Abstract
Background
To address access to dental care and oral health inequity issues comprehensively this project aimed to 1) develop, test and demonstrate a community-based recruitment of oral health workforce capacity in severely underserved areas of Oregon, 2) develop a retention toolkit with the potential to increase the longevity of providers in Dental Health Professional Shortage Areas (DHPSAs), 3) expand the pipeline of oral health professionals willing to practice in rural underserved counties of Oregon through experiential learning, and 4) demonstrate that a teledentistry model would be applicable in severely underserved areas.
Methods
Administrative changes to state loan repayment initiatives were used to leverage recruitment efforts of dental workforce to DHPSAs. Senior dental students on community-based rotations were surveyed about what factors were important to them in choosing a practice location and what their preferred location of practice was after graduation. Counties severely underserved by dental care services were offered teledentistry-supported dental care in community health centers within the framework of the virtual dental home model.
Results
Both dentists (n = 62, 80.5%) and expanded practice dental hygienists (n = 15, 19.5%) were recipients of the state loan repayment awards. Of 117 senior dental students 57 responded (49%) to the survey. The factors of greatest importance for their practice choice were clinic characteristics, clinic and community support, geographic location, and future opportunities with some gender differences. Clinical oral health care in counties without dental clinics was provided in collaborating community health centers supported by teledentistry led by expanded practice dental hygienists.
Conclusion
The combined efforts of the state, dental education, local administrators and clinicians can be successful in addressing the complex problem of access to and utilization of dental care and providing oral health care to underserved populations. Innovative financial, educational, clinical, administrative and human resource methods must be used collaboratively to induce dental graduates to choose practice locations outside of major urban centers and retain their longevity.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-025-05722-y.
Keywords: Dental workforce, Dental students, Competency-based education, Dentally underserved area, Oral health, Rural health services, Teledentistry
Introduction
Access to dental care has been a persistent problem in American oral health care closely related to oral health inequities [1]. The reasons for disparities in oral health are complex. In many instances the underlying factors are socioeconomic [1]. In other cases, disparities are exacerbated by the lack of community programs such as fluoridated water supplies (for instance, only 26% of Oregon’s population reside in a fluoridated community, one of the lowest in the nation) [2]. People’s access to and use of dental services may be hindered by a lack of transportation to a clinic and inflexibility in getting time off from work to address health needs [1]. Lack of resources to pay for care, either out of pocket or through private or public dental insurance, is clearly another barrier. Irrespective of age, income level, or type of insurance, more people reported financial barriers to receiving dental care than they did for any other health care [3]. The implication is that low-income individuals and families, such as Medicaid eligible beneficiaries, are especially vulnerable to a lack of access to dental care.
The Patient Protection and Affordable Care Act (ACA), implemented by Congress in 2010, mandated preventive and routine oral health care as an essential health benefit for children covered by Medicaid [4]. For Medicaid adults, dental care was optional for health insurance plans. In addition to Oregon’s dental program for Medicaid children [5], the state chose to extend its Medicaid program in 2014 to an expanded population (up to 138% of the federal poverty level) increasing the Medicaid population from around 630,000 in 2013 to 964,000 in 2017 and around 1.5 million in 2023 [6]. Simultaneously, the state expanded adult dental care coverage from the traditional emergency services only to a comprehensive preventive and routine dental care program [7], which have put further access strains on the otherwise unchanged dental care delivery system [8].
The National Institutes of Health 2021 follow-up report on Oral Health in America highlighted the critical links between oral health, the utilization of dental services, and dental workforce issues [9]. The report emphasized some areas that had improved since the 2000 report (such as children’s oral health and access to dental care), but also pointed out that major areas had stood still or deteriorated (for instance adult oral health, access to dental services, and diversity of the dental workforce). These interconnected challenges will require a multifaceted approach involving policy changes, innovative care models, enhanced education and training, and a commitment to increasing workforce diversity. The report observed that by tackling these issues holistically, oral health outcomes can be improved, and disparities in dental care access reduced [10].
Traditionally, access to health care has been linked to health professional shortage areas (HPSAs). The concept was expanded to comprise dental HPSAs (DHPSAs) in the 1990s [11]. In Oregon, 33 of the 36 counties have designated DHPSAs based on socioeconomic status as well as provider ratios in the local community [12]. Oregon has a dentist to patient care ratio of 0.5 Full Time Equivalent (FTE) per 1,000 people, with rural and frontier areas averaging 0.3 FTE. All 25 primary care service areas lacking any dentist FTE are situated in rural or frontier areas [13]. However, more recent analyses have shown that the raw dental provider ratio is an insufficient indicator for access issues, because most of the dentists in the state are unavailable for Medicaid patients (57% are not enrolled Medicaid providers and another 15% are enrolled but have no Medicaid patients). Only 17% of the dentists have 100 + Medicaid patients [14].
This imbalance partially relates to the workforce’s racial/ethnic composition, with more dentists being white, while non-white dentists are more likely to treat Medicaid patients [15, 16]. Additionally, under-recruitment of dental students from rural backgrounds may worsen the issue, as studies indicate that dental students from rural backgrounds are more likely to work in rural areas after graduation [17, 18]. To increase dental students’ awareness about a career working with vulnerable population groups such as Medicaid beneficiaries in rural areas, it is therefore of special importance to both recruit dental students from more diverse backgrounds and to expose students to real life working conditions by including extended community-based clinical experiences in the dental curriculum [19–21]. However, questions remain about how to ensure these graduates stay in the community and what personal, financial, and environmental factors will determine their longevity [22, 23].
To expand the availability of a sustainable dental workforce teledentistry has been shown to provide an effective alternative to traditional stationary dental clinics, particularly in locations experiencing significant shortages of dental professionals [24]. An earlier longitudinal project in Oregon implemented a teledentistry practice project based on the Virtual Dental Home model, allowing Expanded Practice Dental Hygienists (EPDHs) to deliver oral health screenings and preventive services, including interim therapeutic restorations, to school children [25]. We believed that the experiences gained from this project could be extended to a broader population in the current initiative, given that smaller underserved counties lacked stationary dental clinic facilities and were relying on temporary and unstable solutions [25].
The challenges described at the national level are clearly reflected at the state level. To address these issues, the Oregon Health Authority (OHA, Primary Care Office) in collaboration with Oregon Health & Science University (OHSU, Department of Community Dentistry, now the Division of Dental Public Health, and the Oregon Clinical and Translational Research Institute (OCTRI)) launched a multi-year joint project. This initiative aimed to address as many of the identified challenges as possible with the goal of improving access to dental care in underserved communities and the population oral health.
The specific goals of the project were to:
Develop, assess and demonstrate an innovative, community-based approach to recruitment of oral health workforce capacity in areas of Oregon with the greatest unmet oral health needs.
Create a retention toolkit in Dental Health Professional Shortage Areas (DHPSAs) to increase the longevity of providers in these areas.
Expand the pipeline of oral health professionals willing to practice in rural underserved counties of Oregon through experiential learning.
Demonstrate the applicability of a teledentistry model in severely underserved areas to address the lack of a stable dental workforce.
Methods
The project was conducted from 2018 to 2023. Both clinical and educational activities were impacted by temporary closures due to the COVID-19 pandemic. However, most of the planned activities were successfully completed, albeit with some delays. Institutional Review Board (IRB) approval from OHSU was obtained for collecting survey data from students (STUDY00020330) and for the clinical teledentistry part (STUDY11534). Due to the multi-faceted nature of the project, a variety of methods were developed and applied to address each of its goals:
Identifying target counties and stakeholder engagement
Using available demographic and workforce data, five rural counties were identified as particularly underserved: the southern coastal counties of Josephine (population 87,060), Coos (population 64,065), and Curry (population 22,605), as well as the upper-central counties of Gilliam (population 1,985) and Sherman (population 1,780). These counties are referred to as the “targeted counties”. Supportive activities also involved workforce development in other eligible counties, referred to as “non-targeted counties”.
Initial site visits to the targeted counties were conducted to gather feedback from local stakeholders on strategies to effectively recruit and retain oral health care providers. Clinic administrators, providers, and representatives from community-based organizations informed the Oregon Health Authority (OHA) about gaps in the oral health workforce, barriers to recruitment and retention, infrastructure limitations, and issues in increasing Medicaid dental care utilization.
The Health Care Provider Incentive Program (HCPIP), created in 2017 by OHA’s Primary Care Office, was leveraged to unify the state’s various healthcare workforce incentives. The program’s Loan Repayment Program served as the primary tool to provide state matching funds for recruiting and retaining dental providers [26].
Retention focus for existing providers
In addition to financial incentives aimed at encouraging new graduates to practice outside metropolitan areas, retention efforts targeted dentists and dental hygienists already working in underserved communities. Focus groups with local community leaders and healthcare staff identified key factors influencing retention. These included:
Compatibility between providers and clinics,
Implementation of orientation and onboarding processes,
Regular formal check-ins with providers,
Recognition of clinicians and their contributions, and
Development of formal retention plans.
To address these factors, the Dental Workforce Assessment Retention Tool was developed. This survey helps clinic administrators identify what is important to their staff for recruitment and retention. The Handbook on Retention (Appendix A), an online resource, includes this tool and guides clinical and administrative leaders in addressing challenges. The tool asks respondents to rate 11 clinic characteristics as either a challenge or advantage for recruitment and retention. Response options include: Major challenge, Minor challenge, Neither a challenge nor an advantage, Minor advantage, Major advantage. Respondents also rate the importance of each item (Very unimportant to Very important). Additional domains covered in the survey include dental community and professional development, future opportunities, and geographic location. Open-ended questions explore barriers to recruitment and retention, reasons for not accepting or staying in a position, and potential solutions. The data collection from the retention tool will be reported on later.
Student engagement through clinical rotations
As part of their senior year, OHSU dental students participated in an eight-week (40 h/week) full-time clinical rotation at community dental clinics. The rotation was a required course, and students could choose their location where possible. After their rotation, students completed a Dental Student Clinician Career Assessment Tool. Table 2 shows the details of Dental Student Career Assessment Tool. This 35-item survey was divided into four sections: Geographic location, Clinic characteristics, Clinic and community support, and Future opportunities. Students rated each item on two 5-point Likert scales: with:
Level of Importance (how important the item was in choosing a future practice site), and
Level of Strength (how well the rotation site aligned with their preferences).
Table 2.
Dental student clinician career assessment tool. OHSU senior dental students’ perception of 1) the relative importance of selected community factors (Geographic location; Clinic characteristics; Clinic and community support; Future opportunities) that might impact their choice to practice in the community in the future and 2) how strongly they feel their rotation site met the list of characteristics which would attract them to that site as a potential future practice location
| Factor | Perceived importance of selected community factors N = 57 Mean value ± (Standard Deviation) |
p-values for significant gender differences | Perceived level of strength N = 57 Mean value ± (Standard Deviation) |
p-values for significant gender differences | ||
|---|---|---|---|---|---|---|
| Men N = 23 |
Women N = 34 |
Men N = 23 |
Women N = 34 |
|||
| Geographic location: | 3.68 (0.70) | 3.64 (0.53) | NS | 3.28 (0.65) | 3.17 (0.78) | NS |
| Close to a large community/urban center | 3.22 (1.20) | 3.91 (0.75) | P = 0.005 | 3.45 (1.18) | 3.32 (1.30) | NS |
| Community/patient demographics | 4.00 (0.80) | 3.85 (0.89) | NS | 3.82 (0.96) | 3.47 (1.11) | NS |
| Social networking | 3.48 (1.38) | 3.56 (1.05) | NS | 3.09 (0.92) | 3.03 (1.19) | NS |
| Recreational opportunities | 4.13 (1.14) | 3.94 (0.81) | NS | 3.45 (1.01) | 3.21 (1.07) | NS |
| Spousal satisfaction (education, work, general) | 4.52 (0.99) | 3.91 (1.42) | P = 0.040 | 3.27 (1.42) | 2.68 (1.34) | P = 0.059 |
| Schools | 4.00 (1.31) | 3.41 (1.28) | P = 0.049 | 3.41 (1.14) | 2.97 (1.14) | NS |
| Shopping and other services | 2.65 (1.43) | 3.65 (0.92) | P = 0.001 | 2.91 (0.87) | 3.18 (1.24) | NS |
| Religious/cultural experiences | 2.96 (1.39) | 2.47 (1.31) | NS | 2.73 (1.12) | 2.85 (0.99) | NS |
| Climate | 3.78 (1.04) | 3.68 (0.91) | NS | 3.27 (1.08) | 3.35 (0.98) | NS |
| Perception of community | 4.09 (0.79) | 4.06 (0.89) | NS | 3.36 (1.00) | 3.68 (1.01) | NS |
| Clinic characteristics: | 4.55 (0.56) | 4.59 (0.37) | NS | 4.17 (0.59) | 4.12 (0.61) | NS |
| Quality of care | 4.70 (0.56) | 4.85 (0.36) | NS | 4.36 (0.58) | 4.27 (0.88) | NS |
| Financial Stability | 4.65 (0.65) | 4.74 (0.45) | NS | 3.95 (0.99) | 3.73 (1.13) | NS |
| Staff/Personal Relations | 4.65 (0.65) | 4.71 (0.52) | NS | 4.36 (0.79) | 4.27 (0.94) | NS |
| Community Rapport | 4.30 (0.82) | 4.33 (0.65) | NS | 4.09 (0.68) | 4.24 (0.75) | NS |
| Adequate resources to provide care | 4.57 (0.66) | 4.68 (0.54) | NS | 4.00 (0.93) | 3.79 (1.08) | NS |
| Positive Work Environment | 4.74 (0.62) | 4.85 (0.36) | NS | 4.59 (0.67) | 4.45 (0.79) | NS |
| Meets oral health needs of community | 4.70 (0.56) | 4.74 (0.57) | NS | 4.41 (0.59) | 4.33 (0.82) | NS |
| Interprofessional Opportunities | 4.13 (1.06) | 3.97 (1.11) | NS | 3.59 (1.10) | 3.88 (0.89) | NS |
| Clinic and community support: | 4.10 (0.65) | 4.06 (0.38) | NS | 3.82 (0.65) | 3.66 (0.62) | NS |
| Physical space and equipment | 4.36 (0.79) | 4.35 (0.60) | NS | 4.00 (0.84) | 3.56 (0.98) | P = 0.050 |
| Plans for capital investment | 3.41 (1.33) | 3.18 (1.03) | NS | 3.33 (1.07) | 2.72 (1.30) | P = 0.039 |
| Electronic health records | 4.45 (0.74) | 4.47 (0.66) | NS | 4.29 (0.78) | 4.34 (0.94 | NS |
| Innovation (dental home model, teledentistry, etc.) | 4.18 (0.91) | 4.03 (0.83) | NS | 3.43 (1.03) | 3.25 (1.16 | NS |
| Clinic leadership | 4.50 (0.60) | 4.09 (0.90) | P = 0.032 | 4.19 (0.81) | 3.87 (0.87) | NS |
| Information technology support | 3.82 (1.09) | 4.06 (0.89) | NS | 3.81 (0.93) | 3.91 (0.73) | NS |
| Clinic sponsored Continuing Education | 4.23 (1.07) | 4.18 (0.72) | NS | 3.81 (1.03) | 3.31 (1.33) | NS |
| Community support of provider | 4.09 (0.75) | 4.35 (0.60) | NS | 4.00 (0.73) | 3.94 (0.80) | NS |
| Mentoring opportunities | 4.64 (0.66) | 4.50 (0.66) | NS | 4.20 (0.95) | 4.47 (0.62) | NS |
| Community volunteer opportunities | 3.95 (0.90) | 3.82 (0.90) | NS | 3.81 (0.93) | 3.63 (1.16) | NS |
| Welcome and recruitment plan | 3.67 (1.11) | 4.65 (0.69) | NS | 3.75 (0.91) | 3.35 (0.99) | NS |
| Future opportunities: | 3.64 (0.64) | 3.38 (0.51) | P = 0.056 | 3.32 (0.58) | 3.26 (0.66) | NS |
| Income potential | 4.32 (0.72) | 4.36 (0.74) | NS | 3.57 (0.93) | 3.33 (0.96) | NS |
| Payor Mix | 3.67 (0.80) | 3.09 (0.73) | P = 0.005 | 3.30 (0.87) | 2.97 (0.89) | NS |
| Competition | 3.23 (0.97) | 2.73 (1.07) | P = 0.042 | 3.10 (0.77) | 2.73 (1.05) | NS |
| Mid-level supervision | 3.33 (0.97) | 3.27 (0.98) | NS | 3.21 (0.79) | 3.53 (1.07) | NS |
| Teaching | 3.86 (1.21) | 3.34 (1.00) | P = 0.046 | 3.67 (1.07) | 3.84 (1.00) | NS |
| Administration | 3.73 (1.20) | 3.81 (0.86) | NS | 3.52 (1.12) | 3.58 (0.77) | NS |
Responses based on Likert-like scale with 1=least important, 5=most important
Mean value ± (Standard Deviation) by gender. p-value at an item indicates significant gender difference by t-test, NS indicates no significant difference
A score of 1 indicated least importance and a score of 5 indicated the greatest importance. Higher scores indicated greater importance or stronger alignment. A pre-test of the survey tool was conducted prior to its implementation, and minor amendments were made based on the results. The item descriptions, along with their mean scores, are presented in Table 2. We used SPSS (version 28) for data analysis and performed a t-test to identify any significant differences in mean scores between male and female participants. Open-ended questions explored barriers to working in the area, solutions to overcome them, and the potential influence of incentive awards on the respondents’ decision. Both students in targeted and non-targeted counties completed the survey.
Mobile teledentistry model
To improve access to dental care, the project implemented a mobile teledentistry model, aligning with Oregon’s 2022–2024 oral health strategic plan, which prioritized workforce development and telehealth [27]. In the smaller targeted counties of Gilliam and Sherman, which lack stationary dental clinics, community-based health centers integrated teledentistry services part-time. Expanded Practice Dental Hygienists (EPDHs) from Advantage Dental (focused on Medicaid populations in rural areas) provided oral health assessments and preventive care. EPDHs, uniquely qualified in Oregon for their broad scope of practice without direct dentist supervision, used a store-and-forward teledentistry methodology [25, 28]. Key steps included:
Conducting patient screenings with consent,
Taking dental radiographs using a portable X-ray unit (NOMAD™ Pro 2),
Capturing intraoral images using an intraoral camera (Carestream),
Uploading clinical data and care plans to a cloud-based electronic health record.
Facilitating ongoing EPDH training sessions and refresher courses by means of the Canvas platform.
A supervising dentist reviewed the data and provided diagnoses and treatment plans within 48 h.
Results
1. Initially, in 2017, only licensed dentists were eligible to receive loan repayment through the HCPIP. Auxiliary providers, such as expanded practice dental hygienists (EPDHs), were excluded. In Oregon, EPDHs are the only dental providers permitted to deliver dental care, including teledentistry services, without the direct supervision of a licensed dentist.
As the demand for dental services grew, the need to expand loan repayment eligibility to EPDHs became evident. New administrative processes were developed to enable the Oregon Health Authority (OHA) to track the direct patient care hours of EPDHs at community-based clinics. This development made it possible to include EPDHs in the loan repayment program in 2019.
Table 1 shows oral health loan repayment awards by oral health provider in targeted or non-targeted counties in Oregon and year of award. As illustrated in Table 1, loan repayment awards were granted to 77 oral health providers between 2018 and 2024, including 62 dentists (80.5%) and 15 EPDHs (19.5%). Of these, one-third of the dentist awards (32%, N = 20) and 20% of the EPDH awards (N = 3) were allocated to providers in targeted counties. Whenever possible, these awards were distributed based on each county’s population size and needs. While not all HCPIP loan repayment recipients provided services in targeted counties, OHA made concerted efforts to mitigate access issues in these areas through the strategic use of loan repayment resources.
Table 1.
Oral health loan repayment awards by oral health provider in targeted or non-targeted counties in Oregon and year of award
| Year | Dentists | Expanded Practice Dental Hygienist (EPDH) | Total | ||||
|---|---|---|---|---|---|---|---|
| Targeted counties | Non-targeted counties | Dentists Total |
Targeted counties | Non-targeted counties | EPDHs Total |
||
| 2018 | 3 | 5 | 8 | 0 | 1 | 1 | 9 |
| 2019 | 3 | 4 | 7 | 0 | 3 | 3 | 10 |
| 2020 | 2 | 7 | 9 | 0 | 3 | 3 | 12 |
| 2021 | 4 | 11 | 15 | 1 | 2 | 3 | 18 |
| 2022 | 4 | 9 | 13 | 1 | 1 | 2 | 15 |
| 2023 | 2 | 5 | 7 | 0 | 2 | 2 | 9 |
| 2024a | 2 | 1 | 3 | 1 | 0 | 1 | 4 |
|
Total (%) |
20 (32%) |
42 (68%) |
62 (100%) |
3 (20%) |
12 (80%) |
15 (100%) |
77 (100%) |
aPartial year data
2. Using data from OHA’s Health Care Workforce Reporting Program, we assessed the dental full-time equivalent (FTE) presence in targeted counties from 2018 to 2024. This program collects data from Oregon’s 17 licensing boards during bi-annual provider license renewals. The FTE data, illustrated in Fig. 1, shows the number of dental full-time equivalent practitioners (FTE) in selected counties in Oregon by year. One FTE equates to a provider who filed 4,000 Medicaid dental claims in a calendar year. Data for each year reflects the FTE from the previous year, meaning the 2020 FTE reflects provider activity in 2019.
Fig. 1.
Number of dental full time equivalent practitioners (FTE) in selected counties in Oregon by year
The dental provider-to-population ratio (FTE:population size) varied by county, with Josephine County at 1:2,194, Coos County at 1:2,435, and Curry County at 1:2,691. Gilliam County had 0.6 FTE, provided by a dental hygienist offering teledentistry services across two community-based health centers, while Sherman County had no registered FTEs.
Out of 117 dental students surveyed, 57 (49%) completed the Dental Student Clinician Career Assessment after receiving two reminder emails. Nine of these students were from targeted counties, while 48 were from non-targeted counties. The mean age of respondents was 27 years (± 2.7 years), and 59.6% were females. When asked about their preferred site of future practice, 52.5% chose suburban areas, 24.6% rural areas, 21.1% urban areas, and 1.8% military service. The preferred practice mode was private practice (38.6%), followed by community health (29.9%), group practice (22.8%), and corporate practice, hospital, military, or other settings (8.7%).
No significant differences were found between students from targeted and non-targeted counties, so responses are presented by gender (Table 2). Overall, all genders gave higher scores on the “importance” scale than on the “strength” scale. Clinic characteristics were rated as the most important domain by both males and females, with females consistently assigning higher scores (Males: 4.55, Females: 4.59, p > 0.05). Within this domain, quality of care (M: 4.70, F: 4.85) and positive work environment (M: 4.74, F: 4.85) received the highest ratings.
Males rated clinic leadership significantly higher than females (M: 4.50, F: 4.09, p = 0.032). Males also rated physical space and equipment (M: 4.00, F: 3.56, p = 0.050) and plans for capital investment (M: 3.33, F: 2.72, p = 0.039) significantly higher.
In the domain of geographic location, males scored spousal satisfaction (M: 4.52, F: 3.91, p = 0.040) and school quality (M: 4.00, F: 3.41, p = 0.049) significantly higher, while females rated proximity to urban centers (M: 3.22, F: 3.91, p = 0.005) and access to shopping and services (M: 2.65, F: 3.65, p = 0.001) significantly higher.
For future opportunities, males assigned higher importance to factors such as payor mix (M: 3.67, F: 3.09, p = 0.005), competition (M: 3.23, F: 2.73, p = 0.042), and teaching opportunities (M: 3.86, F: 3.34, p = 0.046). The least important factor for both groups was religious/cultural experiences (M: 2.96, F: 2.47, NS).
3. The majority of students (N = 47, 82.5%) indicated they did not plan to provide care in the area of their clinical rotation. When asked to elaborate, students cited spousal or family circumstances, geographic considerations, and professional opportunities, such as specialist training or access to specialist support. Many also mentioned the lack of resources in rural clinical environments. A subset of students on scholarships, such as WICHE (Western Interstate Commission for Higher Education), noted they were required to return to their home state after graduation, limiting their options.
Despite these barriers, most students expressed positive sentiments about their rotation experiences, noting professional satisfaction and pride in their contributions. When asked if they would consider working in the area if offered an incentive award, more than half of those who had initially said “No” (57.4%, N = 27) reconsidered. Table 3 shows Dental Student Clinician Career Assessment Tool, OHSU senior dental students’ plans of providing dental care in the community where they undertook their community rotation and the impact of a potential financial incentive award on their choice, by Gender. Significantly more females than males responded positively (62.1% vs. 50.0%). This increased the potential number of graduates willing to work in rural sites from 10 to 36 (63.2%). The primary motivator for this change was financial assistance, which could address burdens such as loan repayments, moving expenses, and commuting costs. The students for whom the financial incentive would not be a sufficient motivator, highlighted the location, distance to family, and in general, other geographic issues as main barriers.
Table 3.
Dental student clinician career assessment tool. OHSU senior dental students’ plans of providing dental care in the community where they undertook their community rotation and the impact of a potential financial incentive award on their choice, by gender
| Would you be more likely to provide care in the service area if an incentive award was made available to you? | Total | ||||||
|---|---|---|---|---|---|---|---|
| Are you planning to provide care in the service area where you did your clinical rotation? | Yes | No | |||||
| Response | Gender | N | % | N | % | N | % |
| Yes | |||||||
| Female | 5 | 100.0 | 0 | 0.0 | 5 | 100 | |
| Male | 4 | 80.0 | 1 | 20.0 | 5 | 100 | |
| Total | 9 | 90.0 | 1 | 10.0 | 10 | 100 | |
| No | |||||||
| Female | 18 | 62.1 | 11 | 37.9 | 29 | 100 | |
| Male | 9 | 50.0 | 9 | 50.0 | 18 | 100 | |
| Total | 27 | 57.4 | 20 | 42.6 | 47 | 100 | |
| Total | 36 | 63.2 | 21 | 36.8 | 57 | 100 | |
4. From 2021–2022, three health center sites provided teledentistry services to 198 patients (95% under Medicaid), of whom 40% (n = 80) received EPDH teledentistry services and 60% (n = 118) received on-site EPDH dental exams. Patients ranged in age from 1 to 67 years, with more than half (58%) under 18 and 55% identifying as female. Dental caries was the primary oral health issue, with patients evenly divided between low and medium-to-high caries risk. Nearly all patients (97%) reported high satisfaction with the services and expressed willingness to utilize them again if available.
Discussion
This project adopted a comprehensive approach to addressing complex dental care challenges at the state level, including access to dental care, shortages, and retention of dental workforce, and leveraging new technology to deliver dental care to rural Medicaid beneficiaries. To tackle these multi-faceted issues, a close collaboration was set up between the state’s Health Care Workforce Initiatives Team and a dental school. This partnership facilitated the integration of policy-based initiatives, such as a state-coordinated loan repayment program, workforce development strategies like community-based dental education placements, and the expanded use of teledentistry targeting Medicaid beneficiaries.
The findings of this project complement an earlier analysis of OHSU senior dental students, which showed that dental graduates from rural backgrounds were seven times more likely than those from urban backgrounds to practice in rural areas two to three years post-graduation [18]. However, that analysis could not link location data to specific clinics in specific counties, and in the present project, students’ views and suggestions could not be tied to their background data. Future dental workforce projects should aim to encompass all these essential components.
The 2021 National Oral Health Report emphasized that the systems for educating dental providers and delivering care to populations remain critical determinants of oral health. Our project outcomes validated the report’s assumptions about the complexities of implementing systemic changes in the dental care system. However, the findings also suggested that targeted interventions, especially financial incentives, could drive meaningful change.
One of the most striking findings was the impact of financial incentives on dental graduates’ willingness to practice in rural areas. When students were asked if they planned to work in the rural community-based sites of their clinical rotations after graduation, only 17.5% responded affirmatively. However, when asked if they would consider doing so if an incentive award were available, the number rose significantly to 63.2% (Table 3).
This finding aligns with broader trends. Over the past decade, the cost of dental education and student debt levels have risen substantially [29, 30], with many dental graduates facing 20–25 years of repayment [31, 32]. Students’ feedback highlighted overwhelmingly positive experiences during their community-based rotations. A clear financial incentive could help overcome some of their hesitations about choosing rural practice locations.
Finally, the project highlighted that certain state areas face dental workforce shortages that cannot sustain permanent clinics due to population and financial constraints. However, a combination of expanded practice authority for EPDHs, teledentistry, and collaboration between flexible dental care organizations and community health centers can provide a stable foundation for delivering consistent dental services.
The community-based approach in a longitudinal project as this requires ongoing contact with the local community and the dental care providers. This was implemented by regular visits and meetings during the entire project. Ongoing training and refresher courses for the EPDHs was to ensure calibration of clinical decision making. The approach and the related activities align with calls to integrate oral health care into general health care in vulnerable counties, particularly those with aging populations facing both oral health and chronic disease challenges [33, 34].
Limitations of the study
The most significant limitation of this project was its interruption by the pandemic, which shut down the entire dental care system and dental education system for several months. Recovery to normal operations was slow, particularly in targeted counties where few alternatives existed if dental care staff left, and replacements could not be found [35].
The lack of access to more detailed information concerning the participating students’ rural or urban background limited our understanding of possible confounding effects of this factor [18]. Another limitation was the students’ response rate (49%), which reduced the generalizability of the findings. However, based on unpublished data from similar student populations, the response patterns in this project were considered valid and reflective of broader trends.
Conclusions
The combined efforts of the state, dental education, local administrators and clinicians can be successful in addressing the complex problem of access to and utilization of dental care and providing oral health care to underserved populations. Innovative financial, educational, clinical, administrative and human resource methods must be used collaboratively to induce dental graduates to choose practice locations outside of major urban centers and retain their longevity.
Supplementary Information
Acknowledgements
We gratefully acknowledge the grant support by the Health Resources and Services Administration (Award No. T12HP31868) and the ongoing encouragement by our project officer, Dr. Jennifer Holzman, HRSA. The mentor dental clinicians, preceptors and local administrators are thanked for their patience and support throughout the project. We are deeply thankful for our collaboration with clinicians and administrators in Advantage Dental from DentaQuest, which ensured the collection of teledentistry data as well as the post-pandemic repopulation of dental clinics in the targeted counties. We are also very thankful to Ms. Leah Brandis from OHSU for her assistance with data collection and initial descriptive reporting of data. Finally, we are indebted to our dental students who experienced some very difficult times during their senior year and nonetheless willingly participated in our surveys.
Clinical trial number
Not applicable.
Authors’ contributions
Each author made significant contributions to the development of this publication. ES, RK and JM conceptualized and conducted the study. ES, RK and AD contributed to the data collection, and data analysis. ES drafted the initial manuscript. All authors provided critical revisions and supported the interpretation of results. All the authors have read and approved the final manuscript.
Funding
Health Resources and Services Administration (Award No. T12HP31868).
Data availability
The datasets used and/or analyzed during the study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
OHSU Institutional Review Board (IRB) approval was obtained for the collection of survey data from students (STUDY00020330) and from the clinical teledentistry component (STUDY11534). Informed consent was obtained from the participants. All methods were performed in accordance with the relevant guidelines and regulations and complied with the Declaration of Helsinki guidelines for research carried out on humans or using human data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analyzed during the study are available from the corresponding author on reasonable request.