthy Families;, numerous county governments, local hospitals, and foundations;, civic groups such as Kiwanis clubs;, and individual donors such as former students, practicing dentists, and the lay public who hear about the work of the clinic. A Web site that enumerates federal, state and private funding sources for rural areas of California can be found at http://www.ruralhealth.ca.gov/funding.htm.

Antidotes for Isolation

Isolation from peers, specialists, and continuing education opportunities are negative aspects of a rural practice cited in the literature and by some of the interviewees. One dentist interviewed left a rural practice 25 years ago in part because of the isolation. Rural dentistry was frequently cited by interviewees as requiring a command of a wide variety of general dentistry procedures and therefore a need for ongoing continuing education in a variety of areas.¹¹ Modern electronics including computers, video teleconferencing, and interactive television are all part of the emerging health care technology that is particularly well-suited for rural practices.¹² Although use of computers in dentistry appears to be gaining ground, all areas of potential use are not equivalent. Whereas 66.8 percent of dentists have office computers, a 1994 study indicated that only 7.5 percent of the 48.3 percent who had computers equipped with modems participated in on-line discussion groups; and 19.7 percent used e-mail.¹³ A 1996 study of Internet-using dentists indicated that 19 percent of the respondents participated in Internet continuing education courses.¹³¹ Twice that rate were planning to use the Internet for access to continuing education in the future.¹⁴ A 1997 study indicatedpointed out that 32 percent of dentists with computers used them for diagnosis and monitoring treatment.¹⁵

The uses of the Internet for rapid access to experts for consultations through teledentistry and telemedicine, free Medline access from the National Library of Medicine, on-line library access for reprint services, on-line texts and databases for the latest treatment protocols, evidence-based medicine care models, and drug interaction information are only a few of the possibilities that help to eliminate the isolation of a rural practice from intellectual pursuits and provide access to specialists as a result of this electronic age. Connectedness with other dentists can easily be achieved through e-mail, listservers, and chat rooms dedicated to the specific professional interests of the dentist. Dentists have commented that that the sense of professional isolation they previously experienced has been reduced with their participation in an on-line discussion list.¹⁵³ E-mail has been shown to be an important way to rapidly distribute new or evolving material to health care providers at extremely low cost.¹⁶ Videoconferencing in telehealth models is a particularly attractive model for rural sites.¹⁷ Consultations can be achieved no matter how remote the source through telecommunication with specialists in a variety of health care disciplines that previously would have seemed unlikely participants in such a venture. Witness the telepsychiatry program in eastern Oregon.¹⁸ Can the fields of oral medicine and orofacial pain be far behind?

Summary

Final Caveats

It is apparent from the experiences with the USC Mobile Dental Clinic and data from organizations interested in rural care delivery that thousands of young people are still not receiving dental care in rural California, though children have many more programs targeted to them than adults. The rural adult population faces an even more severe problem in obtaining care, since typically the treatment needs of the adult population are much more complicated as a result of accumulated years of lack of treatment and available services.

Practicing dentistry in the rural areas of California offers a great deal in the way of availability and opportunity. Many of the negatives associated with such practices have been neutralized through communication advances and the realization that quality of life in rural settings may in mvarious any ways exceed that of urban environs. When interviewees were asked what words of wisdom they would extend to recent graduates about practicing in a rural environment, they were upbeat regarding the professional and personal satisfaction of living their lives in a rural setting. They did recommend that each person considering such a choice look at the advantages and disadvantages with their eyes wide open to be sure the match will be a fortuitous one.

Although this paper has attempted to provide an accurate representation of a variety of factors one could consider when making a practice location/employment decision, there are many intangibles, personal and impersonal, to be considered. No matter how comprehensive the database is, some information is just not available without the investment of personal time and energy in meeting and talking to the populace and potential employers and/or colleagues, observing first hand the culture and energy of the people and place. From the business perspective, for example, there is no database that would give the proportion of dentists in each county nearing retirement (or just considering cutting back), presently working part-time, or no longer accepting new patients.

The goal of this paper was not to provide all the answers but to pique the readers’ interest in a professional opportunity not previously considered as feasible. Nothing will replace the individual’s investigation, on paper and in person, of such an important life decision. Such research is to be encouraged so that more people can consider practicing dentistry in the less populated and dentally needy localities of the state.

Acknowledgments

The authors would like to thank the dentists interviewed for this article: Dr. Ken Welch, Lake Cowichun, and Dr. Perry Vitoratos, William’s Lake, British Columbia, Canada; and Dr. Virginia Meek, Ukiah; Dr. Dick Reimers, Sacramento; and Dr. Cindy Lyon, Murphy, Calif.

Authors

Roseann Mulligan, DDS, MS, is a professor and chair of the Department of Dental Medicine and Public Health at the University of Southern California School of Dentistry.

Charles Meyer Goldstein, DDS, MPH, is a clinical professor of dentistry and chair of the Section of Community Dentistry and Public Health in the Department of Dental Medicine and Public Health at the USC School of Dentistry.

Randall E. Niederkohr, DDS, is an assistant professor of clinical dentistry and director of the USC Mobile Dental Clinic for the Department of Dental Medicine and Public Health at USC.

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To request a printed copy of this article, please contact/ Roseann Mulligan, DDS, MS, Department of Dental Medicine and Public Health, USC School of Dentistry, 925 W. 34th St., Room 4338,

Los Angeles, CA 90089-0641.