19 minute read
Bridging the Dental Care Gap
Bridging the Dental Care Gap
Addressing Oral Health Disparities in New York State Nursing Homes
Apeksha Phulgirkar, B.D.S., PGCert, M.P.H.; Stacy McIlduff, CFRE
ABSTRACT
Oral health is a critical component of overall wellbeing, yet disparities in access to dental care disproportionately affect vulnerable populations, particularly elderly residents in nursing homes. Poor oral hygiene is linked to systemic health conditions, such as cardiovascular disease, diabetes and cognitive decline. Despite federal regulations mandating oral health assessments in nursing homes, many facilities lack adequate resources, and care often falls to undertrained staff.
This study assesses the availability of onsite dental care services in New York State’s nursing homes and the role of mobile dental clinics in bridging the access gap, especially in rural and underserved areas. A mixed-methods approach combining geospatial analysis and a review of publicly available datasets was employed. The study analyzed dental care resources in 603 licensed nursing homes, focusing on facilities in dental health professional shortage areas (HPSAs).
Results revealed that only 198 of New York’s nursing homes provide onsite dental services, with significant service gaps in HPSA-designated counties. Additionally, only 17 organizations offer mobile dental services across the state, further limiting access to care for nursing home residents
in underserved regions. The findings underscore the urgent need for targeted interventions, including expanding mobile dental clinics and improving onsite dental care services.
A phased implementation of mobile dental units, prioritizing nursing homes in full shortage areas, is proposed as a cost-effective solution to address these disparities. By focusing on collaborative community partnerships, this approach could significantly improve oral health outcomes and serve as a model for addressing healthcare disparities in other underserved populations.
Oral health is an essential component of overall well-being, influencing physical, psychological and social health. Poor oral health can cause pain, impair functionality and significantly diminish quality of life. Emerging evidence suggests strong associations between oral diseases and systemic health conditions. For instance, chronic periodontitis has been linked to an increased risk of atherosclerotic vascular disease, while dental diseases have been found to exacerbate pulmonary conditions, such as chronic obstructive pulmonary disease (COPD) and pneumonia.
In some cases, orofacial pain has been identified as the sole presenting symptom of stroke, highlighting the pivotal role of oral health in the early detection of broader systemic health problems.[1] A growing body of research emphasizes connections between periodontal disease, tooth loss, oral cancer and diabetes. Although periodontal treatments may offer only short-term benefits for metabolic control, the association between oral health and chronic conditions, particularly diabetes, remains clinically significant.
Additionally, poor oral hygiene has been associated with cognitive decline, as conditions such as gingivitis, dental caries and tooth loss have been shown to increase the risk of dementia and cognitive impairment.[1] These findings underscore the necessity of maintaining good oral health to support overall well-being, particularly among vulnerable populations.
Despite advancements in dental care, significant barriers to access persist, disproportionately affecting low-income, rural and underserved communities. In the United States, approximately 68.5 million adults either lack dental insurance or face limited access to essential oral health services.[2] Data show that 2.8 million New Yorkers live in dental health professional shortage areas,[3] and 21.55% of the population resides in rural areas,[4] where dental care access is particularly limited.
According to a 2024 report from the Health Resources and Services Administration (HRSA) on health professional shortage areas (HPSA), only 16.15% of New York’s dental needs are currently being met, with an estimated shortfall of 588 dental practitioners.[5] These disparities are most acute among underserved populations, including nursing home residents, individuals with disabilities and those living in rural areas.[6,7] Among these vulnerable groups, elderly residents in nursing homes face particularly significant challenges in accessing dental care.
Nationwide, approximately 1.4 million individuals reside in nursing homes,[1] with New York State alone housing 96,866[8] residents across 603 licensed facilities.[9] Many of these residents suffer from conditions such as dementia and Alzheimer’s disease, which complicates their ability to perform routine oral hygiene practices. As cognitive conditions progress, residents may forget or be unable to comprehend the importance of maintaining oral hygiene, leading to severe deterioration in oral health.[10,11]
Research demonstrates that oral care in nursing homes is often inadequate. A 2006 study conducted in upstate New York found that only 16% of nursing home residents received any form of oral care, and when provided, care often lasted as little as 16.2 seconds.[12]
Similarly, a study in North Carolina revealed that over onethird of tooth surfaces and more than half of denture surfaces were covered in plaque. A 2018 study in Japan further highlighted that caregivers in nursing homes often lack formal dental hygiene training, leading to inconsistent and substandard care—a problem exacerbated in rural areas with limited access to dental professionals.[1]
The delivery of dental care in nursing homes is often restricted by the facility’s ability to provide such services.[13] Daily oral care responsibilities typically fall to registered nurses (RNs), licensed practical nurses (LPNs) and certified nursing assistants (CNAs), many of whom lack adequate training in oral health.[14] High staff turnover, with 38% of nursing home employees expected to leave their positions within two years, further complicates the provision of consistent care.[15]
Additionally, assessments such as the Minimum Data Set (MDS) often underreport oral health conditions like gingivitis and tooth loss, resulting in unmet needs. Improving staff training and adopting better assessment tools, as recommended by the American Dental Association (ADA), could significantly improve oral health outcomes in these settings.[16]
In the U.S., Medicare, the national health insurance for older adults and those with disabilities, does not cover routine dental care. As a result, most older adults lack dental insurance, limiting access or leading to high costs. For Medicaid recipients, including about 70% of long-term nursing home residents, dental coverage varies by state. In 2016, roughly one-third of states offered extensive dental benefits, including a wide range of services with annual expenditure caps of $1,000 or more. Another third offered limited benefits and a few states provided no dental coverage, while the rest offered emergencyonly benefits.[1]
Another challenge is transportation to the dental office. Older adults with travel times greater than 30 minutes to see a dentist are more likely than others not to utilize oral health services when needed.[26] Inability to travel to a dentist was cited by 65.7% of older adults, and difficulty in finding a dentist was cited by 63.1% of older adults as barriers for those who needed but were unable to get services.[26]
In October 2023 and October 2024, the New York State Dental Foundation organized mobile dental clinic events that underscored the crucial role of mobile care in addressing dental access issues. These events were especially important after the closure of two local dental clinics, which left nearly 4,000 individuals, many of whom were Medicaid recipients, without access to dental care. A total of 120 patients registered to attend the event in 2023, and 26 of those individuals received emergent care on the mobile dental vans. The 2024 event saw an increase in registrations, with 137 patients signing up to attend the event and a waiting list of more than 30 additional patients. These numbers highlight the significant demand for dental care and the critical need for improved access.[20]
Despite the success of these events, logistical challenges remain, such as the high costs of contracting with out-of-state organizations to bring dental vans onsite due to the lack of in-state units available, limiting the consistency of care delivery. To address these issues, the New York State Dental Foundation is hoping to start tracking which of New York’s 603 licensed nursing homes provide onsite dental services, while also monitoring mobile dental van operations to identify service gaps. These efforts would ensure that future community dental events are scheduled in areas with the most critically underserved populations.
Significance
In 2018, 56-year-old Brenda Bidwell, a medically fragile resident of Waverly, NY, moved to a nursing home for rehabilitation. Living with multiple chronic conditions—diabetes, a double amputation, lymphedema and obstructive sleep apnea—Brenda required specialized care and was especially vulnerable to infections. When COVID-19 hit, her situation became dire. Limited access to dental care during the pandemic led to rapid oral health deterioration, painful decay and infections that compromised her overall health.
Brenda’s case illustrates the urgent need for mobile dental units in nursing homes, as her complex needs made regular visits to a distant hospital dental clinic an overwhelming challenge. Mobile dental vans could provide onsite, essential care for nursing home residents like Brenda, helping to prevent severe complications, reduce travel stress and ensure continuity of health care in familiar, supportive environments.
Methods
This study employed a mixed-methods approach, integrating geospatial analysis with a review of publicly available datasets to assess dental care resources and service gaps in New York State. This combination allowed for a comprehensive understanding of the distribution of dental services, particularly in nursing homes and underserved rural areas.
Data Collection
To analyze the distribution of dental care resources in nursing homes and mobile dental services, we compiled a comprehensive dataset using publicly available information from key sources, including:
• The U.S. Census Bureau
• Centers for Disease Control and Prevention (CDC)
• Health Resources and Services Administration (HRSA)
• New York State Department of Health
These sources provided demographic data, such as population distributions (urban vs. rural), prevalence of disabilities and the number of individuals residing in nursing homes, which are all pertinent to understanding dental care needs. A list of 603 licensed nursing homes was obtained from the New York State Department of Health. This dataset included the names, addresses and ZIP codes of each facility.
Each nursing home was then assessed for the availability of onsite dental care services. Facilities were coded as offering onsite dental services if this was explicitly mentioned on their official websites. Facilities where no information was available or where clarification could not be obtained through virtual chat systems (when present) were coded as “no.” This verification process was necessary due to the lack of comprehensive, publicly available datasets on onsite dental care in nursing homes.
To supplement our assessment of mobile dental services, we used data from the New York State Department of Health’s extension clinic list,[23] which identified seven organizations operating mobile dental clinics. This list was further expanded by reviewing the websites of other organizations providing mobile dental van services across the state.
Geospatial Analysis
We used ArcGIS software for geospatial analysis to visualize and analyze the distribution of dental care services. ArcGIS was chosen for its ability to process and map large datasets, providing a clear spatial representation of service disparities across New York State. Using geocoded ZIP codes, we mapped the locations of nursing homes, mobile dental clinics and areas designated as dental health professional shortage areas (HPSAs) by HRSA. This geospatial approach enabled us to identify geographic disparities in dental care, with a particular focus on rural and underserved regions. Detailed maps were generated to illustrate the distribution of nursing homes offering onsite services, the reach of mobile dental clinics and areas where shortages of dental professionals are most acute.
Limitations
Several limitations of this study must be acknowledged. First, our assessment of onsite dental services relied heavily on the availability of information from nursing home websites. This approach may have led to underreporting or inaccuracies, as not all facilities update their websites regularly or provide detailed information about their dental services online. Additionally, facilities coded as “no” for onsite services may, in fact, offer dental care, but this cannot be confirmed through publicly available information.
Another limitation is the scope of the mobile dental services data. While our dataset included information from official state sources and additional organizations, it is possible that some smaller or less formalized mobile dental services were not captured. Future studies could address these limitations by conducting direct surveys with nursing homes or partnering with county health departments to obtain more reliable data. Despite these limitations, the combination of geospatial analysis and the comprehensive review of publicly available data provided critical insights into disparities in dental care access across New York State.
Results
Of the 603 licensed nursing homes in New York State, only 198 facilities offer onsite dental services. The remaining 405 either do not provide these services, or their status remains unclear. This disparity becomes even more pronounced when cross-referenced with data on dental health professional shortage areas (HPSAs). Currently, 24 counties in New York are designated as full shortage areas,[24] meaning these entire counties lack sufficient dental care providers.
Within these 24 shortage-designated counties, 111 nursing homes operate. Alarmingly, 81 of these homes do not provide onsite dental services, leaving just 30 nursing homes with dental services available. This highlights a substantial gap in dental care access for residents in areas where the shortage of dental professionals is most severe.
Compounding this issue, only 17 organizations statewide offer mobile dental services, a critical resource for reaching underserved populations. The shortage of mobile dental vans further underscores the barriers to quality dental care faced by nursing home residents, particularly in rural and underserved counties. These mobile services are vital in regions with a limited presence of dental professionals, yet their scarcity exacerbates the challenges in addressing the significant disparity in care access.
Discussion
“silent epidemic” of oral diseases is ravaging nursing home residents, representing a critical yet overlooked gap in healthcare with severe consequences for this vulnerable population. Despite the Oral Health Strategic Framework outlining important steps to eliminate oral health disparities, it notably lacks specific attention to nursing home residents, who are disproportionately affected by this crisis.[1] Federal regulations require nursing homes to assess and address the oral health needs of their residents, but there is little oversight or data on compliance. This lack of accountability exacerbates the issue, as many facilities may not be fulfilling their mandated responsibilities. Additionally, the absence of a centralized database of dental care in nursing homes, as well as mobile dental clinics operating in New York, complicates efforts by nonprofit organizations like the New York State Dental Foundation, which works to improve oral health across the state. More accessible information about where services are most needed would help organizations like the foundation to more efficiently and strategically allocate resources and begin to address the significant inequities in dental care access for this vulnerable population.
One proposed solution is the introduction of a dedicated mobile dental van to serve populations in dental health professional shortage areas (HPSAs), particularly nursing home residents and individuals with disabilities. These clinics eliminate the need for transportation, reduce costs and provide a higher quality of care.[17] Mobile dental services are especially beneficial for frail, elderly individuals with limited mobility, offering treatments such as fillings, extractions and routine cleanings. These services are also cost-effective, reducing hospitalizations caused by untreated dental conditions and eliminating transportation-related expenses.
Programs such as Gerodent in Belgium have demonstrated substantial improvements in oral health outcomes for nursing home residents. Additionally, mobile clinics have been shown to improve the oral health knowledge and daily care practices of nursing home staff. Mobile dental vehicles (MDVs) present a strategic solution for expanding dental care in underserved and rural areas. These vehicles can provide a range of services, from routine cleanings to extractions, in areas with limited access to dental professionals.[18,19]
A phased implementation approach is recommended, beginning with nursing homes in areas facing complete dental provider shortages, then expanding to homes in partial shortage areas and, finally, to those without onsite dental services. This phased approach ensures that the most underserved areas are prioritized. Success will depend on building collaborative partnerships with local dental providers for staffing, dental schools to assist with training, and community dental health coordinators and faith-based organizations to facilitate outreach and raise awareness. However, financial barriers pose a significant challenge. The estimated cost of acquiring a dedicated mobile dental van is $479,728.[25]Beyond the initial acquisition, securing ongoing operational funding—including staff salaries, vehicle maintenance, storage and insurance, and medical supplies—will be essential. Grants, donations and partnerships will be pivotal in ensuring the sustainability of the program.
The consequences of inadequate dental care in nursing homes extend beyond oral health, leading to systemic issues such as malnutrition, pain and a heightened risk of infections, further diminishing the quality of life for residents. Expanding the use of mobile dental units is, therefore, crucial to addressing these widespread disparities in New York State. By targeting vulnerable populations and focusing on coordinated, community-driven care, this initiative has the potential to significantly improve oral health outcomes for New Yorkers in nursing homes and other high-need settings.
Conclusion
Addressing the significant gaps in dental care for nursing home residents, particularly in underserved and rural areas, is essential to improving overall health outcomes. Contemporary data on oral health among long-stay nursing home residents is urgently needed to inform targeted interventions. Research into the association between organizational characteristics (e.g., staffing, presence of a full-time medical director, cited deficiencies in oral health care) and area-based factors (e.g., market-level racial segregation of nursing homes, Medicaid generosity, availability of dentists) will help pinpoint causes of oral health decline and guide solutions.
Expanding access through mobile dental clinics and enhancing onsite services in nursing homes, particularly in states like New York, can address these disparities and make significant strides toward equity in oral healthcare. This must be paired with effective community engagement and robust financial and logistical planning to ensure the long-term success of these initiatives. Additionally, understanding the barriers and facilitators of oral healthcare for nursing home staff, such as employer-based oral healthcare training and daily care practices, will be crucial in supporting care improvements.
Ultimately, by addressing the pressing need for equitable dental care and focusing on both organizational and area-based factors, these models can serve as a blueprint for broader systemic changes in healthcare delivery to underserved populations.
Queries about this article can be sent to Ms. McIlduff at smcilduff@nysdental.org.
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Apeksha Phulgirkar, B.D.S., PGCert, M.P.H.-Global HealthTrack, Vanderbilt University, Nashville, TN.
Stacy McIlduff, CFRE, is executive director of the New York State Dental Foundation.
