Demographics and distribution of dentists in Mississippi: a dental work force study.

Abstract

Many segments of the population experience one or more barriers to accessing quality oral health care, including availability of licensed dentists. The purpose of the authors' study was to analyze the availability of dentists in Mississippi by county over four decades to determine the geographic distribution of dentists, shifts in their distribution over time and how this distribution relates to population demographics.
Dentist-to-population ratios were determined by county from 1970 through 2000. The authors analyzed these data using standardized z scores and geographic information systems (GIS) technology. Results are presented graphically and geographically.
Results showed that 55 counties were designated as dental health professional shortage areas in 1970, 51 counties in 1980, 30 in 1990 and 40 in 2000. Counties that have a more favorable ratio of providers to population were determined, indicating areas in which dentists are more likely to practice.
Many geographic areas in Mississippi remain underserved. Identifying these areas is a critical first step when addressing the current state of Mississippi's dental work force. This type of information is useful for decision making as well as responding to the population's oral health care needs.
Results of this study can assist current and future practicing dentists, dental school administrators and policy-makers in making informed decisions for determining suitable practice locations, dental school admissions criteria and areas to target for public health initiatives. This model also is useful for studying work force disparities in other health care professions.

Full text

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TRENDS
Background. Many segments of the popu-
lation experience one or more barriers to
accessing quality oral health care, including
availability of licensed dentists. The purpose
of the authors’ study was to analyze the avail-
ability of dentists in Mississippi by county
over four decades to determine the geographic
distribution of dentists, shifts in their distri-
bution over time and how this distribution
relates to population demographics.
Methods. Dentist-to-population ratios
were determined by county from 1970
through 2000. The authors analyzed these
data using standardized z scores and geo-
graphic information systems (GIS) tech-
nology. Results are presented graphically and
geographically.
Results. Results showed that 55 counties
were designated as dental health professional
shortage areas in 1970, 51 counties in 1980,
30 in 1990 and 40 in 2000. Counties that have
a more favorable ratio of providers to popula-
tion were determined, indicating areas in
which dentists are more likely to practice.
Conclusions. Many geographic areas in
Mississippi remain underserved. Identifying
these areas is a critical first step when
addressing the current state of Mississippi’s
dental work force. This type of information is
useful for decision making as well as
responding to the population’s oral health
care needs.
Practice Implications. Results of this
study can assist current and future practicing
dentists, dental school administrators and
policy-makers in making informed decisions
for determining suitable practice locations,
dental school admissions criteria and areas to
target for public health initiatives. This
model also is useful for studying work force
disparities in other health care professions.
Key Words. Work force; geographic infor-
mation systems; access to care; underserved
populations.
Demographics and
distribution of dentists
in Mississippi
A dental work force study
DENISE KRAUSE, M.S., M.A.; DENNIS A. FRATE,
Ph.D.; WARREN L. MAY, Ph.D.
O
2002 Report Card released by Oral Health America,2the
United States received a national grade of C for its
overall oral health status. The report showed that policy-
makers need to place more emphasis on
oral health across the nation and called
attention to areas in need at the state
and national levels. The state of Missis-
sippi received an overall grade of C−. In
one individually scored category, avail-
ability of dentists, Mississippi received
an F on the basis of a dentist-to-popula-
tion ratio greater than 1:2,501,2which
we believe is substandard for delivering
adequate access to dental care.
In 2000, the U.S. Department of
Health and Human Services reported
that Mississippi ranked 35th in the
nation in dentists per capita.3There
were 1,056 professionally active dentists
in Mississippi in that year, with a
population-to-dentist ratio of 1:2,694.4In
the United States in 2000, there were
166,383 professionally active dentists5to
serve an estimated population of 281,421,906,6with a
national population-to-dentist ratio of 1:1,691. This is
significantly more favorable than the population-to-
dentist ratio in Mississippi.
The majority of Mississippians live in rural settings.
ral health is an integral part of general
health.1Awareness of this connection is
growing, and increasing emphasis has been
placed by the U.S. surgeon general on
addressing the issues contributing to the
nation’s poor oral health status. According to the 2001-
A B ST RACT
Results of this
study can assist
current and
future
dentists, dental
school
administrators
and
policy-makers
in making
informed
decisions about
dental work
force needs.
Copyright ©2005 American Dental Association. All rights reserved.

Page 2

The latest figures available from the U.S. Depart-
ment of Agriculture (for 2003) reveal that approx-
imately 57 percent of Mississippians reside in
nonmetropolitan areas.7In contrast, less than
one-fifth (17 percent) of the total U.S. population
lives in nonmetropolitan areas nationwide.8Cur-
rently, 63 areas in Mississippi are designated as
dental health professional shortage areas
(DHPSAs), including whole counties, partial
counties, population groups and facilities.10
(According to the Health Resources and Serv-
ices Administration,10a geographic area is desig-
nated as having a dental professional shortage if
the area is a rational area for the delivery of
dental services and one of the following conditions
prevails in the area:
dthe area has a population–to–full-time-
equivalent dentist ratio of at least 5,000:1;
dthe area has a population–to–full-time-
equivalent dentist ratio of less than 5,000:1 but
greater than 4,000:1 and has unusually high
needs for dental services or insufficient capacity
of existing dental providers;
ddental professionals in contiguous areas are
overutilized, excessively distant or inaccessible to
the population of the area under consideration.)
The critical shortages may be caused by actual
work force shortages of dentists, or by a perceived
shortage caused by a maldistribution of practicing
dentists. In 1999, for example, approximately 40
percent of active Mississippi dentists were prac-
ticing in only two major metropolitan areas: the
city of Jackson in the tricounty area of Hinds,
Madison and Rankin counties and the Mississippi
Gulf Coast on the southernmost border of the
state,11while only 28 percent of the state’s total
population resides in these two areas.12
To promote and provide for oral health, espe-
cially among rural and otherwise underserved
populations, it is useful to assess the historical
and current distribution of the dental work force
in relation to population demographics. Geo-
graphic information systems (GIS) are one viable
tool to aid in that assessment. GIS computer tech-
nology allows the user to visualize, explore, query
and analyze data geographically in the form of
presentation-quality maps. The mapping allows
the researcher to visualize spatial relationships
in data in ways that may reveal new relation-
ships, patterns and trends that might not be evi-
dent in other data presentation formats. These
computer-based technologies have been applied to
gathering geographical data, but they are proving
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669
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to be an effective tool for exploring health data
relationships.
We used GIS technology as a tool to help illus-
trate and visually analyze the current work force
situation and the time-series shifts of dentists
and population distributions. Information
presented in our report may be useful for
determining
dsuitable locations for dentists to establish
practices;
dareas to target for effective community out-
reach programs;
dunderserved regions from which to recruit
dental students, who ideally will return to a
shortage area within the state.13
Findings from our study and its model of inves-
tigation will be useful to educators and policy-
makers in addressing underserved populations’
burden of access to dentists. In addition, our
model could be used to address the work force
status and needs of other health care profes-
sionals, including physicians, nurses, pharmacists
and allied health care professionals.
REVIEW OF THE LITERATURE
Numerous studies in the literature address the
issues of geographic distribution of the health
care work force in various professions, especially
medicine. Only a handful of studies, however,
address the geographic distribution of dentists.
As in physician work force planning, it is not pos-
sible to precisely determine an exact number of
dentists needed to provide services to a certain
population. Because of this, dental work force
issues can be particularly challenging to address,
especially when one attempts to make predictions
for the future.
One factor contributing to the complexity of
dental work force planning is the predominance of
individual practices and the subsequent lack of
large institutionalized practice settings. Limita-
tions exist in studying the availability of
providers without addressing a number of addi-
tional variables that can influence productivity,
such as the characteristics and work patterns of
individual dentists. Other limitations are an
inability to address cultural and socioeconomic
factors of the population and other access issues.
Because of this complexity, “health manpower
planning … is a process of continual ‘suboptimiza-
tion’—that is, making the best of what data are
available.”14
The use of GIS in health work force studies is
Copyright ©2005 American Dental Association. All rights reserved.

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in its early infancy. In dentistry, only two studies
investigating dental services used GIS as an anal-
ysis tool. White and colleagues15conducted a
study of the usefulness of using GIS in the inves-
tigation of the provision of dental services. To
assess the utility of GIS, these authors used it to
answer three study questions pertaining to dental
provision in a particular region. They found that
while a GIS increases the usefulness of informa-
tion, it may not be a viable solution in many areas
because of financial and training issues.
In another study, Susi and Mascarenhas16used
GIS to map the distribution of dentists in Ohio.
The purpose of their study was to analyze the
state’s distribution of dentists in terms of vari-
ability, availability and accessibility. The GIS
maps were useful for visualizing dental practice
locations geographically, mapping the population-
to-dentist ratio and illustrating dentists’ rural-to-
urban ratio. The GIS assisted the researchers in
identifying disparities in the distribution of den-
tists throughout Ohio.
Mertz and Grumbach17conducted a study to
determine the geographic distribution of dentists
in California, and the community characteristics
associated with the supply of dentists. They used
a GIS to “geocode,” or pinpoint geographically, the
location of dentists and to match them to a geo-
graphic study area. They created a GIS to identify
the number of communities that they thought
might have a shortage of dentists, but they pub-
lished no maps in their report for clearer visual-
ization. Mertz and Grumbach used regression
analysis and Pearson correlation analyses to
examine the associations between dentist supply
and community characteristics. This observa-
tional study provided a good example of using
GIS in conjunction with other statistical analyses
to reinforce findings and to identify relationships,
patterns or trends that might not otherwise be
detectable.
There are only a few studies using GIS to study
health work force availability and accessibility
issues. In addition, there do not appear to be any
studies using GIS to map work force changes over
time. We used a GIS and traditional descriptive
statistics in our study to examine the geographic
distribution of dentists in Mississippi.
METHODS
We obtained secondary data sets from the Missis-
sippi Department of Health18and the U.S. Census
Bureau19on the dentist work force in Mississippi
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from the years 1970, 1980, 1990 and 2000. These
data were collected to provide a historical per-
spective of growth trends and geographic distri-
bution patterns of the availability of primary
dental services. From the U.S. Census Bureau
and the Environmental Systems Research Insti-
tute (ESRI) (Redlands, Calif.), we obtained histor-
ical population data,20Census 2000 population
demographics for the state of Mississippi21and
Topologically Integrated Geographic Encoding
and Referencing (TIGER)/Line files22,23for use in
building the GIS. TIGER/Line files contain
boundary information for both legal and statis-
tical entities and are used by the Census Bureau
for statistical data collection and tabulation pur-
poses only. We obtained additional data for
building the GIS infrastructure from the Missis-
sippi Automated Resource Information System,24
an agency of the state of Mississippi. Finally, we
obtained data from the Mississippi State Board of
Dental Examiners25on all licensed dentists prac-
ticing in Mississippi in the year 2002, including
age, race, sex, alma mater, specialty and practice
locations.
We calculated population-to-dentist ratios to
examine growth trends of Mississippi’s dentist
population as compared with the state’s general
population during a period from 1970 through
2000. For each 10-year interval between the years
1970, 1980, 1990 and 2000, we determined the
aggregated population-to-dentist ratio per
100,000 people by geographic region. We used
counties as the geographic regional boundaries
for statewide data. We also calculated the
population-to-dentist ratio by county, the per-
centage of dentists practicing in each county, the
percentage of the total population residing in
each county, median family income and z scores.
Using the statistical method of z scores enabled
us to identify counties that were more than two
standard deviations from the mean of the distri-
bution. We obtained these data using the fol-
lowing equation:
Observed – Expected
Expected
Additionally, we calculated growth rates of the
number of dentists by county for the periods from
1972 through 1980, 1981 through 1990 and 1991
through 2000.
We created a GIS using ArcGIS 8.2.1 software
(ESRI). In turn, we used that GIS to create a geo-
database that would provide a visual representa-
tion of population demographic variables and

Page 4

dental practice locations for
the state of Mississippi, and
that would assist in deter-
mining patterns of distribu-
tional shift of dentists
over time.
RESULTS
The number of active dentists
practicing in Mississippi has
nearly doubled from 1970 to
2000, increasing the state’s
overall ratio of dentists per
100,000 people from 27 to 37
dentists per 100,000 (Figure
1). Comparing this information
with data for the number of dentists per 100,000
population, there is a continuous rise in the ratio,
and the number of dentists per 100,000 for the
United States overall is significantly higher than
in Mississippi for all years we studied (Figure 1).
A limitation of this comparison is that it does not
take into account characteristics of the population
that would seek dental care.
We obtained from the U.S. Census Bureau a
ranking of Mississippi counties in descending
order by rate of population growth from 1990 to
2000. We correlated the faster-growing counties
with growth in the number of dentists and
growth in median family income for those coun-
ties. Figures 2 and 3 provide graphic representa-
tion of population growth and loss correlated
with the growth of dentists and median family
income.
Figure 2 illustrates that of the 10 counties with
more than 20 percent growth, five of them (Han-
cock, Greene, Lamar, Pearl River and Pontotoc)
actually had negative growth in the number of
dentists. These may be counties in which condi-
tions would be favorable to locate a dental prac-
tice. They also have relatively high median family
incomes. DeSoto was the fastest-growing county
and also had the highest growth rate of dentists,
but it did not show growth as significant in
median family income. Madison County, however,
was high in all three categories. Greene County
experienced 30.13 percent population growth, but
had a loss in dentists. Lafayette County had the
highest median family income and high popula-
tion growth, but no change in the number of
dentists.
None of the counties that had negative popula-
tion growth between 1990 and 2000 gained any
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671
TRENDS
dentists during that period (Figure 3). Hinds
County had by far the largest population of all
Mississippi counties, but lost population and den-
tists during this period. Hinds County also expe-
rienced less growth of median family income than
did most other counties. It is interesting to note
that Montgomery and Sharkey Counties experi-
enced more than 100 percent increase of median
family income.
The calculation of z scores for dentists showed
that there were a growing number of counties
that exceeded two standard deviations from the
mean from one decade to the next, meaning that
these counties could be considered extreme “out-
liers” during a particular period. In 1970, four
counties had z scores of 2.0 or higher. There were
eight counties in 1980, 10 in 1990 and 15 in 2000.
Of these, only two had negative z scores (DeSoto
in 1980 and Lamar in 2000). These findings sug-
gest that there is a growing number of counties
with a maldistribution of dentists. DeSoto County
had the lowest negative z score overall in 1980, at
2.31 standard deviations below the mean. This
indicates that there was a high population-to-den-
tist ratio in that county—that, in other words,
there were significantly fewer dentists per person
in DeSoto County. DeSoto has not been more than
two standard deviations from the mean since that
time. In 2000, Lamar County was the only county
with a negative z score (−2.17).
The remainder of z scores more than two
standard deviations from the mean were positive,
indicating a lower population-to-dentist ratio, or a
higher number of dentists per person in these
counties. (Editor’s note: A table showing the
specific scores is available from the corresponding
author.) Hinds County has consistently main-
70
60
50
40
30
20
10
0
19701980 19902000
YEAR
NO. OF DENTISTS PER
100,000 POPULATION
27
44.7
31
48.6
41
53.8
37
59
Mississippi United States
Figure 1. Dentists per 100,000 population, Mississippi and national average.
Copyright ©2005 American Dental Association. All rights reserved.

Page 5

tained the highest z score, showing the lowest
need for additional dentists. Madison County had
a z of score more than 2 for the first time in 2000.
Figure 4 illustrates the changes of distribution
of practicing dentists for each decade. The coun-
ties are divided into three groups: low, medium
and high distributions. To determine these distri-
butions, we divided total numbers of dentists per
100,000 into three groups so that these groups
are relative to each other and not to a national
comparison. DeSoto County had relatively low
distributions of dentists until 2000, when it
changed to a high distribution of dentists and also
was the fastest-growing county in terms of popu-
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TRENDS
lation from 2000. There was a
high distribution of dentists
per population for all years in
15 counties, while there were
low distributions for all years
in eight counties. All other
counties have changed their
status at least once over the
four decades. By examining the
maps showing changes in dis-
tribution over time, we found
what may be a growing ten-
dency for dental practices to
locate in closer proximity to
interstate highways.
Fifty-five Mississippi
counties qualified for desig-
nation as DHPSAs in 1970,
51 counties in 1980, 30 in
1990 and 40 in 2000 (Figure
5, page 674), using the cri-
teria defined by the Health
Resources and Services
Administration.10Five coun-
ties with relatively low total
populations had no dentists
in 2000, though all of them
except Issaquena did have a
population greater than
4,000. Figure 6 (page 675)
provides a detailed view of
the population-to-dentist
ratio and the changes in
distribution over time. In
Hinds County, for example,
there was a ratio of 1,348
people per dentist in 2000.
In Amite County in the
southernmost part of the
state, there were 13,599 people and only one
dentist in 2000.
DISCUSSION
Health work force planning can be complex and
challenging, but it is important to address the
issue to be able to better respond to the health
needs of the population. A logical starting point is
to create a model, which we did to determine the
number of dentists by specified geographic areas
(in our case, all counties in Mississippi), the total
population of these areas and population demo-
graphics. Rather than examine distribution at a
single point in time, it is useful to look at it over a
150
100
50
0
—50
—100
—150
Denton
Noxubee
Jefferson Davis
Hinds
Montgomery
Tallahatchie
Adams
Bolivar
Coahoma
Quitman
Sharkey
Washington
Humphreys
Population Growth Growth of No. of Dentists Increase of Family Median Income
GROWTH (%)
COUNTY
Figure 3. Mississippi counties with negative population growth, growth of
number of dentists and family median income, 1990 through 2000.
250
200
150
100
50
0
—50
—100
DeSoto
Madison
Hancock
Rankin
Greene
Lamar
Stone
Pearl River
Lafayette
Pontotoc
Population GrowthGrowth of No. of DentistsIncrease of Family Median Income
GROWTH (%)
COUNTY
Figure 2. Mississippi counties with population growth greater than 20 percent,
growth of number of dentists and family median income, 1990 through 2000.

Page 6

period, which makes evident any significant
changes that have occurred and, if they did occur,
where. Are there any noticeable trends? What
might be expected for the future if trends con-
tinue? How do these data compare with national
averages? Yet, a limitation of this study is that
we did not take into consideration dentists’
migration across state and county boundaries.
The population in Mississippi from 1970
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TRENDS
through 2000 has shown continual growth,
though the trend is not as rapid as for the nation
as a whole. The median family income in the
state continues to rise, but it remains well below
the national average.21The number of dentists
has continued to increase, but has begun leveling
off since 1990. The number of dentists per
100,000 population in Mississippi decreased from
1990 to 2000, as the growth rate of the number of
Figure 4. High, medium and low distributions of Mississippi dentists by county, 2000. MS Interstates: Mississippi inter-
state highways.
Copyright ©2005 American Dental Association. All rights reserved.

Page 7

dentists has not kept pace with population
growth in the state (Figure 1). The ratio of den-
tists to population in the United States has
increased steadily, and across all four decades,
there have been more dentists per 100,000 in the
U.S. population than there have been in Missis-
sippi. On the basis of numbers alone and
assuming that graduates of the University of Mis-
sissippi School of Dentistry stay in the state to
practice, there may be a case for increasing the
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Copyright ©2005 American Dental Association. All rights reserved.
TRENDS
number of dental school admissions to narrow the
gap in provider-to-population ratio.
Several variables were not addressed in this
study. What factors may be contributing to this
dramatic slowdown? It is possible that fewer den-
tists are coming to Mississippi from other states.
Perhaps more University of Mississippi School of
Dentistry graduates are leaving the state to prac-
tice elsewhere. It could be that more dentists
have retired recently. Even if a dentist is actively
Figure 5. Dental Health Professional Shortage Areas by county, 2000.

Page 8

practicing in the state, how can his or her produc-
tivity be measured? How many dentists do not
work full-time? How is full-time defined? How
many dentists work full-time but complete fewer
procedures and see fewer patients than do den-
tists who work part-time? Although these vari-
ables are not addressed in this study, it may be
important to collect data on them, especially as
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TRENDS
accountability issues move to the forefront.
Many variables factor into Mississippi work
force planning issues. Some of these may be mea-
surable, such as the number of dentists from Mis-
sissippi as opposed to those coming from out of
state, practice locations of graduates of the Uni-
versity of Mississippi School of Dentistry and
ages of the state’s active dentists. Still, the issue
Figure 6. Mississippi population-to-dentist ratio, 1970 through 2000. MS Interstates: Mississippi interstate highways.
Copyright ©2005 American Dental Association. All rights reserved.

Page 9

is further complicated because it is impossible to
predict accurately at what age a dentist will
retire to define forecasting models. It can be
determined (and graphically represented) where
older dentists are practicing, and projections can
be made that dentists soon may be needed in
those areas to replace those who retire. Regard-
less of the complexities, one variable that can be
measured is the number of dentists practicing in
a certain area, or the availability of dentists.
The trends in growth rates of Mississippi’s den-
tist population over time might suggest that more
providers are necessary to meet the needs of the
public. While this may be true, it is important to
look more closly at the data. There may be an
issue with the distribution, not just the total
number, of dentists. The density ranking of coun-
ties by high, medium or low distributions of
number of dentists per 100,000 provides useful
information, especially when one looks at changes
over time (Figure 4). Population-to-dentist ratios
also make it easier to determine areas that may
be in need of attention. Future dental school
graduates considering potential practice locations
may find promising opportunities in counties that
have high numbers of people per dentist (in
Figure 5, for example, the counties with the
darkest shades of orange).
There may be many other barriers besides den-
tist availability that hinder access to health care
and thus contribute to racial, ethnic and geo-
graphic disparities in oral health. Existing data
are insufficient to address many of these barriers.
However, by means of studying these and similar
maps, specific areas can be targeted that may
need dentists or that may be well-suited for out-
reach programs from dental schools or the dental
community. To answer these and other questions
specifically for Mississippi, it will be important
for an oral health needs assessment to be con-
ducted with data gathered across the state.
CONCLUSIONS
Disparities in access to health care affect many
segments of the U.S. population. It can be diffi-
cult to attract health care providers to rural
areas, which contributes to geographic dispari-
ties.1,26However, even in areas with adequate
availability of dentists, other barriers may exist
that inhibit people from gaining access to care,
such as economic issues, cultural barriers, phys-
ical disabilities or confinement in institutional-
ized settings.
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TRENDS
The type of information provided in this study
may be useful for dental school administrators
taking a proactive approach to oral health work
force planning. Administrators may be better able
to determine the number of students to accept
into programs, as well as admissions criteria.
Additionally, this information may assist in
determining locations throughout the state from
which students might be selected to get a repre-
sentative group from different geographic regions.
With this type of framework, dental schools also
could make informed decisions about locations or
populations for which to target community out-
reach initiatives. Dental students could use this
information as a tool for determining suitable
locations in which to establish practices after
graduation. The findings also may be of interest
to policy-makers and public health officials when
addressing oral health and access-to-care issues
in Mississippi. This study provides a foundation
on which to continue building and integrating
more data as they become available for decision
making about, and responding to, the oral health
care needs of Mississippians. Still, it is important
to emphasize that the usefulness and practicality
of this type of model is not limited to Mississippi.
It could be used in any state or geographic region
as a tool for analyzing and visualizing dental
work force and oral health data, and for
improving access to quality oral health care.
I
Ms. Krause is an assistant professor, University of Mississippi School
of Dentistry, Department of Periodontics and Preventive Sciences, and
a doctoral student, Preventive Medicine, University of Mississippi Med-
ical Center, 2500 N. State St., Jackson, Miss. 39216, e-mail “dkrause@
sod.umsmed.edu”. Address reprint requests to Ms. Krause.
Dr. Frate is a professor, Preventive Medicine, University of Missis-
sippi Medical Center, Jackson.
Dr. May is an associate professor, Preventive Medicine, University of
Mississippi Medical Center, Jackson.
The authors wish to express appreciation to Diane Howell, executive
director, Mississippi State Board of Dental Examiners, for her assist-
ance in providing critical data for the preparation of this article.
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AboutNIDCR/SurgeonGeneral/ExecutiveSummary.htm”. Accessed
March 25, 2005.
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health in America. Available at: “www.oralhealthamerica.org/pdf/
2001-2002ReportCard.pdf”. Accessed March 25, 2005.
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and Services Administration, National Center for Health Workforce
Analysis. State health workforce profiles. Available at: “bhpr.hrsa.gov/
healthworkforce/reports/profiles”. Accessed March 15, 2005.
4. Mississippi State Board of Dental Examiners. Dental workforce
database. Jackson, Miss.: Mississippi State Board of Dental Exam-
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5. ADA Survey Center. Distribution of dentists in the United States

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