A Cross‐Sectional Investigation of Rural Dental Practice as Related to Gender, Hometown, and Career Stage

ABSTRACT

Objectives

This investigation explores how gender, career stage, and rurality of graduates' hometowns relate to dental practice location, specifically within Alabama's rural communities.

Methods

This cross‐sectional study explored demographics and practice locations for 2000–2020 graduates (N = 1233) from the state's dental school. This investigation compared findings across multiple definitions of rural status.

Results

Gender emerged as a significant predictor of rural practice for only one of the rural definitions. Females were less likely than males (6% vs. 12%) to practice in a low‐population county (< 50,000), χ ² = 11.03, p < 0.001. When controlling for both career stage and rurality of hometown, males are 2.04 times more likely (95% CI [1.29, 3.21]) to practice in a low‐population county as compared to females, p = 0.002. Among graduates from rural or workforce shortage areas, no differences emerged in practice location based on either gender or career stage. Graduates from a rural county are significantly more likely than their non‐rural peers to practice rural. Early‐career dentists are not working in rural locations at significantly different rates from their mid‐career peers.

Conclusions

More providers are needed to serve rural residents and graduates with rural upbringing are the most likely to fulfill this need. Rural practice appears to attract males and females in similar proportions, but more males than females gravitate towards low‐population counties. Given populations and workforce trends, dental educators, policy makers, organized dentistry, and rural communities must all implement initiatives incentivizing dental practice in Alabama generally and her rural communities specifically.

1. Introduction

The current proportion of dental providers serving US rural residents is a major workforce issue, as recruiting and keeping healthcare providers in rural communities is challenging [1]. Data collected in 2025 indicate 32.7 dentists per 100,000 people in rural communities, compared to 64.7 dentists in urban areas [2]. The rural–urban dental provider gap continues to increase, as it has for at least two decades [2]. The current US dental workforce is majority male, although the share of females is increasing (16% in 2001 vs. 38% in 2024) and composes about half of dentists 35 years and younger [2]. Overall, today's dental workforce skews younger [3], and younger dentists appear to be less likely to practice in rural areas [2]. Considering these current workforce data and trends, further understanding of factors such as gender and career stage in conjunction with hometown rurality can help illuminate future dental workforce distribution.

Alabama's dental workforce in particular trails national benchmarks. Recent data suggest that, of the state's approximately 2129 dentists, Alabama experienced only a 0.8% positive net migration of dentists from other states [4, 5]. Not only is Alabama's overall dentist‐to‐population ratio nearly the lowest in the country (40.4 per 100,000 population) [2], but her rural workforce ratio is also lower than the national average (23.1 vs. 32.7 per 100,000 population) [6]. Over the past 10 years, Alabama's overall dental workforce ratio decreased by almost 8% [2]. In short, Alabama's residents need more dentists, and her rural communities are in critical need of accessible oral healthcare providers.

Prior work investigating how demographic factors such as gender and career stage relate to practice location helps further understanding of anticipated workforce trends. Overall, the U.S. dental workforce continues to trend more female, as females nationally composed 57% of the 2023 incoming dental school class [2]. By 2040, half of the national dental workforce is expected to be female [2]. In Alabama specifically, the dental workforce experienced a net loss of 190 male dentists and a net gain of 186 female dentists during 2017–2024 [7]. This trend is expected to continue, as the current authors note that males composed only about one‐third of the 2024–2025 application pool at Alabama's only dental school. As of 2024, 30 of 67 Alabama counties had no dentists younger than 40 years and nine counties contained either no dentists or a single practitioner [7]. Nationally, early‐career dentists appear less likely to gravitate to rural communities, as the most recent available data indicate that only 7% of dental school graduates reported intentions to begin their practice in a rural setting [8]. This trend towards urban areas is evident in Alabama as well, as most early‐career providers are situated in non‐rural communities [9].

In addition to gender and career stage, work exploring the rurality of the dentist's hometown is relevant. Not surprisingly, institutions located in smaller, more rural states produce graduates more likely to work in rural communities [1]. This expectation should apply to Alabama, where most counties are classified as rural and almost half of the state's population lives in rural areas, well exceeding the 20% of Americans living in rural areas nationally [9, 10]. Although a rural hometown is a predictor for rural practice [1, 11, 12], including for Alabama's dental school graduates [6], it may not be a critical requirement [1]. Prior analyses of the sample investigated in this study suggest that approximately 36%–40% of graduates from an American rural hometown practice dentistry in a US rural community, and 37% of those from rural Alabama specifically work in rural Alabama [6]. Not only do most dentists from rural areas end up practicing in urban communities, but graduates from Alabama's dental school largely do not return to their home counties for practice, regardless of rural or urban upbringing [6].

However, it remains unclear how the intersection of gender, career stage, and rurality of hometown all relate together to likelihood of rural dental practice. For example, some previous research suggests that males are more likely to work rural [13, 14, 15, 16], but other studies suggest females are more likely [11, 17] and still others have found no difference between genders [18, 19]. To further obscure matters, an Australian study suggests that rurality of hometown predicted rural practice for women but not men [20]. Among Alabama dental students specifically, females reported greater perceived professional responsibility to serve low‐income rural areas than did their male counterparts, but intent to serve did not differ [21]. Given that the future dental workforce is expected to be younger and more female than it is currently, and rates of rural practice have been decreasing for decades already, better understanding can help clarify expected future challenges and opportunities.

The aim of the present paper is to provide further understanding of a rural state's dental workforce by investigating practice locations after graduation from Alabama's only dental school. Specifically, this study addresses two research questions. First, how do gender and career stage relate to dental practice location, specifically within Alabama's rural communities? Second, what role does rurality of the graduates' hometown play in better understanding these relationships? This study evaluates practice locations across multiple definitions of rural classification and dental workforce shortage needs. This investigation will help provide benchmarks and illustrate anticipated trends, thus facilitating understanding and assessment of interventions designed to enhance the Alabama dental workforce.

2. Methods

Investigators compared multiple sources of data to generate a database of current practice locations for The University of Alabama at Birmingham School of Dentistry (UAB SOD) 2000–2020 graduate classes. The UAB SOD utilized data housed within the registrar and alumni offices to cross‐examine with a database generated by the American Dental Association Health Policy Institute (ADA HPI). Institutional data sources included commencement records, class rosters, degree verification systems, address records within alumni/development, and the internet. The appropriate Institutional Review Board reviewed and approved this study (IRB‐300014747).

2.1. Participants

UAB SOD produced 1233 DMD graduates during 2000–2020, 1225 (99.4%) of whom were living at the time of this analysis. The ADA HPI records included 95% of UAB SOD graduates. Of the 61 living UAB SOD graduates not included in the ADA HPI database, investigators pinpointed practice location data for 43 dentists (70%). If a practitioner had multiple practice locations identified, the single location included for analysis represented the highest degree of rurality and/or in‐state status. Only traditional DMD graduates were included, and graduates from UAB SOD's International Dentist Program (IDP) were excluded.

2.2. Variables

2.2.1. Career Stage

This dichotomous categorical variable distinguished between more recent graduates who graduated 2010–2020 (early career stage) versus practitioners who graduated 2000–2009 (middle career stage).

2.2.2. Gender

Graduates' status as either female or male informed this dichotomous variable, as indicated on ADA HPI records.

2.2.3. Hometown

Each practitioner's hometown, self‐reported on UAB SOD commencement records at the time of dental school graduation, informed rural status at the county level.

2.2.4. Rural—Board of Dental Scholarships (BDS) Eligibility

This categorical variable reflected counties eligible for a state‐funded financial award for rural service. Of Alabama's 67 counties, 54% (N = 36) have been eligible for this award at some point since this initiative's launch in 2020. As workforce shortage indices dictate county eligibility, this list is adjusted each year. This definition of rural applied to both graduates' home counties and practice locations.

2.2.5. Rural—County Population

Population values at the county‐level from 2020 census data informed this categorical variable [22]. Four categories composed this variable as follows: rural (5000 and less), moderately rural (5001–9999), moderately urban (10,000–49,999), and urban (50,000 and more). Due to the very low number of Alabama counties classified as rural (N = 0) and moderately rural (N = 2) based on this restrictive definition, the non‐rural definition comprised only counties with 50,000 people or more. The categories collapsed to create a dichotomous variable: rural (less than 50,000) and non‐rural. This definition of rural applied to both graduates' home counties and practice locations.

2.2.6. Rural—Rural–Urban Continuum Codes (RUCC)

This categorical variable documented degree of rurality at the county level per the 2023 issuance [23]. Code descriptions distinguish metropolitan from nonmetropolitan counties. Dichotomous categories differentiated rural (codes 4–9) from non‐rural (codes 1–3) counties. This definition of rural applied to both graduates' home counties and practice locations.

2.3. Statistics

Statistical analyses utilized IBM SPSS Statistics for Windows, version 28.0.1.1, and comprised binary logistic regression and cross‐tabulation analyses with chi‐square tests. For all analyses, p‐values < 0.05 were considered statistically significant.

3. Results

Based on the three definitions of rural explored here, 54%–60% of Alabama's 67 counties met the criteria for at least one of the three definitions of rural. Table 1 provides a summary of the state's rurality.

TABLE 1.

Summary of Alabama's counties' (N = 67) rural classifications.

Definition of rural	N	%
Rural per RUCC	36	54%
Rural per population	40	60%
Rural per BDS award eligibility	36	54%
Rural per both RUCC and population	30	45%
Rural per both population and BDS eligibility	32	48%
Rural per both RUCC and BDS eligibility	24	36%
Rural per all: RUCC, BDS eligibility, population	22	33%

Abbreviations: BDS = Board of Dental Scholarships; RUCC = Rural–Urban Continuum Codes.

The first research question addressed gender and career stage as related to dental practice location within rural communities. Gender emerged as a significant predictor of rural practice for only one of the rural definitions. Females were less likely than males (6% vs. 12%) to practice in a county with a population less than 50,000 residents, χ ² = 11.03, p < 0.001. Overall, only 10% of graduates practiced in these low‐population counties whereas 17% of graduates practiced in a county defined as rural per the RUCC issuance. Graduates' rural versus non‐rural practice locations did not significantly differ based on career stage across all three definitions of rural. Table 2 summarizes these results.

TABLE 2.

Univariate analyses of rural practice location by gender, career stage among UAB SOD 2000–2020 DMD graduates practicing in United States. ^a

	Rural practice location—RUCC							Rural practice location—population b							Rural practice location—eligible for financial service award c
	Rural (N)	Rural (%)	Non‐Rural (N)	Non‐Rural (%)	Total (N)	χ 2	p	Rural (N)	Rural (%)	Non‐rural (N)	Non‐rural (%)	Total (N)	χ 2	Rural (N)	Rural (%)	Non‐rural (N)	Non‐rural (%)	Total (N)	χ 2	p
Gender
Female	67	15%	383	85%	450	1.76	0.185	28	6%	422	94%	450	11.03	< 0.001 d	23	5%	427	95%	450	2.87	0.090
Male	126	18%	579	82%	705			86	12%	619	88%	705			54	8%	651	92%	705
Total	193	17%	962	83%	1155			114	10%	1041	90%	1155			77	7%	1078	93%	1155
Career stage
Mid‐career	91	17%	440	83%	531	0.13	0.719	60	11%	471	89%	531	2.26	0.133	40	8%	491	92%	531	1.19	0.276
Early career	102	16%	522	84%	624			54	9%	570	91%	624			37	6%	587	94%	624
Total	193	17%	962	83%	1155			114	10%	1041	90%	1155			77	7%	1078	93%	1155

Abbreviation: RUCC = rural–urban continuum codes.

^a Included living with known US practice location; excluded International Dentist Program graduates.

^b Rural defined as county population less than 50,000.

^c Included all Alabama counties deemed eligible 2020–2024.

^d Significant at α = 0.05.

These two factors—gender and career stage—were significantly related to each other within this sample, reflecting the increasing share of females in dentistry, as more early‐career dentists are female as compared to mid‐career dentists (44% vs. 33%), χ ² = 15.85, p < 0.001. When analyzed together, gender and career stage together only related to rural practice as defined by county population, as the omnibus test generated via binary logistic regression analysis indicated a significant predictive model, χ ² = 12.94, p = 0.002. Holding career stage constant, males are 2.04 times more likely (95% CI [1.31, 3.19]) to practice in a county with less than 50,000 people as compared to females. Table 3 summarizes the results of these analyses.

TABLE 3.

Multivariate binary logistic regression analysis investigating gender, career stage for rural practice location. ^a

Term	N	Rural practice location—RUCC				Rural practice location—population b				Rural practice location—financial service award c
		Full model		Omnibus test		Full model		Omnibus test		Full model		Omnibus test
		OR (95% CI)	p	χ 2	p	OR (95% CI)	p	χ 2	p	OR (95% CI)	p	χ 2	p
Gender: female	450	Referent		1.82	0.403	Referent		12.94	0.002 d	Referent		3.76	0.152
Gender: male	705	1.24 (0.90, 1.72)	0.197			2.04 (1.31, 3.19)	0.002 d			1.50 (0.91, 2.49)	0.116
Career stage: early	624	Referent				Referent				Referent
Career stage: mid	531	1.03 (0.76, 1.41)	0.837			0.80 (0.54, 1.18)	0.262			0.81 (0.51, 1.29)	0.371

Abbreviation: RUCC = rural–urban continuum codes.

^a Included living with known US practice location; excluded International Dentist Program graduates.

^b Rural defined as county population less than 50,000.

^c Included all Alabama counties deemed eligible 2020–2024.

^d Significant at α = 0.05.

The second research question investigated the role of rurality of the graduates' hometown in these relationships. When including only those graduates with a hometown in a county classified as rural or with substantial workforce need, no differences emerged in practice location based on either gender or career stage. Although females are less likely than males overall to work in counties with less than 50,000 residents, this significant difference in gender did not emerge among graduates from rural counties. Across definitions, a greater percentage of rural males practiced in rural communities than did their female counterparts, but analyses detected no statistically significant differences. Additionally, the findings did not suggest that early career dentists are working in counties classified as rural or with substantial workforce need at significantly different rates from their mid‐career peers. Table 4 summarizes these findings.

TABLE 4.

Summary of rural practice location by gender, career stage among UAB SOD 2000–2020 DMD graduates with rural hometown and US practice. ^a

	Rural practice location—RUCC							Rural practice location—population c							Rural practice location—eligible for financial service award d
	Rural (N)	Rural (%)	Nonrural (N)	Non‐rural (%)	Total (N)	χ 2	p	Rural (N)	Rural (%)	Non‐rural (N)	Non‐rural (%)	Total (N)	χ 2	p	Rural (N)	Rural (%)	Non‐rural (N)	Non‐rural (%)	Total (N)	χ 2	p
Gender b
Females from hometown in rural county	20	30%	47	70%	67	2.06	0.151	11	25%	33	75%	44	0.56	0.453	8	27%	22	73%	30	0.13	0.723
Males from hometown in rural county	45	41%	66	59%	111			23	32%	50	68%	73			14	30%	32	70%	46
Total	65	37%	113	63%	178			34	29%	83	71%	117			22	29%	54	71%	76
Career stage b
Mid‐career from hometown in rural county	34	37%	58	63%	92	0.02	0.900	19	34%	37	66%	56	1.24	0.266	15	37%	26	63%	41	2.53	0.112
Early career from hometown in rural county	31	36%	55	64%	86			15	25%	46	75%	61			7	20%	28	80%	35
Total	65	37%	113	63%	178			34	29%	83	71%	117			22	29%	54	71%	76

Abbreviation: RUCC = rural–urban continuum codes.

^a Included living with known US practice location and rural US hometown; excluded International Dentist Program graduates.

^b Rural hometown definitions for each analysis consistent with definition of rural for outcome variable (RUCC, population, BDS eligible).

^c Defined as county population less than 50,000.

^d Included all Alabama counties deemed eligible 2020–2024.

Comparable percentages of both female and male graduates hailed from rural counties (approximately 18% rural per RUCA, 10% rural per population, 9% from BDS‐eligible counties). When analyzed together via binary logistic regression, rural hometown emerged as a significant factor for each definition of rural, even when holding gender constant. Graduates from a rural hometown were more likely to practice in a rural county as compared to graduates from a non‐rural county for each of the three following definitions of rural: RUCC (3.72 times more likely; 95% CI [2.60, 5.33]), population (4.90 times more likely; 95% CI [3.08, 7.81]); financial service award eligibility (6.67 times more likely; 95% CI [3.73, 11.91]). Gender emerged as a significant predictor only for the population definition. When holding rurality by home county population constant, males were 2.09 times more likely (95% CI [1.33, 3.29]) than females to practice in a low‐population county, χ ² = 49.72, p < 0.001. Taken together, these findings suggest that rural hometowns consistently increase likelihood of rural practice, regardless of gender. Low‐population counties specifically seem to attract more male graduates than female practitioners. Overall, however, rural hometown matters more than gender for likelihood to practice rural.

Comparable percentages of both early (14% rural per RUCC, 10% rural per population, 8% from BDS‐eligible counties) and mid‐career stage (18% rural per RUCC, 11% rural per population, 10% from BDS‐eligible counties) practitioners hailed from rural counties (RUCC χ ² = 2.53, p = 0.112; Pop χ ² = 0.14, p = 0.708; BDS χ ² = 0.827, p = 0.363). When analyzed together via binary logistic regression, rural hometown again emerged as the significant factor for each of the following three definitions of rural practice location, even when holding career stage constant: RUCC (3.73 times more likely; 95% CI [2.606, 5.338]), population (4.824 times more likely; 95% CI [3.041, 7.635]); BDS award eligibility (6.429 times more likely; 95% CI [3.609, 11.452]). Career stage did not emerge as a predictor in these combined models. Taken together, these findings suggest that rural hometowns consistently increase likelihood of rural practice, regardless of career stage. These values are summarized in Table 5.

TABLE 5.

Multivariate binary logistic regression analyses investigating gender, hometown and career stage, hometown for rural practice location. ^a

Term	Rural practice location—RUCC					Rural practice location—population b					Rural practice location—financial service award c
	N	Full model		Omnibus test		N	Full model		Omnibus test		N	Full model		Omnibus test
		OR (95% CI)	p	χ 2	p		OR (95% CI)	p	χ 2	p		OR (95% CI)	p	χ 2	p
Gender: female	436	Referent		49.91	< 0.001 d	436	Referent		49.72	< 0.001 d	320	Referent		37.27	< 0.001 d
Gender: male	691	1.25 (0.90, 1.75)	0.19			691	2.09 (1.33, 3.29)	0.002 d			550	1.69 (0.96, 2.97)	0.069
Hometown: non‐rural	949	Referent				1010	Referent				794	Referent
Hometown: rural	178	3.72 (2.60, 5.33)	< 0.001 d			117	4.90 (3.08, 7.81)	< 0.001 d			76	6.66 (3.73, 11.91)	< 0.001 d

Term	Rural practice location—RUCC					Rural practice location—population b					Rural practice location—financial service award c
	N	Full model		Omnibus test		N	Full model		Omnibus test		N	Full model		Omnibus test
		OR (95% CI)	p	χ 2	p		OR (95% CI)	p	χ 2	p		OR (95% CI)	p	χ 2	p
Hometown: non‐rural	949	Referent		48.2	< 0.001 d	1010	Referent		40.99	< 0.001 d	794	Referent		34.14	< 0.001 d
Hometown: rural	178	3.73 (2.61, 5.34)	< 0.001 d			117	4.82 (3.04, 7.65)	< 0.001 d			76	6.43 (3.61, 11.45)	< 0.001 d
Career stage: early	606	Referent				606	Referent				444	Referent
Career stage: mid	521	1.03 (0.75, 1.42)	0.87			524	0.74 (0.50, 1.10)	0.135			426	0.86 (0.51, 1.42)	0.545

Abbreviation: RUCC = rural–urban continuum codes.

^a Included living with known US practice location; excluded International Dentist Program graduates.

^b Rural defined as county population less than 50,000.

^c Included all Alabama counties deemed eligible 2020–2024.

^d Statistically significant at α = 0.05.

With all three predictors (gender, career stage, and rural home county) combined, only rural home county emerged as a consistent, significant factor for all three definitions of rural practice location. Even when career stage and gender are held constant, graduates from a rural county are significantly more likely to practice rural as compared to their non‐rural peers (RUCC: 3.74 (95% CI [2.61, 5.35]); population: 4.897 (95% CI [3.07, 7.81]); BDS eligible: 6.62 (95% CI [3.70, 11.85])). Among these combined models, only the model containing the rural population definition also generated a significant relationship for gender. When controlling for both career stage and home county rural status per population, males are 2.04 times more likely (95% CI [1.29, 3.21]) to practice in a rural county (per pop) as compared to females, p = 0.002. Table 6 summarizes these values.

TABLE 6.

Multivariate binary logistic regression analysis investigating hometown, gender, career stage for rural practice location. ^a

Term	Rural practice location—RUCC					Rural practice location—population b					Rural practice location—financial service award c
	N	Full model		Omnibus test		N	Full model		Omnibus test		N	Full model		Omnibus test
		OR (95% CI)	p	χ 2	p		OR (95% CI)	p	χ 2	p		OR (95% CI)	p	χ 2	p
Gender: female	436	Referent		50.00	< 0.001 d	436	Referent		51.06	< 0.001 d	320	Referent		37.45	< 0.001 d
Gender: male	691	1.26 (0.90, 1.76)	0.183			691	2.04 (1.29, 3.21)	0.002 d			550	1.67 (0.95, 2.94)	0.077
Hometown: non‐rural	949	Referent				1010	Referent				794	Referent
Hometown: rural	178	3.74 (2.61, 5.35)	< 0.001 d			117	4.90 (3.07, 7.81)	< 0.001 d			76	6.62 (3.70, 11.85)	< 0.001 d
Career stage: early	606	Referent				606	Referent				444	Referent
Career stage: mid	521	0.95 (0.69, 1.31)	0.765			521	1.27 (0.85, 1.90)	0.247			426	1.12 (0.67, 1.86)	0.674

^a Included living with known US practice location; excluded International Dentist Program graduates.

^b Rural defined as county population less than 50,000.

^c Included all Alabama counties deemed eligible 2020–2024.

^d Statistically significant at α = 0.05.

4. Discussion

Alabama's dental workforce distribution is a critical issue compromising access to care, with many of the state's rural counties lacking adequate providers [7]. Increasing the proportion of rural providers requires a multi‐prong approach. Educational interventions and financial incentives are two of four recommendations made by the World Health Organization [24]. As regulatory measures are pinpointed as the most effective of these recommendations, at least in the short‐term [25], policy makers must contribute solutions to improve rural residents' access to dental care. Dental education can contribute to workforce composition but is not alone capable of alleviating rural communities' workforce shortages.

Among educational interventions, programs that incorporate both rural upbringing and extended, high‐quality rural rotation experiences appear to produce more rural practitioners [25, 26, 27, 28]. Dental school admissions and enrollment initiatives can help produce more graduates with greater potential to serve in rural and workforce shortage communities. Today, educational institutions both nationally and in Alabama produce more dentists, with 21 new dental schools opening since 2001 [2] and an incoming class size increase of around 36% at UAB SOD since 2021. Targeted programs focused on the development and recruitment of qualified candidates from rural hometowns may help increase rural enrollment, as the Rural Dental Scholar collaboration spearheaded by UAB SOD intends [29]. Rural graduates are more likely to both practice in‐state [1] and in rural areas [6, 27, 30]. The present study suggests that rural hometown matters the most for likelihood of rural practice, even when controlling for gender and career stage. However, given that only around one‐quarter of rural graduates return to their home county for practice [6], rural communities may choose to deploy broader recruitment initiatives rather than heavy reliance on locally grown providers.

In this study, career stage did not emerge as a predictor of practice in rural counties. As research generally suggests urban areas attract younger dentists [2], the current finding may be influenced by the lack of granularity associated with grouping 10 classes of graduates together. Younger dentists typically carry greater educational debt, which may affect practice location decisions. Even though recent data suggest that rural dentists fare better economically than their urban counterparts [2], substantial educational debt and corporate dental opportunities may hinder or discourage investment opportunities. However, as some graduates may perceive finances as a barrier to rural practice [31], proactively addressing these concerns may help. Financial service incentives such as those provided by the Alabama Board of Dental Scholarships [29] thus may help recruit practitioners to rural areas, although existing evidence for such incentives' long‐term effectiveness is weak [25]. Financial incentives do appear to be effective in increasing intentions among dental students for rural practice, however, especially for females [30]. Additionally, financial service incentives may help debt‐laden graduates pursue a private, solo practice suitable for a rural community earlier in their career, as this practice model is currently less common and more delayed than in previous years [2, 3].

Interestingly, among the graduates with a rural upbringing investigated here, males and females composed both the graduate pool and the rural workforce evenly. This study suggests that gender does not factor for counties defined by shortage area or non‐metro RUCC codes, which generally aligns with recent research [27]. The 67% of Alabama's counties classified as rural dental health professional shortage areas, mostly because of a lack of providers for low‐income populations [32], would benefit from graduates well‐suited to serve. Given that females are more likely to participate in Medicaid [33, 34], report greater perceived professional responsibility to serve low‐income rural communities [21], nationally work approximately the same number of weekly hours as their male counterparts [2], and appear to be as likely as males to serve in most rural communities [27], the increasing share of females in dentistry may not present a significant additional challenge for the future rural workforce. However, the consistent lower percentages of females versus males working in rural counties could present a larger issue moving forward if these differences persist and compound. Additionally, the present finding that females are less likely to go to low‐population counties may be a cause for concern. This may be in part because more females than males report proximity to a larger community with retail and other services as important [30], although further understanding of this relationship is needed. Regardless, given the increasing share of females in dentistry, rural communities, organized dentistry, policy makers, and educators must work to make practice in rural and workforce shortage communities more attractive to female providers.

The dearth of dentists in rural communities across America is certainly not a new issue and has been documented for decades [35]. Nationally, approximately 11% of dentists serve rural communities [36], which falls short of the approximately 20% of Americans that reside in such areas [10]. Around 17% of UAB SOD DMD graduates in this sample practice in a US rural county as defined by RUCC code, outpacing the previous 11% reported by the ADA HPI [37]. Although the percentage of UAB SOD graduates practicing rural exceeds the national benchmark, given the large percentage of Alabama residents in rural communities coupled with an aging rural dental workforce, this value still falls short. To match the national workforce ratio within rural communities, the percentage of UAB SOD graduates serving rural areas needs to be closer to 27%. Given that approximately 67% of all graduates stay in Alabama for practice [37] and 74% of those from Alabama work in the state [6], increasing retention of the state's workforce is a key component. Organized dentistry and policy makers in the state must address issues that incentivize dental practice in Alabama and her rural communities, such as increasing private and public third‐party dental insurance reimbursement and expanding the rural dentist tax credit to align with financial incentives for Alabama's rural physicians.

There are several limitations to this study. First, this sample of active practitioners does not include any data on the extent or type of practice. So, this study cannot indicate how much time is spent in each location or how many patients are served. Second, despite best efforts and triangulation among multiple data sources, graduates' practice locations are dynamic and subject to error, especially among practitioners early in their careers. Although errors should be minimal enough not to influence big picture findings, they undoubtedly exist and compound in importance if related to areas with very few dentists. Third, rural definitions are imperfect and alone offer an incomplete picture of workforce needs. Sixty‐seven percent of those Alabama counties featuring the highest dentist shortage ratios are classified as rural per RUCC, which mirrors the national landscape [32]. Many of these Alabama counties (89%) are rural per population, all of which met at least one of the other definitions of rural. Workforce research thus benefits from a multi‐faceted view of rural classification. Fourth, graduates' hometown identification relied upon self‐report, which may not accurately or comprehensively capture characteristics of upbringing. Finally, although geographic accessibility to providers matters, other factors heavily influence dental service utilization rates, especially socioeconomic indicators [1, 38]. Thus, addressing workforce alone is insufficient for improving Americans' oral health status.

In conclusion, more providers are needed to serve Alabama's rural residents and graduates with rural upbringing are the most likely to fulfill this need. The relationship of gender with rural practice is nuanced, with more males than females gravitating towards low‐population counties. Otherwise, rural practice appears to attract males and females in similar proportions. Given both rural populations and dental workforce composition trends, dental educators, policy makers, organized dentistry, and rural communities must all implement initiatives incentivizing dental practice in Alabama generally and her rural communities specifically.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Research data are not shared.