There’s a dental crisis happening in Alabama, as some patients have to wait up to a year for oral surgeries and dentists say they are struggling to keep their offices open.
“The access to care in Alabama is worse than any state I’ve ever practiced in,” said Carson Cruise, a pediatric dentist in Florence. “Mississippi is usually the worst at everything when it comes to health metrics. But if Mississippi is the floor, Alabama brought a shovel.”
In 2023, Alabama had the nation’s second-lowest ratio of dentists per population, according to the American Dental Association at just 41.6 dentists per 100,000 residents. Alabama narrowly topped Arkansas, which had 41.2 dentists for every 100,000 people.
Both fall far below the national rate of about 60 dentists per 100,000 residents.
Children, people with disabilities and those living in rural areas are hit hardest by the shortage.
Two rural counties in the state, Greene County near the Mississippi border, and Clay County, on the east side of Alabama, have no dental providers. And another 18 counties are seeing either all or most of their dentists reach retirement age.
In rural Alabama, there are nearly 3,845 patients for each dentist, according to an August report by the Alabama Department of Public Health.
“This situation puts many Alabama counties at risk of losing vital dental services in the near future,” the health department report said. “The oral health disease burden in Alabama presents a pressing challenge that necessitates immediate attention.”
Dentists told AL.com that the biggest problem they face is low insurance reimbursement rates, especially from the state Medicaid agency.
Cruise said he sees about 60 patients a day, with some families driving over two hours to his practice in Florence. Because over half of his patients are on Medicaid, he said, the only way to stay in business is to see a high number of cases.
“When you look at the number of patients I have, I’m doing great. We get north of 100 new patients a month,” he said. “But if you look at the amount of money the business collects, expenses have gone up so much that what goes in my pocket is about 10% less than what it was three years ago.”
Cruise said two dental offices in his town have stopped accepting Medicaid in the last year because they can’t afford to treat those patients.
More than 50% of children in Alabama are on Medicaid. And according to the state health department there is “a growing crisis in oral health among children in the state.”
Cruise moved to Alabama in 2020. Before that he practiced in Virginia, Louisiana and his home state of Mississippi.
It’s taken four years for Cruise to get access to a hospital for surgical cases that require anesthesia. He said the Medicaid reimbursement rate was so low that hospitals were losing money and wouldn’t give him privileges to operate.
It was a problem nationwide, prompting the Centers for Medicare and Medicaid Services to increase their reimbursement for dental procedures at hospitals from $200 to $2,000 beginning this year.
Beginning next month, Cruise will see his first case at Helen Keller hospital in Sheffield. He’s been having to send patients two hours away to Children’s hospital in Birmingham, where the wait time for an operation is anywhere between six months to a year.
“We care about our patients, that’s why we went into this profession, and it just gets increasingly heartbreaking when we feel like there is just no way to meet the need in this state,” said Stephen Mitchell, an associate professor in the UAB School of Dentistry who performs about three surgeries a week at Children’s.
In urgent cases, Mitchell said those patients can be seen earlier, in about four to six weeks.
“If we have a kid that’s got swelling and is in acute pain, then things will get shifted around for them,” Mitchell said. “But then that pushes the kid that’s got chronic issues back a little bit further and you wind up with a kid who maybe starting out wasn’t hurting, but by the time we get to them, they’re hurting, they’re infected, or instead of being able to save the teeth, we’re having to take them out.”
Cruise said a lot of those emergencies could be prevented if kids had better access to routine dental care.
Mitchell said he also has to pull a lot of teeth on patients at the Sparks Clinic, a UAB dental practice that works with people with disabilities.
Alabama is the only state in the country that doesn’t provide any dental coverage for adults on Medicaid, meaning they have to find a private insurer to cover their teeth or pay for costs entirely out of pocket.
Alabama provides the benefit through the age of 21.
Mitchell said that hurts his poorer adult patients with disabilities, who sometimes can’t work and end up having to pay for dental appointments using their social security checks.
“I can’t get them the dental care they need when they’re scraping out of a social security check enough to pay for our preventive services,” Mitchell said. “But when something more serious comes up and they need sedation, frequently with this population we get to the point where the only thing we can do is just have all their teeth taken out because there’s no other realistic mechanism to do differently.”
A spokesperson for Alabama Medicaid did not answer questions about why the state doesn’t provide dental coverage for adults. She said the benefit is available for pregnant adult Medicaid recipients through 60 days postpartum.
Meanwhile, not every state is in crisis. Some states have twice as many dentists as Alabama, when adjusted for population. Massachusetts and Alaska have about 80 dentists for every 100,000 people, while Washington, DC has over 100.
In its report, ADPH said that the ‘access-to-care issues’ combined with the lack of insurance coverage and the growing population of people being diagnosed with disabilities “will place a burden on Alabama’s oral health system in the next decades more than ever experienced in the past.”
“In the end, we are left in a situation where the most vulnerable of us, children and people with disabilities, are being left without any care,” Mitchell said.
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