Long lines and a mobile clinic: Tennessee’s dentist shortage reshapes how people get care

Dental students at Meharry Medical College perform free dental care to patients on a newly purchased mobile clinic as part of an oral health day at Meharry Medical College on March 10, 2018. Photo/Holly Fletcher

What you’ll read about: Many parts of Tennessee have a shortage of dentists so free dental care at charity events is a big draw for people who may not have seen a dentist in years.

Meharry Medical College is taking a mobile clinic around to parts of the state to provide care.

While in other states, including Minnesota, legislatures have changed laws allowing a midlevel type of practitioner trained to do basic preventative and restorative work.

Dr. David Rosania made a mad 24-hour dash from New Hampshire to Nashville in March to do two things: eat the city’s famous hot chicken and administer charity dental care.

The chicken from Hattie B’s was “clucking awesome,” and the turnout of hundreds of people who lined up for free dental cleanings, extractions or fillings at Meharry Medical College is exactly what he expected, said Rosania.

This was Rosania’s first charity clinic, and he was glad to find one that didn’t espouse a mission other than dental health, so he paid for his own flights and accommodations.

Five hundred people were expected for the second annual free oral health day on March 10 at Meharry but closer to 700 showed up.

Dr. David Rosania, a dentist from Portsmouth, N.H., talks to a patient who came for free dental services at Meharry Medical College on March 10. Courtesy/Meharry Medical College

Some people took Uber or Lyft to get to Meharry. Others came by bus or had someone drop them off.  Still, others drove hundreds of miles. One of the first people to be registered came up from Huntsville, Ala. Another was from Shelbyville.

The hundreds who stood in line for dental services spotlight the brokenness and irregularity of the system, said Rosania, who would catch a flight home later that night.

Austin Hart; Photo/Holly Fletcher

Austin Hart, a first year dental student who helped register and show people around, said the long line of people was a clear and present reminder of the pent-up demand of the world he’d graduate into.

“A lot of people are running on little to no sleep to get dental work done,” said Hart.

Tennesseans outside the greater Nashville area often have less access to dentists so free care is a big draw of charity events. In 2017, Saint Thomas Health hosted four Medical Missions at Home, which treated 488 dental patients and extracted 854 teeth, in aggregate.

The state ranks among the worst for access to dentists, a problem which is exacerbated outside of the metro areas. Wayne County, for instance, has one dentist for 16,100 people — the lowest ranking in the state, according to the 2018 County Health Rankings.

Outside of Tennessee, other states such as Minnesota and Alaska are trying to close the access to care gap in their own rural areas by credentialing a new-to-the-U.S. type of clinician: the dental therapist.

Dental therapists are trained to do about 80 of the 550-600 procedures that dentists do, but have more training and a greater scope than dental hygienists. It’s a middle level clinician similar to a nurse practitioner or physician’s assistant.

Dental therapists work in 53 countries but are found, so far, in four states. There are a handful of other states considering changing statutes to allow dental therapists to practice, said Jane Koppelman, research director of The Pew Charitable Trusts’ dental campaign.

In 2005, Native Alaskans began to have access to dental therapists through the federally-run Indian Health Service. They had trained in New Zealand and then relocated to remote communities.  



After a few years, Alaska developed a training program so students didn’t have to travel to the Southern Hemisphere to learn routine preventive and restorative care, how to address tooth decay, drill and fill teeth and perform non-surgical extractions, said Koppelman

Sarah Wovcha, executive director of Children’s Dental Services in Minneapolis, pushed for the Minnesota legislature to change its law in 2009.

“The problem we were trying to solve was the lack of access to care for low income people,” said Wovcha. “The reality is dentists are very expensive, and safety net clinics like mine had a hard time recruiting and being able to afford their salaries.”

There was strong opposition to the plan at first, but the legislation passed in the first year it was proposed. Now, some of the opponents are proponents of dental therapists.

Most of the dental therapists in Minnesota are now in private practice because they increase efficiency and cut costs, Wovcha said. A 2014 report to the Minnesota legislature found that therapists at the clinics it studied saw 6,338 new patients.

Dr. James E.K. Hildreth

Dr. James E.K. Hildreth thinks dental therapists are part of a more sweeping and longer-term solution to the access problem facing Tennessee and much of the U.S.

Meharry used to train dental therapists, Hildreth said, but stopped years ago.

Hildreth said he’s had talks with Fisk University and Tennessee State University about the possibility of starting another training program.

Hildreth, standing amidst the bustling free oral health day, said the nearly two hundred extra people who showed up that day reflects the limited access.  

“We know oral health impacts the whole body and self-esteem,” said Hildreth.

More states, including Tennessee, would have to change laws to allow dental therapists to practice. In Tennessee, it could be a challenge given the years’ long legislative battle to make changes to nurse practitioners’ scope of practice.

“We’re trying to get that to be part of the national conversation,” said Hildreth. “It would be a way to impact millions.”

‘The need is so great and this will just scrape the surface’

In the interim, looking to take dental care to areas that need it, Meharry recently bought an 18-wheeler retrofitted as a dental clinic from an East Tennessee foundation.

The mobile clinic has been on the road a few times across the state. Recently, on a two-day trip to Memphis, supervising dentists, dental students and assistants assessed, cleaned and treated 61 people, said Dr. Walter Owens, associate dean of development and external affairs at Meharry.

The trailer is designed to make use of every space. Four exam chairs are nestled in around an X-ray machine in addition to a space that can be used for more extensive treatment.

Owens said it’s an ongoing effort to figure out the logistics of the supplies and the location. The truck needs to be near a facility with bathrooms and for overnight trips the students and truck have to be safe.

Administering care in a trailer is a different experience than in a brick and mortar building. Yet it prepares students to work in different environments — a valuable lesson as the practice of health care continues to evolve.

The mobile unit is currently only treating youth and children in state custody but there are plans to make a variety of different stops, including nursing homes, said Owens. It’s also equipped with a ramp for those who require easier access.

Mary Ashlee Tosh waited to find out how many fillings she might need. The 24-year-old Nashvillian hasn’t been to a dentist in several years.

The college made the purchase with help from a grant it gets from the United Methodist Church.

Cynthia Bond Hopson, assistant general secretary of the black college fund and ethnic concerns at the United Methodist Church General Board of Higher Education and Ministry, jumped at the chance for Meharry to use a portion of its grant for the mobile clinic.

Hopson grew up in a rural area where dentists came at a premium and she’s excited to be involved in an experiment that could deliver routine care to people in neighborhoods and counties where affordable access is a challenge.

She hopes the mobile clinic can be a model for other non-profit or educational institutions as well as for-profit groups.

“So much of what goes on with people’s health starts with their healthy or unhealthy mouth,” Hopson said. “The need is so great and this will just scrape the surface. One step at a time, one person a time.”

Trips to the dentist can ‘get put on the back burner’

Mary Ashlee Tosh, 24, waited that Saturday to find out how many fillings she might need. She hadn’t been to a dentist in several years and her coverage through TennCare expired at age 21.

According to the National Association of Dental Plans, 5.28 million Tennesseans, or 79 percent, had some sort of dental coverage in 2017. Of that, 1.83 million were enrolled in TennCare or the Children’s Health Insurance Plan, which extends coverage to children in families who make too much money to qualify for TennCare.

Dental care in the state is cheaper than other states, according to WalletHub, which used Healthy Grid data: a crown costs $809, a cleaning costs $56, having a tooth pulled is $267 and a root canal treatment is $843.

But people have to call around to find the lowest prices and taking time off work for an appointment can cost someone on an hourly wage, a significant portion of their income.

Brittney Hawkins, a second year dental student at Meharry Medical College, knew she wanted to be a dentist in middle school even though she’d only seen one a handful of times as a kid in Houston. Photo/Holly Fletcher

Brittney Hawkins, a second year dental student at Meharry, grew up in a single-parent household in Houston and trips to the dentist “were put on the back burner” because there were always other expenses that took precedence.

Hawkins decided in middle school that she wanted to be a dentist — despite having been to one herself only a handful of times.

Mobile clinics are a great resource and better than nothing for areas that lack enough dentists or enough providers that take Medicaid, but it’s not the most efficient mechanism, said Pew’s Koppelman.

Buying and retrofitting a trailer can cost $1 million and that doesn’t include the upkeep, fuel and diesel for the generator. There’s also lodging costs for clinicians and the potential for equipment to be damaged in transit — even though there are straps and bungee cords to strap it all down, said Owens.

The gap between the number of dentists and demand for care is expected to grow in all 50 states by 2025, per HRSA data.

Using Bureau of Labor Statistics and Census data, WalletHub found that Tennessee ranked last for number of dentists per capita. The state has 15.9 per 100,000, compared to Massachusetts which ranked first at 47.6 dentists per 100,000.

It’s more common in Tennessee than most other states for older adults to have no natural teeth.

Extractions are popular at charity events as people have let problems fester until the tooth would require expensive treatment or needs to be pulled.

One of the first people in line at Meharry left “happy as a lark” after having three extractions, said Dr. Julie Gray, assistant dean of student affairs for Meharry’s School of Dentistry.

Most people are grateful for the care and relieved about the extractions because it solves a problem, said dentists.


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