Introduction A concept analysis is written in order to clearly define a selected topic and provide understanding of its uses, attributes and how it will relate to a certain field. The goal of this paper is to convey the conceptual meaning of rurality as it relates to oral health and its impact on advanced practice nursing.
Purpose
The purpose if this concept analysis is to present a theoretical understanding of oral health among rural populations. Despite important links between oral health and general health, oral diseases are common and public health and prevention efforts aimed to improving oral health have lagged prevention efforts. Research shows that the key to improving oral health is through preventative care and early treatments. However, many individuals within rural communities do not have access to preventive programs and early treatment; whether it is due to financial burden, uninsured, distance to treatment, lower rates of water fluoridation or poor access to care providers. People who have the least access to preventive services and dental treatment have greater rates of oral diseases (“Oral Health”, 2013).
Evidence
In 2000, the United States Surgeon General’s report on “Oral Health in America” defined oral health broadly, emphasizing that oral health is “integral to general health; oral health means more than healthy teeth and that you cannot be healthy without oral health.” The World Health Organization defines oral health as “a state of being free from mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.”
Growing literature indicates that an oral health status disparity has existed between people living in urban and rural areas (Vargas, 2002, p. 1673). Geographic disparities in oral health are particularly seen in areas of Appalachia, with West Virginia, Kentucky, Louisiana and Arkansas as having the highest percentage of adults older than 65 years of age without any natural teeth remaining. “Rural persons are more likely to have lost all their teeth than their non-rural counterparts; in fact, adults aged 18 to 64 are nearly twice as likely to be edentulous if they are rural residents” (Frisbee, 2010, p. 177). In a 2005 National Rural Health Association (NRHA) policy brief, oral health was addressed as having a distinct disparity in rural America. Rural adults are significantly more likely than non-rural adults to lack dental insurance, have untreated tooth decay, and report having to travel long distances to receive oral care (NRHA). It was also discussed that the percentages of rural Americans who are older and sicker are greater than those of urban Americans, and Medicare does not provide dental benefits.
A study by the American Journal of Public Health examined the demographic and socioeconomic association between dental caries in children and whether exposure to water fluoridation and sugar sweetened beverages modified the association. They found that dental caries were higher in children that tended to be from lower income households, having parents with lower educational backgrounds, living in regional and remote areas, and who had lower fluoridated water exposure (Armfield, J. M., Spencer, A. J., Roberts-Thomson, K. F., & Plastow, K., 2013, p. 496).

Defining Attributes The defining attributes of oral health that appear most frequently in the literature are access to preventative care and treatment, socioeconomic status, age demographic and rural living situations. While data on rural oral health and health care are somewhat limited, sufficient evidence exists to suggest a distinct disparity in rural America.
People in remote rural areas have farther to travel to obtain care and there are fewer practitioners to provide the care. Lack of adequate transportation and proximity to treatment is a common causal factor for lack of oral care for many living in rural America. Fluoridated water is the most basic preventative treatment against tooth decay; however it remains unavailable in countless rural communities. Low-income status prevents many people from seeking and obtaining oral health care. It also prevents them from purchasing dental insurance. In addition, rural employers are less likely to purchase or offer dental insurance for their employees due to the smaller average size for most rural employers. With increasing age come increasing dental and oral health problems. The percentages of rural Americans who are older and sicker are greater than those of urban Americans, and Medicare does not provide dental benefits (“Oral Health”, 2013).
Model Case Mrs. LC is a 63 year old female born and raised in a small rural community. She grew up with fluoridated water and has maintained annual visits to the dentist for routine preventative care. She is retired with full medical and dental benefits, allowing her to receive any and all necessary dental treatments. Mrs. Carson reports having excellent dental health, all her natural teeth, and free from disease. The small town that she resides in has one dentist, which is easily accessible to her.
Borderline Case MC is a 53 year old female attorney who was recently diagnosed with periodontal disease, requiring four teeth extractions. She is a highly educated woman, living in a small rural community. She reports having dental insurance but does not seek yearly preventive care treatment. She has not been to the dentist in ten years and reports only seeking treatment when she is experiencing oral discomfort. MC lives in close proximity to the community dentist, but she states she has never liked going to the dentist. She is however, going to purchase partials for missing teeth. After explaining the prognosis of her disease process, she states that she understands that without proper dental follow up care, she will continue to lose her teeth.
Contrary Case
Mr. GL is a 64 year old man, born and raised in a small, rural, farming community. He owns a dairy farm that was passed down to him from his father. Being self-employed, he reports that he is unable to afford private dental insurance and does not receive preventative dental care. Mr. Lamb did not graduate high school, but quit in the 11th grade to work full time on the family farm. GL is edentulous, he reports that he began losing his teeth twenty years ago. He reports having never been to the dentist, “it wasn’t a necessary expense.”
Conclusion
This concept analysis was performed to better understand the discrepancies that exist between oral health and rural populations. We as health care practitioners can improve care and impact the health of underserved populations if we better understand the basis of the discrepancy. Research shows that many individuals within rural communities do not have access to preventive programs and early treatment; whether it is due to financial burden, uninsured, distance to treatment, lower rates of water fluoridation or poor access to care providers. By recognizing community as well as individual attributes we can better treat this patient population. Oral health is directly related to overall health and we as rural health nurse practitioners can bridge the gap that exists.

References
Armfield, J. M., Spencer, A. J., Roberts-Thomson, K. F., & Plastow, K. (2013). Water fluoridation and the association of sugar sweetened beverage consumption and dental caries in australian children. American Journal of Public Health, 103(3), 494-500.
Frisbee, S.J., Chambers, C.B., Frisbee, J.C., Goodwill, A.G., & Crout, R.J. (2010). Association between dental hygiene, cardiovascular disease risk factors and systemic inflammation in rural adults. The Journal of Dental Hygiene, 84(4), 177-184.
Long, K.A., & Weinert, C. (1989). Rural nursing: Developing the theory base. Scholarly Inquiry for Nursing Practice, 3(2), 113-127.
U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon
General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
U.S. Department of Human and Health Services. (2013). Oral health.
Retreived from http://www.healthypeople.gov/2020/ topicsobjectives2020/overview. aspx?topicid=32.
World Health Organization. (2012). Oral health, Retreived from
http://www.who.int/mediacentre/factsheets/fs318/en/.