Training a rural oral health workforce: Effects of rural background on dentist practice choice

Abstract

Purpose

The Regional Initiatives in Dental Education (RIDE) program is an educational track of the University of Washington School of Dentistry that aims to produce leaders who practice in rural areas of the Pacific Northwest. This study assesses outcomes of the first 10 years of the RIDE program. The hypothesis tested is that rural background is the most important predictor of long‐term rural dental practice.

Methods

This descriptive study assessed existing data including graduates' location of practice, demographics, rurality of origin, parental occupation, and practice type over time. Subjects are all graduates of the RIDE program from 2012 to 2021 (N = 80), and range in age from 25 to 50 years. Statistical analyses were utilized to explore associations.

Results

Within the study sample 78% of graduates practiced in a rural and/or underserved area, 32.5% of graduates pursued post‐graduate dental training, 40% participated in Medicaid, and 78% practiced in the Pacific Northwest at the time of analysis (March 2023). Statistical analysis demonstrated a strong association and medium to large effect sizes between both rural upbringing and training sites and established dental practice in a rural region.

Conclusions

Graduates of the RIDE program practice in rural areas in greater proportion compared to the general population of practicing dentists. RIDE graduates from the study period tended to be male, and white, and practice in a health professional shortage area or rural site. The rurality of origin analysis was confounded by the substantial number of graduates from Spokane, Washington, an urban area surrounded by extensive rural territory.

1. INTRODUCTION

1.1. Rural dental workforce shortage

Rural populations face many challenges accessing dental care and experience more oral health complications when compared to urban populations. ¹ , ² , ³ Within the United States significant differences exist in the population concentration of urban and rural areas. ⁴ According to the US Census Bureau, as of 2022, 19% of the population resides in rural regions, although rural areas comprise 97% of the nation's land mass. The remaining 81% of the US population lives in urban areas, which constitute 3% of the nation's land mass. An “urban area” has a population density of more than 1000 people per square mile, and a population of 50,000 or more. ⁴ , ⁵ Defining urban and rural is a complex and nuanced task. Urban and rural areas have varying footprints, which can impact resources regionally. Sociopolitical, ethnic, and racial diversity are additional factors impacting rural designations. As defined by the Census Bureau, “rural” areas include communities near metropolitan cities with populations under 50,000 and remote areas. ⁵

Rural residents are at greater risk for general and oral health problems, in part due to increased tobacco use, lower socioeconomic status, provider shortages, and lack of dental insurance. ¹ , ² , ³ Dental healthcare providers are scarce in rural and remote areas of the US, which reduces access to oral health preventive and treatment services and contributes to higher dental pain, caries, and tooth extraction amongst rural residents. ¹ , ² , ³ Fewer dental specialists practice in rural areas, limiting access to specialty services even when preventive and community health services are available. ³ , ⁶ A health professions shortage area (HPSA) is an area with a shortage of healthcare providers as defined by federal government criteria. Certain facilities (such as a community health center) may also be designated HPSA sites. ⁷ The 2023 US Health Resources and Service Administration (HRSA) report stated over 12,000 additional dentists are needed in HPSA sites to properly meet the needs of the population. ⁸

1.2. Rural career incentivization

Strategies to improve dental access in rural areas at the community level include public health initiatives, water fluoridation, interprofessional oral health education, preventive dental services, and mobile clinics. Implementation of grade school‐based dental programs in conjunction with community health centers can increase access to preventive and community‐based oral healthcare services for children in rural areas. ² , ³ , ⁸ At the provider training level, financial incentives for health professionals (scholarships and loan repayment options), as well as academic programs that include rural community‐based clinic experiences for medical and dental students have also been successfully implemented. ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³ Dental students benefit from rotating through clinical sites in remote regions. ¹⁴ Students expand clinical skills by treating advanced diseases and a higher volume of patients in a smaller clinical setting. Community‐based clinical training enhances students' realization of their importance in bridging the gap in oral healthcare disparities. The overall effectiveness of rural educational experiences varies depending on the amount of time that students spend at remote sites and the quality of supervision. ¹⁴ , ¹⁵ , ¹⁶

Recruitment of newly graduated dentists in rural and underserved regions can be challenging. Contributing factors in choosing rural dental practice include geographic location, population and infrastructure, students’ rural background, loan repayment options, as well as family obligations, mentorship, and career opportunities. When recruiting healthcare providers in a rural community, retention has been associated with the rural background of the provider, less educational debt, rural‐based training opportunities in professional school, lower cost of living, and practice ownership opportunities. ¹⁶ , ¹⁷ The cost of dental education in the United States has significantly increased over the past several decades. According to the American Dental Education Association (ADEA), the average education debt for 2021 dental school graduates was $301,583, with the average for public and private schools at $261,226 and $354,901 respectively. ¹⁸ Student debt may deter graduates from pursuing employment in rural communities when higher‐paying jobs exist in more suburban and urban locations. ¹⁹ , ²⁰

Opportunities for loan repayments and scholarships are promising ways to attract new graduates to rural healthcare. The National Health Service Corps (NHSC) has scholarships and loan repayment options available to health professionals who choose to provide care in specified rural sites. ²¹ The components of NHSC include a federal scholarship program and federal and state loan repayment programs. The healthcare provider receives loan repayment or a scholarship in exchange for service commitment at an NHSC‐approved location in a designed HPSA site. The Public Service Loan Forgiveness (PSLF) program is designed to improve repayment of loans to post‐secondary education students through government‐subsidized loan repayment while working for a qualifying public service employer. ²² Although there is improved short‐term rural practice based upon these incentives, long‐term retention rates are low. Retention of dentists and specialists in rural communities remains a significant problem in the United States. ¹ , ² , ³

>Existing literature is unclear whether the impact of graduates’ rural background is a significant factor in employment outcomes, with some reports of strong influence in long‐term retention rates while others suggest minimal impact. ¹¹ , ¹² , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ The relatively small number of publications to date report the strongest independent predictors as prior rural experiences and pre‐placement rural intentions. A 2016 meta‐analysis of new dental school graduates and the rurality of dental practice reported a combined odds ratio of 4.1 for rural educational exposure and the intention to work in a rural area. Clinical rotations in rural areas were slightly more influential than the recruitment of dental students from rural backgrounds. ²³ Implementing clinical rotations in rural communities during dental school and targeting enrollment of students with rural backgrounds are both effective strategies to address the deficiency of dental healthcare practitioners in rural, underserved locations. ¹⁴ , ²³ , ²⁴ , ²⁵

1.3. Community‐based dental education

Community‐based educational models are gaining popularity in dental training programs, wherein students receive clinical training in school‐affiliated community clinics and/or private dental offices outside of the dental school campus. ¹⁶ Most fourth‐year dental school students in the United States partake in external clinical rotations in underserved and/or low‐income settings. ²³ Community‐based dental education (CBDE) positively affects student interest in practicing at community‐based dental clinics in rural & underserved regions. Multiple dental schools have reported outcomes in rural practice after implementing CBDE programs to address shortages of oral healthcare professionals in rural regions. ¹⁴ , ²⁴ , ²⁵ , ²⁶ , ²⁷ At least 8 weeks of CBDE has been identified as a duration that enhanced education experiences for dental students and promoted community practice commitment. ¹⁴ , ²³ , ²⁴ The University of Minnesota, East Carolina University, A.T. Still University, University of Michigan, University of Colorado, and West Virginia University have all reported CBDE positively impacting student attitudes towards rural practice and the choice of rural practice after dental school. Among the reasons cited for the effectiveness of CBDE are the increased number of procedures performed by learners, building relationships in rural settings, addressing access to care challenges, and lifestyle differences. ¹¹ , ^{12 14} , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷

1.4. Description of the regional initiatives in dental education program

Training dentists committed to rural practice is a foundational principle of the University of Washington School of Dentistry (UWSoD) Regional Initiatives in Dental Education (RIDE) program. Begun in 2007, RIDE is collaboratively administered by the UWSoD, Eastern Washington University (EWU) in Spokane, Washington, and the UW School of Medicine WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) program. RIDE enrolls cohorts of approximately eight students annually as an educational track of the UWSoD. The program provides rigorous community‐based education both clinically and didactically that prepares dentists to serve rural communities and to be leaders in the profession. ² , ¹¹ , ²⁸ RIDE students begin dental school with a 1‐week orientation in Seattle at the University of Washington, followed by a 5‐week long interprofessional Early Clinical Immersion (ECI) course. After the ECI course, RIDE students move to EWU where they spend the remaining 1^st year of dental school. ² , ²⁸ RIDE students maintain communication with the UWSoD Seattle campus through distance‐learning technologies, virtually attending courses with their colleagues from the Seattle campus. Beginning second‐year RIDE students take part in the Rural Underserved Opportunities Program (RUOP), a 4‐week long, immersion experience rotating at affiliated Community Health Center (CHC), Federally Qualified Health Center (FQHC), and tribal dental clinics in rural regions of Central or Eastern Washington (Figure 1). After RUOP completion RIDE students return to the UWSoD Seattle campus, where they spend the 2nd and 3rd years of dental education and continue building clinical skills by participating in comprehensive clinical training. After the completion of the fourth‐year fall quarter at UWSoD Seattle campus, RIDE students return to Central or Eastern Washington to complete their clinical training in community sites. ² , ²⁸

FIGURE 1.

Map of Regional Initiatives in Dental Education (RIDE) affiliate sites and health professions shortage area (HPSA) designations in Washington.

The collaborative education model is a key component of the RIDE program. Rural providers must understand the strong relationship between an individual's oral and overall health and collaborate with other healthcare professionals (primary care physicians, nurses, pharmacists, social work specialists, dental hygienists, etc.) to ensure comprehensive care in the rural setting. RIDE works closely with UW School of Medicine's regional education program, which includes seven regional medical training sites in the WWAMI region. ²⁸ The partnership between EWU's School of Dental Hygiene and RIDE supports interprofessional education for dental students and dental hygiene students, promoting team building and collaborative oral healthcare. ²⁸

The purpose of this study is to assess the effect of rural background and other factors, on dental practice choice for graduates of the UWSoD RIDE program for the first ten years (graduating classes of 2012–2021). The hypothesis tested is that the rural background of the dental student is the most important predictor of rural and underserved dental practice.

2. METHODS

This study was reviewed by the Institutional Review Board at the University of Washington and was exempted. The US Department of Education Family Education Rights and Privacy Act (FERPA) is a federal law that protects the privacy of students’ education records. FERPA allows schools to disclose records without consent under the following conditions: audit or evaluation purposes and organizations conducting research studies on behalf of the school/program. ²⁹ This study complied with FERPA requirements by using anonymized data that was reviewed by the UW Office of the Registrar prior to analysis by authors Arsen A. Melkonyan, Kristopher Kerns, and Anna R. Forsyth. Only RIDE administrators and authors Frank A. Roberts and Natasha M. Flake maintain the link to the de‐identified data as part of routine program assessment and recordkeeping.

Subjects (N = 80) were graduates of the UWSoD RIDE program from 2012 to 2021. The subjects ranged in age from 25 to 50 years.  Data included demographics of the physical location of practice, graduating class year, RIDE provenance (or “home territory”) during dental school, the practice of dentistry or specialty residency, sex, ethnicity, year of birth, and practice address. Additional variables included practice in Community Health Center (CHC), Health Professional Shortage Area (HPSA), Rural‐Urban Commuting Area (RUCA) Code of practice, self‐reported Medicaid proportion of the patient population, post‐graduate training, and self‐reported leadership. RUCA codes are census‐based classifications, that measure population density, urbanization, and daily commuting to characterize rural/urban status. In this study, ZIP codes were used to assign RUCA scores referencing the ‘USDA Economic Research Service US Department of Agriculture’ zip‐code file. A higher RUCA score generally indicates more rurality (Figure 2). ³⁰

FIGURE 2.

RUCA Categorization—WWAMI RUCA Rural Health Research Center Rural‐Urban Commuting Area (RUCA) Primary Codes Classification System.

The primary outcomes of interest were rural practice and staying in a rural practice over time. The variables included rural upbringing and where the graduates completed RUOP and CBDE training. Data was analyzed to assess the relationship between parental home ZIP code and/or RIDE provenance (representative of rurality of upbringing) and practice in a rural area after graduation. Statistical analysis for the association between the RIDE training sites and rural practice in Washington state or a WAMMI region post‐graduation was performed. Additional data were analyzed to assess ethnicity, in‐state status, parental occupation, and gender, in relation to rural practice following graduation.

De‐identified data was imported into R studio, Vienna, Austria, (v. 2022.12.0.353) and analyzed using R statistical software (v 4.2.2). Descriptive statistics for categorical and dichotomous variables were assessed using the tbl_summary() function as part of the “gtsummary” package (v. 1.7.0). The Fishers Exact test was performed using the fisher_test() function as part of the “rstatix” package (v. 0.7.1) and was adjusted for False Discovery Rate for multiple testing. ³¹ Effect size of the association was assessed using the Cramer's V statistic with the cramer_v() function from Cohens' D statistic using the chones_d() function within the “rstatix” package (v. 0.7.1).

3. RESULTS

 Table 1 displays demographic data for the 80 UWSoD RIDE graduates (2012 – 2021), 50 (63%) male and 30 (37%) female. Twenty‐three out of 30 (77%) females and 39 out of 50 (78%) males were practicing in rural and underserved regions. Twenty‐seven (34%) were from a rural county/region, whereas 28 (35%) were not, 10 (13%) were from out‐of‐state, and for 15 (19%) no information was available for parental zip code. In the absence of parental zip code data, RIDE provenance was used as an alternative home location. The RIDE provenance is designated by admissions administrators at the beginning of the program, taking into account the student's background and location preferences. Twenty‐six (32.5%) graduates pursued post‐graduate training, including 13 Advanced Education in General Dentistry (AEGD) and General Practice Residency (GPR), four pediatric dentistry, two endodontics, one anesthesiology, two periodontics, two orthodontics, and two oral and maxillofacial surgery. Fifty‐seven (71%) were white, 13 (16%) were of Hispanic descent, eight (13%) were of Asian descent, and two (2.5%) were of Native American descent. When categorizing parental occupations, the international standard classification of occupations (ISCO‐08) grouping was utilized:32 Manager (10%), Not seeking employment (15%), and Professional (22%) comprised nearly half of the reported parental occupations. Eighty‐seven percent of students who went to high school in WA ended up practicing in the WWAMI region.

TABLE 1.

Demographics data for University of Washington School of Dentistry Regional Initiatives in Dental Education (RIDE) participants (2012–2021).

	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	Total	%
Total graduates	7	8	8	8	8	9	8	8	8	8	80	100%
Sex
Male	5	3	7	4	7	5	5	4	5	5	50	62.5%
Female	2	5	1	4	1	4	3	4	3	3	30	37.5%
Age Group
25–29	2	4	6	4	6	7	8	6	6	5	54	67.5%
30–35	5	4	2	3	2	2	0	2	1	2	23	28.8%
36–39	0	0	0	0	0	0	0	0	1	1	2	2.5%
> 40	0	0	0	1	0	0	0	0	0	0	1	1.3%
State Practicing/Residency
WA Only	6	5	6	6	6	7	6	6	5	5	58	72.5%
WAMI	0	2	0	0	0	1	1	1	1	0	6	7.5%
Out of State	1	1	2	2	1	1	1	1	2	3	15	18.8%
Missing data	0	0	0	0	1	0	0	0	0	0	1	1.3%
County Practicing
East	1	0	1	3	0	0	3	1	2	0	11	13.8%
South Central	1	0	0	0	3	1	2	0	1	1	9	11.3%
North Central	2	1	2	1	0	1	0	1	1	3	12	15.0%
North West	1	2	1	0	0	0	0	0	0	0	4	5.0%
South West	0	0	0	1	0	1	0	0	0	0	2	2.5%
West	0	0	0	0	0	0	0	0	1	0	1	1.3%
North	0	0	0	0	0	0	0	1	0	0	1	1.3%
Puget Sound	1	2	2	1	3	2	1	3	0	2	17	21.3%
Out of State	1	3	2	1	1	1	1	2	2	2	16	20.0%
Missing Data	0	0	0	1	1	3	1	0	1	0	7	8.8%
Rural Upbringing
Yes	4	3	1	2	3	3	2	3	2	4	27	33.8%
No	3	2	2	2	4	4	2	4	4	1	28	35.0%
Out of State	0	1	1	1	1	2	1	0	2	1	10	12.5%
Missing Data	0	2	4	3	0	0	3	1	0	2	15	18.8%
Specialty Training
Yes	2	4	4	1	2	2	3	2	0	6	26	32.5%
No	5	4	4	7	6	7	5	6	8	2	54	67.5%

At the time of data analysis (March 2023), 76 (95%) of the RIDE graduates were actively practicing. Sixty‐two (82%) were practicing in rural/underserved communities, 47 (62%) in rural/underserved practice in Washington state, and 53 (70%) in rural communities in WWAMI designated regions. Fifty‐nine (78%) were practicing in the state of Washington and 36 (47%) were practicing in Eastern Washington. On average 69% of students were practicing in rural/underserved regions including CHC and HPSA. Graduates working in a rural or underserved region increased from 39% in 2014 to 79% in 2021, portraying a significant upward trend in rural or underserved practice (Figure 3).

FIGURE 3.

Regional initiatives in dental education (RIDE) graduate rural practice over time.

3.1. Statistical analysis—effect of rural upbringing

The Fisher exact test was used to evaluate the association between the home RIDE Provenance and location of practice rurality (p < 0.001). To adjust for multiple testing, the False Discovery Rate (FDR) correction was used, with the Q‐value representing the adjusted P‐value. After adjusting for multiple tests, the association between RIDE graduate rural upbringing and rural practice was highly significant. Cramer's V statistic on the Fisher exact results was used to determine the effect of this association between rural parental zip code and rural practice. The Cramer's V effect ranges from a scale from 0 to 1, based on the degrees of freedom. The degree of freedom was 4 and an effect of 0.431. When testing the association between the rurality of RIDE provenance and choosing to practice in a rural and underserved area, a significant association with a large effect size was noted (p < 0.001, q < 0.001, Cramer's V = 0.431). Similar findings were noted when the rurality of parental ZIP code was used instead of RIDE provenance (p < 0.001, q < 0.001, Cramer's V = 0.418). A slightly smaller effect size was noted, although the results could be because for 19 (24%) individuals no parental home zip code was provided during data collection.

3.2. Statistical analysis—effect of RUOP and CBDE location

Where RIDE participants completed their training had a significant impact on their practice site/location with a medium‐to‐large effect of (0.246 → 0.25). All sites that train RIDE students are considered dental HPSA sites, even though one, Spokane, Washington, is in a ‘Metropolitan’ area. When testing the association between RIDE students’ training sites and practice location, a significant association with a medium‐to‐large effect size was noted (p = 0.026, q = 0.026, Cramer's V = 0.246).

4. DISCUSSION

Rural health workforce shortages in medical and dental professions are well documented. ¹ , ² , ³ Proposed solutions include preventative public health initiatives, mobile clinic services, financial incentives for health professionals (scholarships and loan repayment options), and community‐based training. A significant limitation in CBDE training is if students rotate only during their senior year, at which time most have already made significant career decisions or are applying for residency training. The RIDE program incorporates CBDE as early as the first year of training, allowing students a prolonged period of study in which to gain clinical skills in rural and underserved educational settings.

This study assessed outcomes for the first 10 years of RIDE graduates. Our findings demonstrate statistical significance regarding RIDE students’ rural upbringing and the rurality of training sites associated with practice in rural and underserved regions after graduation. We found positive associations between the rurality of training sites and working in rural and/or underserved regions post‐graduation. These findings are consistent with previous research in that providing students with rural and community‐based dental opportunities during dental school is effective in encouraging graduates to choose rural practice. ¹¹ , ¹² , ¹⁴ , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ Of note is that while approximately two‐thirds of RIDE graduates were male when examining the graduates practicing in rural and underserved areas, near gender parity was observed.

This data has been captured cross‐sectionally over a decade, and because of that, we are not adjusting for changes in the size of towns. An additional limitation was the small sample size (n = 80) with each cohort comprising approximately eight participants. Given that UWSoD's entering class size is about 63 students, the RIDE program participants comprise approximately 12% of the total dental school class size. Select data was self‐reported and for purposes of our study, there was missing data/information within each cohort, which impacted the overall findings. Data regarding acceptance of Medicaid insurance and leadership was self‐reported and bears further investigation in a more formalized manner. An additional variable of interest that was not investigated in this study due to lack of data is the family obligations of the graduate, including partnership/marital status.

A confounding factor in the analysis was the fact that Spokane, Washington, was a location of origin for many (13.75%) of the graduates. While Spokane itself is a metropolitan area with a RUCA code of 1, it is surrounded entirely by rural counties and is the only metropolitan hub in Eastern Washington. Further analysis of the dental practice choices of graduates originating from Spokane is warranted as the RIDE program continues.

Further areas for exploration related to the findings of this study include more granular definitions of urban versus rural in the realm of healthcare practice. Additional confounding variables meriting additional investigation include diversity and sociopolitical issues in rural America, components of CBDE that support long‐term rural practice, and the marital or partnership status of program graduates.

5. CONCLUSIONS

Graduates of the RIDE program practice in rural areas in greater proportion compared to the general population of practicing dentists. Statistical analysis demonstrated a strong association with rural upbringing and practice in rural and/or underserved regions post‐graduation. Statistical analysis demonstrated a strong association with the rurality of training sites and practice in rural and/or underserved regions post‐graduation. Of the RIDE graduates, 77% of females and 78% of males were practicing in rural and/or underserved regions. Fifteen percent of RIDE graduates were of Hispanic or Native American descent, with 50% of these practicing in rural and/or underserved regions. Training a rural oral health workforce is multifaceted and warrants further investigation and expansion to meet the oral healthcare needs of all communities.

Forsyth AR, Melkonyan AA, Kerns K, Flake NM, Greene RM, Roberts FA. Training a rural oral health workforce: Effects of rural background on dentist practice choice. J Dent Educ. 2025;89:177–185. 10.1002/jdd.13713