At 6:04 a.m. on a chilly Friday in April, Katheryn Newton was standing outside the Conway Expo Center, near the front of a long line that snaked around the building’s exterior. She and a friend, Michelle Conrad, had driven to Conway from Bradford (White County) the night before so they could arrive early for Mission of Mercy, an annual, two-day free dental clinic. A friend fronted them money for gas. When they arrived at 5 a.m., “there were already umpteen people in line ahead of us,” Conrad said.
By the time the sun came up, the line was hundreds of people deep. Some had toted camp chairs along for the wait. When the women returned for follow-up care the second day of the clinic, they arrived at 2:30 a.m. and still weren’t first in line.
Newton, a 48-year-old native of Bradford, had nine teeth pulled that weekend. She’s been sober for 14 years, but a history of addiction and lack of routine medical care had left her teeth in shambles. “The loose teeth were a big problem,” she said, “because I couldn’t eat anything but soup. I lost 20 pounds in about a month, eating nothing but soup.
“The pain was off the charts,” Newton said. “Over the top on the pain.”
Like its national parent organization, the Arkansas chapter of Mission of Mercy is faith-based; its logo is an angel in ascent over an outline of the state, and its longtime executive director, dentist Terry Fiddler, described his devotion to the volunteer effort this way: “I fully believe that God put every one of us on Earth to help others.”
After nearly two decades of operation, the clinic is a well-oiled machine. On the day we visited, Fiddler directed traffic in the expo center over a microphone as volunteer dentists hovered over patients lying supine on portable exam tables. Administrators and support staff screened incoming patients in a triage area and buzzed between work stations designated by large banners that read “RESTORATIVE,” “SURGERY,” “PARTIALS.” Dental tools whirred, autoclaves sanitized used equipment, and tables of meticulously organized medical supplies — cotton pellets, crown cement, masks — were at the ready on folding tables and on rolling carts. “Uptown Funk” played from a small boombox up front, mirroring the focused energy elsewhere in the event hall. I asked Fiddler what’s kept him doing this for so long. “They got me at the right price,” he said. “Zero dollars.”
“A hygienist or a layperson that knows computer skills,” Fiddler announced calmly over the sound system, “we need somebody to help us in X-ray. If you’re a dental assistant and you work in X-rays and you don’t have a place to be, we need you now.”
By the time the 2024 session ended, volunteers had worked on 2,290 patients and performed roughly 6,000 extractions.
Gaps
Arkansas consistently ranks last or near-last in national surveys of oral health. The Arkansas Department of Health’s Office of Oral Health reported that in 2018, only 56.1% of Arkansas adults visited the dentist in the previous 12 months, well below the national average of 67.6%. The percentage of adult Arkansans who have had permanent teeth extracted was 51% in 2018, while the national average was 41%. The percentage of Arkansans over 65 with no natural teeth left was 21.6% in 2018; the national average was 13.6%.
The statistics echo a refrain heard elsewhere in the medical community: It’s low-income and food-insecure households that are in the most need of urgent dental care. The Office of Oral Health reported in a 2022 behavioral risk study that 62.5% of adult Arkansans from households making less than $15,000/year have had permanent teeth extracted, as opposed to 37.3% from households making $50,000 or more a year.
Dental health affects (and reflects) overall health more than you might imagine. The mouth is the gateway to both the respiratory and digestive systems, and infections that begin in the mouth can spread to other parts of the body. Chronic oral pain can affect a person’s ability to chew, swallow or even speak. In pregnant people, the Mayo Clinic reported, periodontitis has been linked to premature birth and low birth weight. A number of cancers have been linked to gum disease, and conditions like diabetes or HIV/AIDS can impact the body’s ability to fight off an oral infection. In 2018, only 48% of adult Arkansans with diabetes had visited a dentist in the last 12 months, compared to the national average of 60%.
Disparities in dental health are not only socioeconomic, but racial and geographic. The Department of Health screened third-graders in 51 public schools in Arkansas in 2023. Among their findings: Hispanic children had the highest prevalence of tooth decay, and Black children had the lowest prevalence of dental sealants — protective coatings commonly applied to back molar teeth to prevent cavities. In that same screening, children eligible for free or reduced-price meals through the National School Lunch Program had a higher prevalence of tooth decay than their classmates in higher-income households.
So how did we get here? Why is the state of dental health in Arkansas so consistently poor?
For starters, Arkansans are underinsured. A 2022 study from the Arkansas Center for Health Improvement reported that only 10% of Arkansans were without general health insurance in 2022, while a whopping 54% of Arkansans had no evidence of dental insurance in 2019. Like vision insurance, dental insurance is often treated as an optional “add-on.” Faced with health premiums that already make a significant dent in their paychecks, many Arkansans opt out of dental coverage.
But even Arkansans who are insured aren’t going to the dentist. While even the most devout dental patients paused visits to the dentist during the pandemic, the problem’s older than COVID-19; the Arkansas Center for Health Improvement reported in 2022 that only about one in three Arkansans age 19 or older with dental insurance used any dental services in 2019.
If you ask Billy Tarpley, longtime executive director of the Arkansas State Dental Association, “a great deal of this is cultural. Many Arkansans aren’t raised in a household that values oral health,” and don’t visit the dentist regularly regardless of how or whether they’re insured. “They go to the dentist when they’re in pain,” Tarpley said, “which, quite frankly, is the way I was raised.”
One of the chief reasons we’re not seeing Arkansans at the dentist’s office? They’re going to the emergency room instead. “A significant number of people go to the emergency room for conditions that could have been treated in a dental office,” Tarpley said. Severe pain or bleeding from untreated decay may drive someone to seek emergency care, or they may experience trouble breathing or swallowing due to an untreated dental abscess.
“There are people who use the ER as their health care system. … ERs aren’t designed to do dental care. They don’t have a dentist,” Tarpley said.
‘Not a good sell’
Health experts cite another contributing factor to the state’s poor oral health: low dentist-to-population ratios. A state Department of Health review of the geographic distribution of dentists indicated that in 2019, six Arkansas counties — Calhoun, Cleveland, Lafayette, Newton, Nevada and Perry — did not have a permanent address for a dentist’s office at all. Thirteen additional counties had less than one dentist per 2,000 residents.
Compared to the national average of 61 dentists per 100,000 residents, Arkansas has a staggeringly low ratio of 42 per 100,000. That maldistribution can make it difficult for rural residents, especially ones already under financial strain, to travel to the nearest dentist’s office that accepts their insurance.
There might be room for some optimism. Batesville-based Lyon College plans to open the state’s first dental school in Little Rock’s Riverdale neighborhood, with plans to enroll its inaugural class in the summer of 2025. Out-of-state students aren’t charged a higher rate for the three-year, nine-trimester program, and the hope is that both Arkansans and students from elsewhere will stay in Arkansas once they graduate.
Whether they will set up shop in rural areas is unclear. “It’s hard to attract a dentist who comes out of school with $350,000 in student debt and say, ‘Hey, we want you to go down to the Delta, or we want you to go to another part of the state where there aren’t many people,’” Tarpley said. “That’s just not a good sell.”
Other states offer debt-reduction programs for new dentists in underserved areas. Could Arkansas follow suit? “That’s being done on the federal level,” Tarpley said. “It’s never been done on the state level [in Arkansas]. We do it for physicians, but not for dentists.”
Money where your mouth is
Arkansas dentists point to another reason more practitioners might not be setting up shop around here. They say they’re being squeezed when it comes to third-party billing — the way dental offices are compensated (or not) by public or private insurers for services provided.
On one hand, dentist pay in the United States is relatively high compared to other wealthy countries. The median pay for a dentist in the U.S. was $170,910 in 2023, according to the U.S. Bureau of Labor Statistics, and the median for Arkansas dentists was $168,760. Dentists, like other medical professionals, want that dental school tab to yield a high salary, and whether they’re paid fairly for the services they provide is a complicated question.
One consideration is the high overhead. Running a medical clinic of any kind is expensive, but dentists’ offices are a bit more like an operating room than a typical doctor’s exam room, which means they’re incredibly costly to build and maintain. That creates a financial crunch that hits rural dentists — and their patient populations — the hardest. The more remote a dentist’s office is, the more of their patient population is likely impacted by poverty and unemployment. That means patients are less likely to be covered by private insurance, which reimburses dentists at a higher rate than Medicaid, the largest publicly funded insurance program.
In turn, dentists say, they can’t make ends meet on Medicaid’s low reimbursement rates. The roughly 800,000 Arkansans with Medicaid dental insurance (including over 400,000 children) can have a hard time finding a dentist who will see them. Only 61% of the state’s dentists accept Medicaid, according to information from the Winthrop Rockefeller Institute.
“What we’re dealing with,” Tarpley said, “is a fee schedule for Medicaid patients that hasn’t been increased in 16 years.”
Then there’s the paperwork. Health policy advocates say that while higher Medicaid reimbursement rates have been linked with greater use of dental services in some states, simplifying administrative requirements could make those increases even more effective.
ARKids, the Medicaid-funded insurance program that covers the majority of children in Arkansas, pays for most medically necessary dental services, with some requiring a small co-pay. That’s not the case for adults. For people over 18, Medicaid caps its dental coverage at $500 per fiscal year, as did the managed care program. While some procedures do not count toward the $500 allotment — annual cleanings, X-rays, extractions and a once-per-lifetime set of dentures — it can be spent swiftly if a patient needs more care. Once that $500 is maxed out, the burden shifts to the patient to figure out how to pay.
That leaves many people with few options. They can apply for financial assistance from organizations like the Denver-based nonprofit Dental Lifeline Network so long as the care is deemed “medically necessary,” and if they live in the one-third of Arkansas counties that are eligible. They can, as Newton did, seek out charitable dentistry programs like Mission of Mercy, where dentists or dental hygienists are enlisted as volunteers to offer pop-up care for a short window of time. Other programs, like the dental education wing at University of Arkansas for Medical Sciences, focus on preventative care, offering dental exams from its medical student ranks for $40 a visit. Some providers, like College Station Clinic in southeast Little Rock, offer dental care with a sliding scale co-pay based on a patient’s income.
No more Medicaid middleman
The state has made a major change in the way that Medicaid pays dentists in recent months. Beginning in 2018, the Arkansas Department of Human Services (DHS) used a “managed care” model, meaning it contracted with private insurers and sent dental claims through those companies. As of November, it has switched to a “fee for service” model, meaning that dental providers bill Medicaid directly. When recipients report to the dentist now, they check in at the front desk with their Medicaid ID, not an MCNA or Delta Dental card from a middleman private insurer.
The shift from managed care to a fee-for-service model for Medicaid may not be felt suddenly or tangibly from the patient’s perspective. The DHS told us that “the vast majority of services are covered as they were under managed care,” and that claims data showed that less than 5% of adult Medicaid beneficiaries exceeded their $500 annual allotment.
But cutting private insurers out from between the state and dental providers “definitely moves the needle for the dentist,” Tarpley said, because it’s rekindling a long-smoldering conversation about how dentists are paid.
The big question is ultimately whether the state will raise rates. “The state has to do its job to provide a fee schedule that’s appropriate and consistent with the rising cost of dental supplies and how we pay dental auxiliaries and the dentist to keep up with their overhead,” Tarpley said.
The Arkansas Dental Association, in a 2022 survey of dentists who accept Medicaid, reported that 84% of them would drop the program by 2025 if rates aren’t increased. “We continue to work with DHS now,” Tarpley said, in a long-awaited review of the Medicaid fee schedule. “The last three proposals we made to them were simply ignored, and we were told, ‘There’s just not the money available to do that.’ And we know the money’s available to do it; they just had to dedicate it. So we’re trying really, really hard to avoid a crisis situation.” For now, at least, the line is open.
The review, a representative from DHS told us, “will include rates, covered procedure codes, provider authorization requirements, billing rules, and service limits, as well as a full revision of our provider manual. The rate review process and the provider manual revision process will be handled in two separate, but parallel tracks, with the goal of implementation by June 2025.”
A wish list
Alongside a change to the Medicaid fee schedule, there are other changes dental health advocates would like to see:
Less headache and red tape for dentists when billing insurance, whether through Medicaid or private companies. A statewide initiative educating new moms on how to care for their infant’s developing teeth, for one, or regular access to on-campus dental screenings at public schools. State-funded grants, loans and tax incentives for “safety-net” dental clinics that provide free or low-cost care to rural and low-income communities, and for dental school grads relocating to areas of Arkansas with high rates of poverty and unemployment. Education initiatives on tobacco cessation. An increase in the number of schools eligible for the Seal-the-State program, in which cavity-preventing dental sealants can be applied to children’s developing molars.
One hot-button topic is water fluoridation. Arkansas began requiring municipal water systems above a certain size to add fluoride to drinking water in 2011, and the state has seen one of the largest increases in the nation in fluoridation rates since then. In January 2023, the nonprofit Arkansas Oral Health Coalition reported that 86% of Arkansans now benefit from “optimally fluoridated” drinking water. But four Republican state legislators introduced a bill in November that would repeal the 2011 bill and end the state program, threatening to reverse those gains.
Dental health advocates also recommend paying more attention to the broader economic factors that contribute to poor oral health for low-income Arkansans: low wages, lack of access to healthy food, barriers to staying on the Medicaid rolls, lack of public transportation for dental visits and lack of broadband internet for telehealth appointments.
How (and how soon) any proposed changes will affect people like Katheryn Newton is unclear. For now, her plans are to be back at the Mission of Mercy clinic in 2025, and to seek out a set of dentures after her remaining teeth are extracted.
“It would boost my confidence,” Newton told us, “because I don’t like smiling with, you know, the rotten teeth in my mouth. You don’t feel good about yourself that way.”