Rhode Island's Dental Care Crisis
Opinions differ on how to solve it
by Cristina Barbella
Embedded Files
Amy Santiago looking for one of her clients at a homeless encampment.
Image credit: Lynn Arditi / The Public's Radio
By the time the peeling vinyl floors fill with footsteps and the metal shelves begin to empty of their canned goods, Amy Santiago has drunk her morning coffee, worked on five homelessness cases, and stocked the “only take two items” rack. As a case manager at Better Lives Rhode Island, a Providence nonprofit that helps the homeless with hunger, addiction, and legal matters, Santiago begins every work day at 7 A.M.
“People joke that I work too hard because I’m always the first one in,” she said. “The truth is my jaw hurts so badly that I can’t sleep, so I come to work instead.”
The rest of the staff takes a break at noon to eat lunch and talk about the wacky encounters they had throughout the morning, but Santiago remains at her desk in the office, never joining them.
“Not only do they joke that I work too hard, they also joke that I’m too skinny,” she says with a laugh. “But again, I have too much mouth pain to eat at lunch. I only eat once a day, at night, because I’m so hungry.”
Santiago hasn’t seen a dentist since moving to Rhode Island from Massachusetts a few years back. Finding a dentist in Rhode Island willing to take her case has been impossible. Santiago does not have dental insurance, but has been saving for months to fund all of the necessary dental work she needs.
“I’ve basically been throwing all of my money at them through the phone because I’m desperate,” she says, losing her joking tone. “I called countless offices who weren’t accepting new patients, and when they were accepting new patients they wouldn’t take me because I don’t have insurance.”
In addition to private practice, Santiago has tried federally qualified health centers. Rhode Island has eight of these facilities, which offer reduced cost care for people without insurance. When Santiago picked up a weekend job to help her son pay off his college debt, it bumped her slightly above the income limit to use the centers.
Santiago was even willing to commute more than an hour to Boston for care. “Student dentists didn’t even want me as a patient,” she said as she recalled her time as a patient at Tufts Dental School. Dental schools often offer reduced cost care so students can practice procedures. Santiago is not eligible for this care at Tufts because she is no longer a Massachusetts resident, and Rhode Island doesn’t have a dental school to offer a similar option.
Santiago is not alone. In 2023, the American Dental Association (ADA) reported that 68.4% of Rhode Islanders on Medicaid did not visit a dentist because of limited access to providers¹. Rhode Island has the lowest average number of dentists in New England per capita, with just 52 per 100,000, significantly below the national average of 61, according to the ADA². The lack of providers is wreaking havoc on people like Santiago, who are being forced to wait months for care. So how does Rhode Island plan to increase the number of dentists in the state?
Policy makers, public health advocates, providers, and dental insurance companies all agree that the current dental landscape needs improvement. None of them agree on how this improvement should be implemented.
The “dental safety net” in the state is failing, says Dr. Fred Hartman, an oral and maxillofacial surgeon with practices in Cumberland and East Providence. “If someone needs to see a doctor in Rhode Island, it's usually doable,” says Dr. Hartman. “But if you have a tooth abscess”—and need to see a dentist, he says—“forget it. Rhode Island turns into the wild west.” He’s seen firsthand the consequences of this broken system. His most recent patient was a homeless man with a severe tooth infection. The man is now in the hospital because of it. If he had received care at the beginning of his dental issues, he “could have been treated in about 15 minutes with less than $100 worth of material,” Hartman says, shaking his head, “Now he’s going to consume close to $100,000 in healthcare.”
This is what Hartman means when he talks about the dental “safety net.” The shortage of providers in Rhode Island causes many patients to lack basic care, so that minor problems worsen over time. Hartman’s recent case highlights how a simple procedure could have prevented a medical emergency. The lack of providers in Rhode Island increases the prevalence of dental emergencies.
Dr. Fred Hartman in his Providence Office.
Image Credit: Michael Salerno /Providence Business News
But Hartman says everyone in Rhode Island—not just the uninsured and poor—is affected by the scarcity. Residents with private insurance, state insurance, or no insurance at all are unable to make appointments with dentists who feel swamped. Most of Hartman’s patients come from higher-income suburban areas and are covered by good insurance. Still, the current wait is about six months to get an appointment at his office. “The first thing they say when they finally get in is that they’re mad they had to wait so long. I tell them I’m sorry—what else can I do?”
Private practice providers are reluctant to accept patients with state insurance, as Rhode Island has some of the lowest Medicaid reimbursement rates for both children and adults in the nation³. When this happens, patients on state insurance and those who are entirely uninsured have to make appointments at federally qualified health centers. Hartman says the demand at these facilities can cause delays in care of up to two years. This, he says, is the safety net “failing in real time.”
Dr. Mahra Rubinstein shares many of Hartman’s frustrations. “In dental school, people looked shocked when I told them I was going to practice in Rhode Island,” she says. Rubinstein is a general dentist in Providence. Her father had a practice in the same office she works in now. Rubinstein says receiving her dad’s office was the only reason she chose to offer care in Rhode Island.
Rubinstein and Hartman agree that a dominant obstacle in attracting dentists to the Ocean State is because it has some of the lowest insurance reimbursement rates in all of New England. Both Hartman and Rubinstein believe that the state’s primary insurer, Delta Dental, can offer such low reimbursement rates because of low competition in the Rhode Island’s insurance market.
Until recently, Delta Dental has not offered a reimbursement increase since 2008, “We found out that our raise was two dollars more per cleaning and 10 dollars more per crown,” she says, “I should’ve saved my excitement for something else!”
Increasing the number of dentists in Rhode Island depends on dollar signs, Hartman and Rubinstein say. For this reason, both dentists back the The Fair Share for Dental Care Bill, legislation introduced by Rhode Island representative Joseph M. McNamara and state senator Hanna M. Gallo. The bill would require dental insurance companies in Rhode Island to spend a larger portion of the money they collect from customers’ premiums on patient care. With the current system, administrative costs—like marketing and salaries for insurance company executives—eat up too much of patients’ and employers’ insurance premiums, proponents argue. If the law passes, insurers will have to spend at least 85 percent of premium costs on patient care. If the insurance company spends less than 85 percent of the premium on care, they will have to refund the difference to customers.
The Fair Share for Dental Care Bill comes after similar legislation was passed in Massachusetts. Voters approved the “Dental Loss Ratio” Bill in 2022, which requires insurance companies to spend at least 83 percent of premium dollars on dental care. The success of Massachusetts in passing this bill has helped Rhode Island gain widespread support from the American Dental Association of Rhode Island (Rhode Island Dental Association) and many dentists across the state.
Professionals like Hartman and Rubinstein believe that the "Fair Share for Dental Care" Bill will boost insurance reimbursement payments to levels more in line with surrounding states. They say this will create more incentive for dentists to practice in Rhode Island. Supporters of the bill also believe it would help reduce out-of-pocket costs for patients by ensuring that a large majority of premiums go towards patient care.
Delta Dental opposes the Fair Share for Dental Care bill. The company also argues that dental care in Rhode Island is not in crisis. The Ocean State is an “oral health success story,” says Michelle Musctello, Delta Dental’s vice president of communications and external affairs. The non-profit insurance corporation, Muscatello says, is dedicated to improving access to care for underserved populations. Delta invests in public health initiatives to support this goal. “We’re focused not only on our commercial customers, but also on the third of the state covered by Medicaid or with no insurance at all,” she says.
“Our data from the past 10 years shows that the dental workforce has steadily grown, based on the number of dentists we’ve reimbursed,” says James Kinney, a Delta spokesperson. Muscatello emphasized that Delta is concerned by “widespread misconceptions in the dental landscape of Rhode Island” and prefers to “lead with statistics, because statistics don’t lie.”
A report from the American Dental Association (ADA) contradicts Delta’s findings, revealing that the number of dentists in Rhode Island has actually decreased by 2.4 percent over the last 10 years when adjusting for population changes⁴. Delta did not mention accounting for population changes when discussing their data.
Delta also argues that the Fair Share for Dental Care bill would drive up prices and decrease access to care. The company has been closely monitoring a similar law that passed in Massachusetts. “We have seen in Massachusetts that reduced competition will open the door for higher consumer costs and reduced quality,” says Kinney. “So we are focused on other initiatives to increase access to care.”
Presentation of the Delta Dental Hygiene Scholarship at CCRI in 2023.
Muscatello argues that a lack of dental hygienists are the largest barrier to improving access to dental care in the state. She points to a poll from the American Dental Association that found that approximately a third of dentists around the country are trying to hire more dental hygienists, and 94.5% of them are finding it extremely challenging to do so⁵.
To help address the dental hygienist shortage, Delta has partnered with the Community College of Rhode Island (CCRI). This partnership helped expand the dental hygienist training program by 20 percent. The insurance company also offers a “Delta Dental Rhode Island Scholarship” to dental hygienists who commit to working in the state for at least one year after graduation. According to Delta, so far 100 percent of recipients have stayed in Rhode Island beyond that first year.
Another opponent is the Rhode Island Oral Health Coalition, a non-profit advocacy group focused on improving access to dental care, particularly for underserved populations, by promoting policies and addressing barriers to care.
“Right now our concern should be with employers providing insurance in the state, not providers,” says Melissa Cambell, the coalition’s vice president. The group is focused on increasing access to dental care in Rhode Island, Campbell says, and fears the law would raise insurance costs, causing more businesses to drop dental coverage for employees altogether. Rhode Island currently has one of the highest percentages of residents covered by dental insurance compared to the rest of the country. Campbell says the coalition fears this distinction will change if the bill passes.
Galleshaw at the CCRI dental hygiene clinic.
Instead the organization wants to increase the number of Rhode Island dental hygienists and dental therapists. "There is a nationwide shortage of hygienists, and the enrollment at CCRI for dental hygiene is on the decline," says Julie Galleshaw, the coalition’s president. She points out that this shortage means the demand for basic procedures, handled by hygienists, is not being met. This, Galleshaw argues, is the primary reason for the weakening of the state’s dental safety net.
The coalition is also advocating for the introduction of dental therapists to serve as mid-level professionals. “Dental therapists are like nurse practitioners. They could do small procedures like cavity fillings, and they would be a lovely addition to our much-needed safety net in the state,” Galleshaw says. While dental therapists could help address the shortage of providers, this solution would require certification legislation and educational programs to train them.
Zwetchkenbaum (top left) discussing dental workforce strategies with public health officials.
Amy Santiago—who’s been showing up to work with severe jaw pain—has struggled to find dental care in large part because she lacks insurance. Rhode Island State Dental Director Sam Zwetchkenbaum says geography and reimbursement play the biggest role in accessibility to those without insurance. "If you go to Angell or Waterman street in Providence,” he says, “you'll see a lot of dental offices. If you go to Olneyville or South Providence, you won’t see as many.” Zwetchkenbaum says the disparities in dental care stem in part from “long-standing, racist policies” that have shaped neighborhood resources.
Along with the geographic barrier, which leaves many from low-income areas struggling to find transportation to appointments, dental practices located in wealthier areas are less likely to accept Medicaid. “Dentists are busy! So if they are going to take on more patients, they are going to take on those who can pay,” Zwetchkenbaum says. “Many dentists just can’t afford to take on more Medicaid patients when the reimbursement rates are so low.”
Zwetchkenbaum and his department are exploring ways to boost the state’s dental workforce. One idea is to allow foreign-trained dentists to practice in Rhode Island through a limited licensing process. “There are foreign-trained dentists in the state who can’t practice because we don’t have a pathway for them,” he explains. “They need to go back to school. But if we adopt a limited license like Massachusetts, it could help health centers get fully staffed.”
This limited license would allow foreign-trained dentists to start with basic tasks under the supervision of a dental director, potentially advancing to more complex roles over time. Both Massachusetts and Connecticut offer this kind of limited license program, and they have larger dentist populations. In 2021, Massachusetts had the second-highest number of dentists in the country, with 82 per 100,000 people.
This option could be a breakthrough for people like Santiago, who struggled with feeling like a chore rather than a patient, “The office that agreed to take my case almost dropped me when I couldn’t come in mid-workday to fill a cancelation appointment,” she says, “We need more dentists in Rhode Island. This is unacceptable.”
With no true solution currently, everyone is feeling the effects of the provider shortage. “My hair is turning gray,” Hartman says with a mix of frustration and humor. “Provider burnout is real.”
Commentary
I worked to highlight the importance of oral health to overall health and well-being. I wanted to convey this by discussing the dental care shortage in Rhode Island because dentistry is often overlooked when it comes to general medicine, but it truly has a major impact on our lives, as seen by this shortage. I chose Rhode Island because going to Brown has made me fall in love with the state, and has also allowed me to connect with many of the oral health professionals here, who are all amazing people that are passionate about fighting for Rhode Islanders.
In my piece I hoped to provide a comprehensive outlook of the issue with every side's point of view – because at this moment nobody is right or wrong – nothing has been implemented to fix the issue yet. The biggest challenge in writing my piece was surprisingly not interviewing professsionals. The real challenge was finding a patient who didn’t mind sharing with me their tooth troubles. Big thanks to Amy Santiago for actually agreeing to take part in an interview – I believe it was one of the major highlights in my writing.
Interviews
Sam Zwetchkenbaum : September 23, 2024
Fred Hartman : October 4, 2024
Mahra Rubinstein : October 20, 2024
Julie Galleshaw and Melissa Cambell : October 21, 2024
Amy Santiago : November 30, 2024
Works Cited
American Dental Asociation. (2024). Survey of Medicaid Beneficiaries and Survey of Dentist Opinions on Medicaid: Results for Rhode Island. American Dental Association Health Policy Institute. American Dental Association. Retrieved from https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/survey_dentists_Medicaid_beneficiaries_Rhode_Island.pdf
US dentist demographics. (n.d.). Retrieved from https://www.ada.org/resources/research/health-policy-institute/us-dentist-demographics
Health Policy Institute. (2021, October). Reimbursement rates for child and adult dental services in Medicaid by state. Retrieved from https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_1021_1.pdf
The dentist workforce – Key facts. (2021). Retrieved from https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/resources/research/hpi/hpigraphic_0221_1.pdf?rev=1829a4f788c14974a1ac89ff1e288c0f&hash=A27C6AD199EB6FCAB15DB069BAF0CC85#:~:text=DENTIST%2DTO%2DPOPULATION%20RATIOS%20INCREASED,and%20Maine%20(12.5%20percent).
Recruiting hygienists, assistants still challenging for practice owners. (n.d.). Retrieved from https://adanews.ada.org/ada-news/2023/july/recruiting-hygienists-assistants-still-challenging-for-practice-owners/
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