Dental difficulties: Workforce issues dampen rural Minnesotans' access to dental care
There is a pronounced need for more dental providers in Southeast Minnesota's rural towns, many of which don't even have a dental clinic. The challenge: getting graduates to go there.
EYOTA — When Dr. Zach Lechner applied to dental school in the late 2000s, he made sure to express his desire to practice dentistry in a rural community.
"I ended up going into dentistry because I wanted to be in health care and be able to take care of people," said Lechner, who is originally from Sauk Rapids. "And after getting married to my wife, we made it a point to move back to a small town."
And that's what Lechner and his wife, Hannah Lechner, did. Lechner graduated from dental school in 2011, and in 2014, the couple moved to Stewartville, Hannah's hometown. There, Lechner practices at his own clinic, Root River Dental.
"We feel absolutely honored and privileged to raise our kids in rural Minnesota," Lechner said.
But not every community in Southeast Minnesota has a dental clinic, making access to regular dental care difficult for rural Minnesotans. For providers already working in smaller communities, like Lechner, they are often near their patient capacity.
Two major obstacles — a rural workforce shortage and limited access for families on Medicaid — stand in the way of bringing dental care to more Minnesotans.
The effects of these issues show up in Minnesotans' mouths. In the Minnesota Department of Health's latest open mouth assessments of third-graders across the state, 50% of those children had treated or untreated dental cavities, said MDH oral health director Dr. Prasida Khanal. Meanwhile, 42% of nursing home residents surveyed had dental care needs, too.
"One thing is for sure: 99% of dental decay that we see all across the state, is preventable," Khanal said.
One factor that limits access to dental care: a dental workforce shortage in rural communities. Winona and Houston counties are even recognized by the U.S. Health Resources and Services Administration as being dental health provider shortage areas.
"More than 50% of our counties are already known to be in need of more providers," said Khanal.
Katie Ristau, a dental hygienist and faculty member at Rochester Community and Technical College, said there aren't enough dental assistants and hygienists graduating locally to meet small towns' needs. RCTC is the only college in Minnesota south of the Twin Cities to offer a dental hygiene program, and just one of two — along with South Central College in North Mankato — that offer a dental assisting degree.
"We are not graduating enough to meet the need," Ristau said. "We are working on expanding our program, there's just a lot of hoops to go through."
Because many of Rochester's dental clinics are actively hiring new assistants and hygienists, Ristau said many graduates often stay and work in Rochester instead of venturing out into outlying towns.
"It always appears that we're graduating enough people, but you still hear about shortages," added Teri Fritsma, lead health care workforce analyst at MDH. "I think that's because shortages tend to be very local, and they tend to be rural and small. Rural and small town communities tend to be hit the worst."
As for dentists, the U.S. is graduating more than ever before. According to the American Dental Association, total enrollment in predoctoral dental programs across the country increased by 4.9% between 2017 and 2021. But the quantity of graduates isn't the problem, it's the distribution.
"We are graduating a lot more dentists," said Dr. Michael Flynn, who provides dental care at Children's Dental Health Services at the United Way in Rochester. "But when you get to rural areas and underserved areas, the desirability to go out in those areas is less. We tend to want to stay in the large metro areas."
For dentists who are practicing in Minnesota's rural communities, they are more likely to be approaching retirement than their urban counterparts.
According to data from the Minnesota Board of Dentistry, licensed dentists who are age 65 and older make up 15.1% of dental providers in the state's metropolitan areas like Rochester, Minneapolis and Duluth. However, about one in four dentists in Minnesota's isolated rural communities (defined as having fewer than 2,500 residents) are at or beyond retirement age.
"If you look at Greater Minnesota, the rural areas, we are an aging profession," said Flynn, who practiced dentistry at his own clinic in Lewiston for 40 years before retiring in 2018. "I've heard that the average age is in that 58 range. So, if you look at the next 10 years, they'll be 68. ... And will we replace all of those dentists with all new dentists? That doesn't look like the trend."
Even if a community has a dentist or two in town, there's no guarantee they will accept Medical Assistance, Minnesota's low-income Medicaid health plan.
Ristau said Minnesota's reimbursement rates for child and adult dental services has been low, historically. Per the ADA, Minnesota's reimbursement rate for child dental services was 27.8% in 2020, the lowest among all 50 states.
"People get frustrated with the dentist because the dentist won't see patients who have Medical Assistance insurance," Ristau said. "But, financially, they just can't. ... Of a $100 bill, they're going to get reimbursed $28. That doesn't even pay for the wage of the person seeing the patient."
Though Minnesota's dental reimbursement rate for dental services did increase in 2022 , finding a provider who accepts Medical Assistance can be difficult, leading to missed visits and lack of care. Khanal said that in 2018, MDH data showed less than 50% of children eligible for a child and teen checkup under Medical Assistance saw a dentist that year.
Fewer preventative visits ultimately leads to more acute issues. At Children's Dental Health Services, which serves youth on Medical Assistance, Flynn said he sees patients who travel in from as far as Owatonna, Albert Lea and Northfield.
"I like to treat them before they have dental problems," Flynn said. "But, today, almost everybody I see has what I would call an urgent problem."
The local impact
At Lechner's practice, he and his team of eight staff members care for around 1,700 patients each year. While most of his patients are from Stewartville, many travel in from areas where there are few — or no — dentists present.
"We do serve patients from everywhere from Oronoco and Pine Island, all the way down into Iowa and over to the Wabasha area," Lechner said. "We really are at capacity for a solo doctor practice right now."
It's a similar story at Perry Dental in Eyota, where Dr. Joe Line is the primary dentist. His wife, Dr. Ava Perry Line, is the primary dentist at Perry Dental's Lake City office, and the two switch offices one day a week. Just at the Eyota office, the two dentists see between 1,700 and 1,800 patients per year.
"Staffing has been probably the biggest issue, keeping a very strong and motivated, talented staff," Line said. "We have a great team currently, but we're wanting to serve even more patients than we could now."
As relatively recent graduates of the University of Minnesota School of Dentistry, both Lechner and Line said it can be difficult for new dentists to set up a practice in a rural area, especially if they are not from a small town.
"I believe some of it has to do with, you know, the rising tuition is quite harsh," Line said. "Especially for me starting (out), like I had a job right out of dental school, but it didn't look that attractive compared to some other large group practices ... that can offer a large signing bonus to these young graduating dentists."
"Trying to recruit people to a small town, unless they have a connection to that community, is a challenge," added Lechner.
It's an issue that, ultimately, extends beyond dentistry.
"It's all professionals," he said. "How do we backfill the workforce shortage in rural America as small towns shrink and things become more regionalized?"
New roles and rural recruitment
Efforts to incentivize working in small towns have worked in Southeast Minnesota — Line and Perry Line are proof of that. The city of Eyota went without a dentist for 25 years, but in 2016, Eyota began to actively recruit a new dentist. Dr. Phillip Perry — Perry Line's father — took up the offer, expanding the Perry Dental Wabasha practice into Eyota, Lake City and Pepin, Wisconsin, with the help of his dentist son, daughter and son-in-law.
This is the type of active recruitment other communities, such as Chatfield, are eyeing.
"We have a long history of having that service here in Chatfield," said Chris Giesen, the Community and Economic Development Associates representative for Chatfield and Harmony. "And, you know, we're growing. We're on the upward swing, and I think we're going to continue to see that. And in order to do that, we need all the services, like dental."
Chatfield's only dental clinic, Midwest Dental, has been without a dentist since late 2021. If a dentist did want to set up a practice in town, Giesen said Chatfield would "open the toolbox wide up" to help them get established.
But the push for practicing rural dentistry could happen earlier. Line suggested that dentists could receive help for their student loans by practicing in a smaller community. Lechner agreed.
"The workforce in a rural health care setting, I think, should have some tuition forgiveness," Lechner said. "And trying to incentivize people to get back to their hometowns. Rural areas need to not only be able to have a patient population to serve, but have an enticing reason to go back to a small town."
Another solution involves a role only found in this state: advanced dental therapists.
"I compare the dentist to a medical doctor and the advanced dental therapist to like a nurse practitioner," Ristau said.
The advanced dental therapist career exists in other countries, but Minnesota became the first U.S. state to license ADTs in 2009. Only a handful of colleges in the state offer a degree in dental therapy. That education allows dental therapists to do some of the same procedures that a dentist can, and they work under a dentist's supervision. The procedures dental therapists can perform, like children's extractions and fillings, are critical restorative services that go beyond the care that an assistant or hygienist can provide.
"There are opportunities for dentists to delegate procedures within the scope of dental therapists to focus on more complex procedures," Khanal said.
These professionals can pursue additional training to become ADTs who can do more procedures and require less supervision from a dentist. ADTs are also encouraged to work in a public health settings like schools and nursing homes, making them key for advancing dental care access for Minnesotans on Medical Assistance.
"That position was developed to put them into rural settings for access to care," Ristau said. "A lot of them do go to a dental office, but they have to see a certain percentage of Medical Assistance patients."
"Minnesota reimburses for procedures, not providers," Khanal added.
Per the dentistry board, 136 dental therapists are licensed in Minnesota. It's not enough yet to meet the need, as Ristau said a dental therapist has yet to work in Fillmore County, where she grew up and lives now. To get more dental therapists trained and out working in rural areas, students need to know that becoming a dental therapist is an option.
"We usually have a total of 32 hygiene students at a time," Ristau said of RCTC. "We graduate, ideally, 16 a year, and we usually have one in each class that seems interested in doing it."
A potential draw into dentistry for young people looking at their future career path, Fritsma said, is that there is a career ladder in this field, something that isn't present for other areas of medicine.
"If you were to start off as a dental assistant and then move to a dental hygienist, you could very conceivably move up to a dental therapist and then even a dentist as you progress," Fritsma said. "That's a real viable ladder, and so that's a good recruitment tool."
Earlier recruitment, in general, is an important aspect for getting more assistants, hygienists, therapists and dentists to practice rural and local.
"Colleges, whether it's RCTC ... or the University of Minnesota dental school, they need to get in front of kids not at high school, but middle school levels to present the careers, help them understand the track, what it would take to become a professional," Lechner said. "Dentistry is an absolutely necessary health service for everybody, and there's a need in outstate Minnesota. I certainly encourage anybody who wants to make an impact in the community to explore it as a career."
Small town troubles
More than a year after its only dentist departed, Chatfield may soon see its Midwest Dental office permanently close if the community can't find a provider.
"It's terrible to lose a service, any service or any business," said Chris Giesen, the Community and Economic Development Associates representative for Chatfield. "And then you start thinking from a tactical standpoint, you know, trying to get a new one."
The Midwest Dental office at 431 Main St. N in Chatfield has been without a dentist since late 2021, said Jody Martin, chief marketing officer for Smile Brands. Smile Brands merged with Midwest Dental in 2020.
"We are continuing to look for a provider to service our patients in Chatfield," Martin said. "If we succeed, we will reopen. If not, we will have to close down."
Martin said the timeline for reopening the Chatfield office is dependent on the current lease, though she said she could not comment on a potential lease renewal.
"The decision to stay in an individual location versus to leave the community are not always the same decisions," Martin said. "It would just be a matter of whether or not we can find staff."
Midwest Dental's St. Charles office, located at 936 Church Ave., is in a similar position. That clinic's dentist left in mid-2022, Martin said.
The vacancies at the St. Charles and Chatfield Midwest Dental offices coincide with a nationwide workforce shortage felt across the medical field, including dentistry, and a particular need for more dental providers in Southeast Minnesota. Both Fillmore and Winona counties, home to part of Chatfield and St. Charles, respectively, are classified as dental health provider shortage areas by the U.S. Health Resources and Services Administration.
"We need the people in our communities to do these jobs in order to have the services to be able to keep things going and keep things growing," Giesen said. "We need those underlying support services."
Smile Brands is trying to recruit dentists to work in both communities' offices.
"For hard-to-fill locations ... we offer a pathway to ownership," Martin said. "We are definitely looking for folks that want to be there for the long term and would be interested in earning into ownership."
Additionally, Giesen said the city of Chatfield would provide assistance to a dentist wanting to work in Chatfield — at the Midwest Dental location or in their own clinic. That assistance will look different depending on the situation.
"We have other resources that aren't necessarily cash, either," he said. "We can help with site location, the development process. ... I've been aware of a few banks out there in our region that are willing to even do 0% financing for dental practices. We can help them track down the resources they need to be successful."
Midwest Dental also operates offices in Zumbrota, Winona and Red Wing, which all have at least one dentist currently on staff, per the company's website.