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Back to School 2001: Bad teeth epidemic among poor children

Sunday, August 26, 2001

By Rachel Smolkin, Post-Gazette National Bureau

Six-year-old Edith Becerra has a toothache, but her mother can't find a dentist to treat her.

Edith's tooth began hurting when a filling fell out. Now, she's having trouble eating, and her mother worries that the pain will worsen, making it difficult for her to do her schoolwork as she begins first grade tomorrow.

"I know what a toothache is, and I know she's going to have problems in school if they don't attend to it now," said Evelia Becerra, who speaks only Spanish.

First in a series

5 Pitt dental students learn of the need first-hand


Becerra, an apple-packer in Erie, asked a migrant health services coordinator to help her find a dentist quickly. But only two dental clinics in the Erie area take patients on Medicaid, the government program for low-income families. Becerra was told that the earliest possible appointment for Edith was Dec. 28 -- four painful months away.

Tooth decay, a common chronic childhood condition, is easily treated in most young children. But many low-income children in America do not have such care, either because they have no dental insurance or because their parents cannot find a dentist who will treat them.

The barriers that low-income children face are complex. Many involve Medicaid, the health program for poor and disabled Americans that's run jointly by the states and the federal government. There also is a growing shortage of dentists, especially in inner cities and rural areas.

When tooth decay goes untreated, festering cavities can hamper growth, hinder learning and erode self-esteem.

"It is simply impossible for a child to focus and accomplish well in school when they are distracted by a relentless toothache," said Burton Edelstein, director of the Children's Dental Health Project in Washington, D.C. "The child can't sleep at night, doesn't get a good breakfast and heads off to school with a toothache. The whole picture is one of a functional disability."

U.S. Surgeon General David Satcher last year declared that a "silent epidemic" of oral diseases afflicts the nation's most vulnerable populations -- its children, elderly and many minorities.

Statistics compiled by the federal government and pediatric dental experts offer a stark illustration of oral health problems among poor children.

Just one-quarter of U.S. children and adolescents suffer 80 percent of all cases of decay in permanent teeth. An estimated 4 million to 5 million children have dental problems severe enough to impair their ability to eat, sleep and learn.

"We get kids sent to us all the time by school nurses, and we look in their mouths, and their teeth are rotted down to the gum lines," said Jack Whittaker, a pediatric dentist in Bowling Green, Ohio. "They tolerate this because they're used to it. These kids are 6 years old, and the decay has been there two years or three years."

Whittaker, one of the few dentists in northwest Ohio who routinely accepts Medicaid patients, sees children who can chew only on one side of their mouths because the other side hurts so badly. They cry when he touches their aching teeth.

Alba Rodriguez, a Head Start teacher in Erie who helps migrant children learn English, says their teeth frequently are so "messed up" that they have trouble speaking.

A University of Pittsburgh survey requested by the Pennsylvania Department of Health found that northwest Pennsylvania has significantly higher numbers of children with untreated decay than other areas of the state.

David Shapter, a pediatric dentist in Erie, spends one day each week treating children who desperately need dental care. His patients, at an average age of 4, already have eight to 20 cavities, he said.

Many children he treats are 2 years old or even younger. Some are immigrants from Bosnia or Russia who never had dental care. All probably would be denied treatment if it weren't for a special clinic that treats children who can't find another dentist.

Nationally, for every child without medical insurance, nearly three lack dental insurance, the surgeon general's report said. But even for children with dental insurance, access to a dentist is by no means assured.

Medicaid covers dental care for children, but states exercise wide latitude in administering the program. Moreover, low reimbursement rates and burdensome forms have discouraged many dentists from accepting Medicaid patients.

Although some dentists often treat low-income patients free of charge, only 25 to 35 percent of dentists nationwide participate in Medicaid in even a limited way, said Edelstein, who wrote the child section of the surgeon general's report. He estimated that only one in four children enrolled in Medicaid received any dental service within the last year.

Medicaid costly to dentists

Dentists frequently lose money when they treat Medicaid patients. Because each dental office is essentially a mini-surgery center, overhead costs are high. Between 65 percent and 75 percent of each dollar that dentists charge pays for overhead, and Medicaid reimbursements typically fall well below that.

Equally frustrating to dentists is the time lost filling out complex Medicaid forms about procedures for which reimbursement is often rejected. Medicaid rules frequently appear arbitrary, in some cases specifying that for certain procedures a dentist can be paid only for work in half the mouth on any given day.

"To have to deal with stupid, arcane rules which don't make any sense scientifically or socially is a little ridiculous," said Ross Wezmar, a pediatric dentist in northeastern Pennsylvania and chairman of pediatric dental advisers for the federal government's oral health initiative. "Most dentists are going to say, 'To heck with this stuff. This is crazy.'"

Dentists also perceive an increased likelihood of missed appointments among Medicaid patients. Wezmar estimated that 40 percent of his Medicaid patients miss appointments, instead coming in months later when their child has a toothache and the resulting swollen face.

Sometimes parents don't realize the importance of preventive care, and a child's routine dental visit can become an insurmountable challenge for a parent who would lose a day's wages and may not have transportation.

The worsening shortage of dentists further impedes dental access for low-income children and adults. Retiring dentists soon will outpace dental school graduates, and not enough dentists practice in inner cities or rural areas where the need is greatest, according to Oral Health America, an advocacy group for improving dental access.

Although dental access has snared little national attention, some lawmakers are working to narrow the oral health gap between low-income Americans and the more affluent.

Sen. Susan Collins, R-Maine, learned of the rural dentist shortage from her own dentist in Caribou, a northern Maine town that has about one dentist for every 5,000 residents. She introduced a bill to provide state grants to improve access to oral health services in rural and underserved areas. Her bill passed the Senate health committee this month as an amendment to a broader health care safety net bill.

Sen. Jeff Bingaman, D-N.M., is drafting a bill that would increase the availability of dental insurance for low-income children and offer state grants to address shortcomings in Medicaid.

In January, the federal government agency that oversees Medicaid informed states that it would increase oversight activities of their compliance.

"It is apparent that a number of states are not meeting participation goals for pediatric dental services," the letter said. "These states must take further actions to improve access to these services for eligible children."

Some state efforts have met with mixed success. In Pennsylvania, for example, legislators increased Medicaid reimbursement rates for dentists in 1999 but have not seen a significant change statewide in the number of participating dentists. The rates remain below market standards, Wezmar said.

"Until you get up to market rate or close to it, nothing's going to happen," said Wezmar, who said he must limit treatment of Medicaid patients to avoid bankruptcy. He does, however, treat children up to age 7. Patients come to see him with swollen gums and mouths in what he called "disastrous" shape.

"We get people calling all the time," he said. "My name begins with 'W,' and the line [we hear] is: 'I've called everybody in the phone book and finally found you.'"

Tomorrow: Teachers rise above their disabilities to do their classroom jobs.

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