An inside look at rural dentistry

By Theresa Pablos, associate editor

June 29, 2016 -- If you've ever wondered what it's like to work in rural dentistry, you're not alone. A 2015 Canadian study found that there is a need to increase dental students' knowledge about what it's like to practice dentistry in rural communities.

To help shed light on the day-to-day practice of rural dentistry, spoke with Remya Niranjan, DDS. Dr. Niranjan is a dentist at the Hilmar, CA, satellite office of Livingston Community Health, a nonprofit, federally qualified health center in California's Central Valley that focuses on whole-person wellness.

Welcome to Hilmar

Dr. Remya Niranjan and Karissa Moreno
Dr. Remya Niranjan (left) and Karissa Moreno (right) helped lead the effort to bring a dental clinic to Hilmar that accepts dental Medicaid.

Dr. Niranjan has always been interested in helping underserved communities. After she graduated from the University of California, San Francisco School of Dentistry, she began her career by working two days per week in public health and three days in private practice. However, she soon craved the chance to make more of a difference, so she moved from San Francisco to the Central Valley, where she could focus her skills on an in-need population.

About a year ago, she helped launch the first dental clinic for Livingston Community Health at the Hilmar Health Center. Hilmar is a farming town with about 5,000 residents, many of whom have a high school education at most. The residents often work in agriculture and manufacturing, growing sweet potatoes, and nut farming.

"Livingston Community Health started in the 1970s, and really what it was about was addressing the unmet need in the Central Valley," said Karissa Moreno, Livingston Community Health's chief operations officer. "We're nestled in between Modesto and Merced, and it's a largely migrant and immigrant community. This is a breadbasket of California."

Differences from private practice

Before the Hilmar Health Center opened, low-income residents often relied on the emergency department for their regular oral healthcare needs, since most private practice dentists in the county don't take Medicaid. As a result, Dr. Niranjan sees a lot more medically complex cases than she saw in private practice. Many children also have severe early childhood caries.

"Most of the kids who come in here have bombed out teeth," she said. "Just today I saw a patient, 1 year old, who has four teeth in the front and upper jaw and two in the bottom, and all of them have to come out. Those are the kind of cases that we see."

“I have worked in private practice, and I never felt like I was making a huge difference there. But I feel like I'm making a huge difference here.”
— Remya Niranjan, DDS

Another difference from private practice for Dr. Niranjan is the shorter treatment time at the Hilmar Health Center. She sees about 22 patients in one day, and the appointments are 20 minutes apart.

"For private practice, we have one patient in an hour or an hour and a half, and you finish everything in their mouth. Unfortunately, we're not able to devote that kind of time here," she said. "So what we do is we treat something that is really bothering them, maybe like two teeth at a time. So they have to do multiple visits with us."

One of her biggest struggles is when she needs to refer patients out to specialists. Often, the nearest specialist who takes dental Medicaid is in San Francisco, which is more than a two-hour drive from Hilmar.

"We don't find a lot of specialists who take Medi-Cal," she explained. "I do know that there are some general dentists who do take Medi-Cal, but the wait there is around three to six months. That's how resource-poor we are over here."

However, one thing that is not drastically different from urban private practice for Dr. Niranjan is compensation. She said that "although you may not become millionaires overnight," the pay is still competitive. Moreno added that there are other incentives to practicing rural dentistry, such as loan repayment.

"A lot of dental schools really kind of focus on the private practice model," Moreno said. "At a recent symposium that Dr. Remya and I were at, somebody asked if we pay our dentists, and we absolutely do. We're a very competitive employer, as are any community health centers."

Hilmar, CA, is a farming town with about 5,000 residents.
Hilmar is a diverse community, including a large Portuguese population.
Hilmar Health Center provides primary and dental care. It is part of Livingston Community Health, a series of nonprofit, federally qualified health centers.
Hilmar Health Center's dental clinic opened in 2015.
The staff members at Hilmar Health are passionate about providing care to underserved communities.
An inside look at rural dentistry
Hilmar, CA, is a farming town with about 5,000 residents.

Dr. Niranjan also said that she can't beat the feeling of using her skills to help those in such drastic need.

"I have worked in private practice, and I never felt like I was making a huge difference there," she said. "But I feel like I'm making a huge difference here."

Future plans

Livingston Community Health intends to continue expanding dental services, both inside and outside of its clinics. The next location will be a school-based health center on the Livingston High School campus. At the center, staff will provide oral health education and comprehensive dental services for children and their families.

Similar to the Hilmar Health Center dental clinic, the organization plans to add several new dental clinics to other underserved communities throughout Merced and Stanislaus Counties with the goal of improving whole-body healthcare.

"Our goal, as much as possible in those health centers, is to bring in integrated behavioral health, substance abuse programs, as well as dental," Moreno said. "We really want to have whole-person wellness, and we recognize that the mouth lives inside the body, the emotions live inside the body, and we have to treat the whole person."

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A look into rural dentistry in Hilmar, CA.

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