According to the National Conference of State Legislatures Rural Health Brief, Where Have All the Dentists Gone, children, adults, and elders living in rural areas face special challenges when it comes to good oral care. Geographic isolation, lack of transportation, lack of fluoridated water, poverty stricken areas, low Medicaid reimbursement, and the fact that most rural dentists are older and therefore retiring, are all a factor. The elderly lose their dental insurance when they retire, and Medicare does not pay for routine care. Therefore, nearly a third of those over 65 have untreated cavities.
Tooth decay is a common health problem, second in prevalence only to the common cold. It has been estimated 90% of people in the United States have at least one cavity, and 75% of people had their first cavity by the age of five. Children and senior citizens are the two groups at highest risk. Other high-risk groups include people who eat a lot of starchy and sugary foods, people living in areas with inadequate fluoridated water supplies, and people who already have numerous dental fillings and crowns.
From the surgeon general’s report, Oral Health in America, research has shown chronic oral infections can lead to heart and lung diseases, diabetes and stroke, premature births and low birth weights. Tooth decay and associated pain effect daily activities for four to five million children and adults a year.
Oral health is important to everyone’s general health and well-being as well as quality of life. Dental care involves educating people; raising awareness of oral health and oral health issues; involving local governments, day care providers, and corporate and community sponsors in the fight against tooth decay; finding solutions to access problems for older Americans; providing dental care to children; and developing, implementing, and facilitating educational and service programs designed to increase the visibility and public understanding of oral health.
Sources
Oral Health in America: A Report of the Surgeon General
Related Guides
Frequently Asked Questions
Tools
Children's Health Insurance Program (CHIP)
Web site
Low cost health and dental insurance for uninsured children and pregnant women in families with incomes too high for most Medicaid programs. CHIP is financed through the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA).
Dental Volunteer
Database
Searchable database of dental health volunteering opportunities in the United States and abroad. Individuals can search for volunteer opportunities and organizations can use the site to seek dental health volunteers.
Find a Dentist
Web site
Allows the public to search for ADA dentists by city, state, zip code, and area by specialty.
Find Shortage Areas: HPSA by State & County
Database
Provides searching for Health Professional Shortage Areas (HPSAs) by region, state, county, designation status, and type of service- primary medical care, dental, and mental health. Includes date of latest designation status.
Health Professional's Guide to Pediatric Oral Health Management
Tutorial
Series of seven online modules designed to assist health professionals with managing the oral health of infants and children who are at increased risk for oral health problems.
Indian Health Service Division of Oral Health (DOH)
Web site
Offers information on work opportunities, a loan repayment program, and continuing dental education for oral health professionals or students.
National Institute of Dental and Craniofacial Research (NIDCR)
Database
Helps meet oral health information needs for special care patients by producing and distributing patient and professional education materials.
National Oral Health Surveillance System (NOHSS)
Web site
Helps public health programs monitor oral disease, use of the oral health care delivery system, and the status of community water fluoridation on both a state and national level.
Open Wide: Oral Health Training for Health Professionals
Tutorial
Series of four online modules designed to help health and early childhood professionals working in community settings promote oral health for infants, children, and their families.
Oral Health for Infants, Children, Adolescents, and Pregnant Women Knowledge Path
Database
Guide to resources and informative tools that offer suggestions on how to improve the oral health of children, adolescents, and pregnant women.
Oral Health Resources
Web site
Contains articles, fact sheets, and publications on oral health and water fluoridation, plus state-by-state reports. Website also available in Spanish.
Oral Histories: Report from a Dental Fair Video
Web site
This video profiles patients attending a dental fair in rural Virginia and highlights the impact of lack of coverage for oral health services.
Ronald McDonald Care Mobile
Web site
Through relationships with local healthcare providers, the Ronald McDonald Care Mobile program brings medical, dental and health education services to underserved children. There are many of these care mobiles throughout rural areas in the United States.
Rural Health Research: Dental health
Web site
Provides summaries of current and completed rural health research projects and related publications addressing the topic of dental health, produced by the Office of Rural Health Policy's funded rural health research centers.
Safety Net Dental Clinic Manual
Web site
Offers information on partnerships and planning, facilities and staffing, financing, clinic operations, plus quality awareness and improvement of dental clinics. Includes links to sample policies, budget worksheets and design tips.
Smiles Across America
Web site
A national program which links local governments, businesses, and funders with care providers and schools to help fight untreated oral disease.
State Licensure for International Dentists
Web site
Provides information on the state licensure process for dentists who were educated outside the United States and Canada and wish to obtain a state dental license in the U.S.
Maps & Map Collections
Health Professional Shortage Areas (HPSA) - Dental Health, Clinician Priority Scores
Interactive
Geographic coverage: United States
Printable map that shows the clinician priority scores of dental HPSAs nationwide. These scores are used by the National Health Service Corps in determining priorities for assignment of clinicians. Scores range from 1 to 26, with higher scores having greater priority. Data source: Health Resources and Services Administration, Bureau of Health Professions, October 2011.
Date: 2011
Health Professional Shortage Areas (HPSA) - Dental Health, Designated Populations
Interactive
Geographic coverage: United States
Printable map that shows nationwide the location and type of population that is underserved and designated as a dental HPSA. Data source: Health Resources and Services Administration, Bureau of Health Professions, October 2011.
Date: 2011
Health Professional Shortage Areas (HPSA) - Dental Health, Designated Type
Interactive
Geographic coverage: United States
Printable map that shows the designated types of dental HPSAs nationwide by: Geographic Service Area, Population Group and Single County. Data source: Health Resources and Services Administration, Bureau of Health Professions, October 2011.
Date: 2011
Regulations, Forms & Other Useful Documents
Advancing Oral Health in America
Sponsoring organization: Institute of Medicine
Discusses the challenges facing the current oral health system, the connection between oral health and overall health, and how to improve oral health care. Chapters 2 and 3 discuss the oral health system in rural settings.
Date: 2011
Coming Home: The Patient-Centered Medical-Dental Home in Primary Care Training
Sponsoring organization: Health Resources and Services Administration
Outlines nine recommendations for the Title VII, section 747 program to support primary care training and to prepare training programs to educate clinicians to practice in the patient-centered medical home and dental home (PCM-DH). Addresses issues and topics specifically related to rural areas.
Date: 12 / 2008
Cost of Delay: State Dental Policies Fail One in Five Children
Sponsoring organization: Pew Charitable Trusts
Reports that at least one in five U.S. children go without annual dental care and 44 out of 50 states fail to meet at least six key benchmarks or policies to ensure access to preventive care. Addresses workforce concerns in rural areas.
Date: 02 / 2010
Crisis in Rural Dentistry
Sponsoring organization: WWAMI Rural Health Research Center
Lists issues related to oral health care in rural America. Discusses the need for intensified recruitment efforts to increase dental access and improve oral health in rural areas. Proposes potential solutions that may increase the rural oral health care workforce.
Date: 04 / 2009
Dental Crisis in America: The Need to Expand Access
Author(s): Bernard Sanders
Sponsoring organization: U.S. Senate Committee on Health, Education, Labor & Pensions
Describes the issue of oral health care access by some populations, including rural communities, and summarizes the various negative health effects of this issue.
Date: 02 / 2012
Dental Health and Access to Care Among Rural Children: A National and State Portrait
Author(s): Amy Brock Martin, Eric Wang, Janice C. Probst, Nathan Hale, Andrew O. Johnson
Sponsoring organization: South Carolina Rural Health Research Center
Covers topics related to children and their access to dental health services. Information addresses the dental health status, preventive services and insurance received of children in rural and urban areas. Minority populations are also reported on.
Date: 03 / 2008
Dental Health Care Access in Rural Communities
Author(s): Jeyanthi Bhaheetharan
Sponsoring organization: Rural Wisconsin Health Cooperative
Winner of the 2011 University of Wisconsin's Monato Rural Essay for Wisconsin's Best Rural Health Paper explores why dental health care access is a public health problem for rural.
Date: 05 / 2011
Dentists and Head Start: What You Should Know and How You Can Help
Author(s): K. Holt
Sponsoring organization: National Maternal and Child Oral Health Resource Center
Describes the Head Start program, its participants, and the oral health services offered. Recommends actions that dentists can take to help address the participants' barriers to care.
Date: 2011
Evaluation of the Dental Health Aide Therapist Workforce Model in Alaska
Author(s): Scott Wetterhall, James D. Bader, Barri B. Burrus, Jessica Y. Lee, Daniel A. Shugars
Describes findings from an evaluation showing that dental therapists provide safe and appropriate care for underserved and rural populations.
Date: 10 / 2010
Filling an Urgent Need: Improving Children’s Access to Dental Care in Medicaid and SCHIP
Author(s): Shelly Gehshan, Andrew Snyder, Julia Paradise
Sponsoring organization: Kaiser Commission on Medicaid and the Uninsured
Summarizes recommendations on actions that states can take related to children’s access to oral health care in Medicaid and SCHIP. Addresses workforce issues in rural areas.
Date: 07 / 2008
Good Practice: Treating Underserved Dental Patients While Staying Afloat
Author(s): Scott, Mary Kate
Sponsoring organization: California HealthCare Foundation
Outlines techniques and tools related to creating a strategic plan, the reimbursement process and payer mix, achieving a smooth patient flow and staffing patterns, the importance of effective business systems, and implementing new technologies and clinical programs. Website also offers access to an audio clip of three dentists describing their experiences with treating uninsured and Medi-Cal patients and how they were able to improve their practices.
Date: 08 / 2008
Head Start Oral Health Resource Guide
Sponsoring organization: National Maternal and Child Oral Health Resource Center
Describes a variety of resources including recent journal articles, materials for use by health professionals and Head Start staff, and organizations that may serve as additional resources.
Date: 08 / 2007
Improving Access to Oral Health Care for Vulnerable and Underserved Populations
Sponsoring organization: Institute of Medicine
Presents a vision for how to improve oral health care for vulnerable and underserved populations, and recommends ways to achieve this vision. Chapters include oral health status, workforce, expenditures, health care delivery, and oral health settings.
Date: 2011
Increasing Access to Dental Care in Medicaid: Targeted Programs for Four Populations
Author(s): Andrew Snyder
Sponsoring organization: National Academy for State Health Policy
Describes strategies used by several states to better address the oral health of young children, pregnant women, people with developmental abilities, and people living in rural areas.
Date: 03 / 2009
Look What's Coming: Ending Dentistry by Grandpa
Author(s): Wayne Myers
Sponsoring organization: Rural Assistance Center
Argues that licensing dental therapists may be the only way to get dental care to Medicaid patients and other underserved populations.
Journal citation: Rural Monitor
Date: 05 / 2011
Medical Providers and Head Start: What You Should Know About Oral Health and How You Can Help
Author(s): K. Holt, E. Lowe
Sponsoring organization: National Maternal and Child Oral Health Resource Center
Describes the Head Start program and its oral health services. Reports a higher prevalence of oral health problems among children enrolled in Head Start programs and suggests how health care providers can help.
Date: 2011
Mobile-Portable Dental Manual
Sponsoring organization: Association of State and Territorial Health Officials
A companion to the Safety Net Dental Clinic Manual. This online reference tool focuses on using public health approaches to create health care systems to serve populations that have difficulty accessing the traditional system of oral health service delivery.
Date: 2007
Oral Health Coverage and Care For Low-Income Children: The Role of Medicaid and CHIP
Author(s): Julia Paradise
Sponsoring organization: Kaiser Commission on Medicaid and the Uninsured
This updated policy brief provides an overview, with statistics and charts, of oral health care access and coverage for low-income children.
Date: 04 / 2009
Oral Health in America: A Report of the Surgeon General
Sponsoring organization: U.S. Department of Health and Human Services
Alerts Americans to the full meaning of oral health and its importance to general health and well-being.
Date: 09 / 2000
Oral Health Promotion, Prevention, & Treatment Strategies for Head Start Families: Early Findings from the Oral Health Initiative Evaluation, Volume I: Final Interim Report
Author(s): Patricia Del Grosso, Amy Brown, Heather Zaveri
Sponsoring organization: Mathematica Policy Research, Inc.
Describes the early implementation experiences of the Oral Health Initiative grantees in rural and urban areas.
Date: 09 / 2007
Oral Health Promotion, Prevention, & Treatment Strategies for Head Start Families: Early Findings from the Oral Health Initiative Evaluation, Volume II: Site Profiles
Author(s): Patricia Del Grosso, Amy Brown, Heather Zaveri
Sponsoring organization: Mathematica Policy Research, Inc.
Describes the rural and urban sites selected to participate in the Oral Health Initiative.
Date: 09 / 2007
Oral Health Quality Improvement in the Era of Accountability
Author(s): Paul Glassman
Reviews the status and trends in oral health quality measurement and improvement, and outlines efforts in place to expand and enhance them. Describes how to use these measurement and quality improvement systems to improve the oral health of the U.S. population.
Oral Health: Preventing Cavities, Gum Disease, and Tooth Loss Success Stories, 2010
Sponsoring organization: Centers for Disease Control and Prevention
Describes successful oral health programs in Arkansas, Nevada, and Wisconsin.
Date: 2010
Oral Health: Preventing Cavities, Gum Disease, and Tooth Loss Success Stories, 2011
Sponsoring organization: Centers for Disease Control and Prevention
Describes successful oral health programs in Maine, New York, and North Dakota involving dental sealants, water fluoridation, and state policies respectively.
Date: 2011
Oral Health: Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers: At a Glance 2011
Sponsoring organization: Centers for Disease Control and Prevention
Highlights CDC's focus on promoting oral health through public health interventions, helping states strengthen their oral health programs, and promoting oral health in communities, schools, and health care settings nationwide.
Date: 2011
Oral Histories: Report from a Dental Fair for Uninsured Adults
Author(s): Michael Perry, Meredith Lewis, Julia Paradise
Sponsoring organization: Kaiser Commission on Medicaid and the Uninsured
Conveys insights gained from interviews at the Onley, Virginia dental fair in which eight patients, a dentist providing services there, and the fair organizer talk about the oral health care challenges they face.
Date: 09 / 2009
Promoting Oral Health in Schools: A Resource Guide
Author(s): Jolene Bertness, Katrina Holt (editors)
Sponsoring organization: National Maternal and Child Oral Health Resource Center
A resource to help health professionals, program
administrators, educators, researchers, policymakers, and parents working in rural and urban school settings prevent disease and promote oral health in children and adolescents.
Date: 04 / 2009
Recruitment and Retention of a Quality Health Workforce in Rural Areas, Number 4: Oral Health
Sponsoring organization: National Rural Health Association
Presents an overview of issues related to the oral health workforce in rural areas. Part of a series of issue papers addressing rural health care workforce development through career pipeline programs.
Date: 11 / 2006
Retail Dental Clinics: A Viable Model for the Underserved?
Sponsoring organization: California HealthCare Foundation
This report, based on interviews with dentists and other experts, consumer surveys, and published reports, examines factors that would support or inhibit the emergence of retail dental clinics in California and elsewhere.
Date: 11 / 2009
Rural Dental Dilemmas Growing
Author(s): Hope Hanson
Sponsoring organization: Rural Assistance Center
Discusses the oral health programs in rural areas including geographic isolation, lack of transportation, lack of dentists, lack of fluoridated water in certain communities, and lack of dental insurance. Highlights Apple Tree Dental, a Minnesota dental program.
Journal citation: Rural Monitor Volume 2006 Issue Winter
Date: 02 / 2006
Rural Healthy People 2010: The State of Rural Oral Health
Author(s): Pete Fos, Linnae Hutchison
Sponsoring organization: Southwest Rural Health Research Center
Addresses rural health issues associated
with the Healthy People 2010 focus area on
oral health.
Date: 2003
Ryan White HIV/AIDS Program: Oral Health and HIV
Sponsoring organization: Health Resources and Services Administration
Discusses oral health problems people living with HIV/AIDS experience. Includes barriers to oral health care, oral health services available, and special projects, including providing oral health care to those with HIV/AIDS in rural settings.
Date: 01 / 2012
Simulation Model for Designing Effective Interventions in Early Childhood Caries
Author(s): Gary B. Hirsch, Burton L. Edelstein, Marcy Frosh, Theresa Anselmo
Sponsoring organization: Centers for Disease Control and Prevention
Reports on a study that developed a system dynamics model to assess and compare interventions for benefits and costs of early childhood caries - tooth decay among children younger than 6 years. This study and model was based on young children in Colorado, but could be applied to other areas.
Date: 2012
Spotlight on Rural Research: Rural Oral Health - All in the Family?
Author(s): Hope Hanson
Sponsoring organization: Rural Assistance Center
Highlights research in rural oral health throughout the United States. Discusses several oral health research reports.
Journal citation: Rural Monitor Volume 2006 Issue Winter
Date: 02 / 2006
State Policy Levers for Addressing Preventive Dental Care Disparities for Rural Children: Medicaid Reimbursement to Non-Dental Clinicians for Fluoride Varnish and Dental Hygiene Supervision in Primary Care Safety Net Settings (Full Report)
Author(s): Amy Brock Martin, Jessica Bellinger, Jeff Hatala, Jordan Mitchell, Janice C. Probst
Sponsoring organization: South Carolina Rural Health Research Center
Addresses preventive dental care disparities for
rural children by studying access to fluoride varnish applications and the extent that dental hygienists can provide select preventive dental services in primary care safety net settings.
Date: 03 / 2012
State Policy Levers for Addressing Preventive Dental Care Disparities for Rural Children: Medicaid Reimbursement to Non-Dental Clinicians for Fluoride Varnish and Dental Hygiene Supervision in Primary Care Safety Net Settings (Key Facts)
Sponsoring organization: South Carolina Rural Health Research Center
Provides keys facts regarding preventive dental care disparities for rural children.
Date: 03 / 2012
Strategies to Improve Collaboration Between State Oral Health Programs and Head Start State Collaboration Offices
Sponsoring organization: Association of State and Territorial Dental Directors
Describes how a partnership between state oral health programs (SOHPs) and Head Start state collaboration offices (HSSCOs) could improve communication and networking between local Head Start programs and others to enhance oral health services for pregnant women, infants, and children enrolled in Head Start and their families.
Date: 10 / 2011
Use of Emergency Departments for Conditions Related to Poor Oral Health Care
Author(s): Emily F. Shortridge, Jonathan R. Moore
Sponsoring organization: NORC Walsh Center for Rural Health Analysis
Persistent and worsening shortages of oral health care providers in rural areas, combined with limited acceptance of Medicaid and the Children’s Health Insurance Program (CHIP), have left many patients without adequate access to dental care.
Date: 08 / 2010
Water Fluoridation and Dental Health Indicators in Rural and Urban Areas of the United States (Final Report)
Author(s): Michael Hendryx, Constance Weiner, Matthew Gurka
Sponsoring organization: West Virginia Rural Health Research Center
Investigates the availability of fluoridated water across urban-rural settings, and relates measures of fluoride availability to national survey measures of dental health in adults and children.
Date: 11 / 2011
Journals
Oral Health America eNewsletter
Monthly newsletter that provides news regarding oral health programs and initiatives, dental industry and research updates, and opportunities to become involved in helping improve oral health for all.
Oral Health Resource Bulletin
Periodic publication designed to stimulate thinking and creativity within the maternal and child health community by providing information about selected materials of current interest.
Organizations
Academy of General Dentistry (AGD)
National organization
Strives to represent the interests of general dentists and improve the quality of comprehensive dental services, health promotion and wellness.
America's Dentists Care Foundation Missions of Mercy (ADCF MOM)
Nonprofit/Foundation
A gathering of volunteer dental professionals who, along with a volunteer staff of several hundred, hold free, two-day dental clinics at locations around the country.
American Academy of Pediatric Dentistry (AAPD)
National organization
Represents the specialty of pediatric dentistry. Advocates policies, guidelines and programs that promote optimal oral health and oral health care for children.
American Association of Public Health Dentistry (AAPHD)
National organization
Promotes efforts in disease prevention, health promotion and service delivery. Educates the public, health professionals, and decision-makers regarding the importance of oral health to total well-being.
American Dental Association (ADA)
National organization
Professional association of dentists committed to the public's oral health, ethics, science and professional advancement. Site offers a state directory of dental organizations.
American Dental Hygienists' Association (ADHA)
National organization
Represents the interests of dental hygienists. Includes publications on oral health.
Association of Clinicians for the Underserved (ACU)
National organization
A nonprofit, transdisciplinary organization of clinicians, advocates, and health care organizations working to improve the health of America's underserved populations and to enhance the development and support of the medical and dental clinicians serving these populations.
Association of State and Territorial Dental Directors (ASTDD)
State/regional organization
Represents the directors and staff of state and territorial public health agency programs for oral health.
Centers for Medicare and Medicaid Services (CMS)
Federal government
Operates the Medicare and Medicaid programs - two national health care programs that benefit millions of Americans. Part of the U.S. Department of Health and Human Services. Website includes access to research, statistics, and data related to their programs.
Children's Dental Health Project (CDHP)
Nonprofit/Foundation
Promotes public and clinical policies to improve health and increase access to comprehensive dental care for children and other vulnerable populations. Site offers publications, news, resources, and projects.
Dental Lifeline Network (NFDH)
National organization
Provides qualified disabled and elderly people in numerous states with free, comprehensive, donated treatment by volunteer dentists.
Mobile Health Clinics Network (MHCN)
National organization
Dedicated to providing community outreach via the use of mobile medical and dental clinics. Includes news briefs, publications, and funding opportunities.
National Association of County and City Health Officials (NACCHO)
National organization
Provides education, information, research, and technical assistance to local health departments.
National Maternal and Child Oral Health Resource Center (OHRC)
National organization
Responds to the needs of states and communities in addressing current and emerging public oral health issues. Supports health professionals, program administrators, educators, policymakers, and others with the goal of improving oral health services for infants, children, adolescents, and their families.
National Network for Oral Health Access (NNOHA)
National organization
Made up of oral health providers that represent the diversity of safety-net oral health settings, such as isolated, rural, and one dentist clinics.
National Rural Recruitment & Retention Network (3RNet)
National organization
Works to help health care professionals, including dentists and dental hygienists, find practice opportunities in rural areas throughout the country. Includes state information and a list of state contacts.
Oral Health America (OHA)
National organization
Develops, implements, and facilitates educational and service programs designed to raise awareness of oral health's importance to total health. Includes programs such as Smiles Across America, Wisdom Tooth Project, Medical Dental Dialogues, the Campaign for Oral Health Equity, and NSTEP.
Special Care Dentistry Association (SCDA)
National organization
Promotes the oral health of special needs patients. Members include dentists, dental hygienists and assistants, non-dental healthcare providers, health program administrators, residents, students and hospitals.
Terms & Acronyms
Caries Tooth decay or cavity.
Crown A "cap" that covers a cracked or broken tooth to reproduce its normal size and shape.
Deciduous Teeth Primary or baby teeth.
Dental Amalgams Also known as silver fillings, dental amalgams are comprised of a mixture of mercury (45 to 50 percent), and an alloy of silver, tin, and copper (50 to 55 percent).
Dental Implants Small dental appliances that are inserted into the upper and lower jaws to help restore a mouth that has little or no non-restorable teeth.
Dental Safety Net Comprised of dental schools, community-based clinics, school-based programs, hospital clinics, and mobile vans, are few in number compared to the medical safety net.
Dentist Workforce Number of dental school graduates at any given time.
Doctor of Dental Medicine (DDM) Degree given to dental school graduate.
Doctor of Dental Surgery (DDS) Degree given to dental school graduate.
Health Professional Shortage Area (HPSA) Geographic regions that have shortages of professionals working in primary medical care, dental or mental health care. HPSAs may be urban or rural areas, population groups or medical or other public facilities. Geographically, HPSAs can be cities or towns, counties or groups of counties. HPSA designations are reviewed and revised annually by the Secretary of Health and Human Services based on criteria set forth in the Public Health Service Act.
Health Professional Shortage Area - Dental Care (HPSA - Dental Care) The federal designation for a shortage of dental care health professionals that meets the following three criteria. First, the area must be a rational area for delivery of dental care services. Second, the ratio of population to existing providers must meet or exceed 5,000 people to every single provider or meet or exceed a ratio of 4,000 to 1 and have an unusually high level of need for dental services. Lastly, the area under consideration must have dental care professionals in continuous (nearby/adjoining) areas that are over utilized, excessively distant or inaccessible.
Malocclusion Orthodontic problem that means "bad bite," including crowded, missing, or crooked teeth, extra teeth, or a misaligned jaw.
Orthodontics Dental specialty that focuses on the development, prevention, and correction of irregularities of the teeth, bite, and jaws.
Periodontal Diseases Also called gum diseases, periodontal diseases are serious bacterial infections that destroy the gums and the surrounding tissues of the mouth.
Plaque Thin, sticky film of bacteria that appears on teeth and must be removed professionally.
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