Indigent dental care in Virginia.

On 23 August 2006 with 20 comments

I lean back, breathe deeply, and clutch the arms of the chair, preparing myself for what’s to come: the push of the needle into my gum; the thick sensation of fluid forcing itself into flesh; the bittern novocain on my tongue.

Gratitude is not a feeling that comes naturally to me right now, but I’m striving for it. I’m so grateful to have dental insurance, to have been born into an economic class that has made it possible for me to go to the dentist, to have been able to pay for teeth so straight that strangers compliment them.

But, damn, it hurts.

Two Harvard researchers released a book about our healthcare system last year, “Uninsured in America: Life and Death in the Land of Opportunity.” The authors talked to uninsured people across the nation, and found that dental care is their top concern. The New Yorker’s Malcolm Gladwell recently surveyed some of the subjects’ responses (”The Moral-Hazard Myth,” 08/29/2005), and explained what makes the loss of teeth so damaging to health and long-term economic prospects:

Gina, a hairdresser in Idaho, whose husband worked as a freight manager at a chain store, had “a peculiar mannerism of keeping her mouth closed even when speaking.” It turned out that she hadn’t been able to afford dental care for three years, and one of her front teeth was rotting. Daniel, a construction worker, pulled out his bad teeth with pliers. Then, there was Loretta, who worked nights at a university research center in Mississippi, and was missing most of her teeth. “They’ll break off after a while, and then you just grab a hold of them, and they work their way out,” she explained to [researchers] Sered and Fernandopulle. “It hurts so bad, because the tooth aches. Then it’s a relief just to get it out of there. The hole closes up itself anyway. So it’s so much better.”

People without health insurance have bad teeth because, if you’re paying for everything out of your own pocket, going to the dentist for a checkup seems like a luxury. It isn’t, of course. The loss of teeth makes eating fresh fruits and vegetables difficult, and a diet heavy in soft, processed foods exacerbates more serious health problems, like diabetes. The pain of tooth decay leads many people to use alcohol as a salve. And those struggling to get ahead in the job market quickly find that the unsightliness of bad teeth, and the self-consciousness that results, can become a major barrier. If your teeth are bad, you’re not going to get a job as a receptionist, say, or a cashier. You’re going to be put in the back somewhere, far from the public eye. What Loretta, Gina, and Daniel understand, the two authors tell us, is that bad teeth have come to be seen as a marker of “poor parenting, low educational achievement and slow or faulty intellectual development.” They are an outward marker of caste. “Almost every time we asked interviewees what their first priority would be if the president established universal health coverage tomorrow,” Sered and Fernandopulle write, “the immediate answer was ‘my teeth.’”

Heart disease, stroke, and premature births are all exacerbated by the simple inability to have regular cleanings. The matters of the mouth do not confine themselves to the mouth; professional dental maintenance mean a longer life and healthier children. Those who do not have the financial resources for dental care will make less money, suffer from more diseases, and die younger than you and I.

One in five Virginians have had all of their teeth pulled.

By Finizio. Reproduced under the Creative Commons Attribution-NoDerivs 2.0 license.

The state has no program to provide dental care to impoverished adults. If they cannot afford to have a cavity drilled, they have no recourse. Children have access to such care by way of Medicaid’s dental coverage and the state’s Family Access to Medical Insurance Security (FAMIS) program, but the reimbursement rate to dentists was long so low that dentists lost money on each patient. Dentists could afford to take very few such patients, leaving many children without any dental care.

Things have changed recently — for the better — thanks to the Virginia General Assembly. Though the problem is hardly solved, already the landscape of the dentistry business is changing in response to the improvements.

A cavity is a strep infection of the tooth. Streptococcus mutans, an anaerobic bacteria, flourishes when trapped by calculus in the fissures of the teeth. It digests sucrose — common table sugar — and excretes lactic acid. In the process it creates a sticky substance that allows the S. mutans bacteria to clump together, which are collectively known as plaque. The lactic acid eats away at the protective enamel of the tooth, exposing the sensitive dentin and pulp within.

This is the point when most of us become aware that something is wrong. The discomfort of eating cold or sweet foods lands us in a dentist’s chair to get drilled and filled. For those who cannot afford a trip to the dentist, though, it’s only the beginning. The braver among us may solve the problem with some whiskey, a pair of pliers, and a good friend. Others have to grin and bear it, while the rot spreads deep into the root of the tooth, where it will abscess. By this time the afflicted individual is in constant pain, has a difficult time eating, is running a mild fever, and has terrible breath.

If the pus-filled cavity extends down into the jawbone, it becomes a bone infection, osteomyelitis. The abscess within the bone cuts off blood to the rest of the jaw, and the bone tissue starts to die off. Pus bubbles up to the skin, and the individual becomes extremely sick. Treatment requires removing the jaw.

If, on the other hand, the cavity extends into the soft tissues, that’s a case of Ludwig’s angina, an infection in the flesh of the lower jaw, under the mouth. The individual will be terribly ill, have great pain of the neck and throat, and be dehydrated and malnourished from being unable to drink or eat. As the infection worsens, the tongue is pushed back and up, until the individual chokes to death on his own tongue.

The House of Delegates recently commissioned a pair of studies of obstacles to proper indigent dental care [1, 2], and the result looked a lot like a to-do list. It pointed out that the state’s dentist scholarship and loan repayment program isn’t doing a lot of good — it had been allocated just $25,000, a fraction of the cost of sending a single student through VCU’s School of Dentistry. The dental hygienist scholarship program was doing even worse, having been allocated $0. Virginia needs another 145 dentists, carefully distributed, in order to address the shortfall in care in the 43 underserved areas. Forty one percent of Virginians lack dental insurance. The Virginia Division of Dental Health can pay dentists just half of the private practice rate, which makes it tough to recruit. Virginia is just one of seven states in the nation that require direct supervision of dental hygienists for all services at all times, making hygienist-run cleaning clinics illegal. Though licensure by endorsement is available for every other medical profession, dentists from other states cannot easily practice in Virginia, a result of professional protectionism. And for just $8.2M, every Virginia adult enrolled in Medicaid could receive dental care.

By Curtis James. Reproduced under the Creative Commons Attribution-NonCommercial-NoDerivs 2.0 license.

There was, in short, a lot of low-hanging fruit.

Del. Preston Bryant (R-Lynchburg) was one of the representatives to take up the charge. He patroned a bill last year that made a pair of small but important changes: it repealed the prohibition of licensure by reciprocity and it created temporary permits for unlicensed graduates of dental hygiene programs who want to work in a charitable capacity.

But the real improvement came with the increase in Medicaid and FAMIS dental reimbursement rates that were a part of Gov. Mark Warner’s 2005 budget amendments. He pushed for — and received — a 10% increase in reimbursement rates for dentists under Medicaid and FAMIS, at an increased cost of $5.9M for 2006, as well as an addition $1.3M for the Department of Health for 2006 to improve access to dental services. The reimbursement increase was enough that dentists could break even treating economically disadvantaged children; an enterprising few would even retool their business models to treat only those kids.

The increase was tiny in the scope of the budget, but the change would make an enormous difference in the daily lives of thousands of children accustomed to receiving dental care in an abandoned warehouse.

Democratic Fifth District House of Representatives candidate Al Weed spent the day volunteering at a dental outreach clinic in Martinsville in 2003. He told me about the experience shortly after returning, and it was unlike anything I’d ever heard of. It sounded like something done by relief workers in El Salvador or Rwanda, not something that would exist right here in Virginia.

The Virginia Dental Association’s Mission of Mercy clinic was held in the abandoned Tultex plant. The knit outerwear company shut down in January 2000, laying off 445 people, another victim of globalization. Nearly a thousand people showed up, some getting in line at 3:00 am, where over two hundred dentists performed 454 fillings, 787 root canals, 427 surgical extractions, and pulled 1,214 teeth over the course of two days. Forty three chairs were set up, serving absolutely anybody with the patience to stand in line and the willingness to have minor surgery performed on a factory floor.

Weed is no stranger to such medical operations of such scale, having served as a Special Forces medical sergeant in Vietnam. Yet nearly three years later, he still describes the event with something approaching awe. He was 12 years old before he went to the dentist, and so has the sort of appreciation for dental care that might be expected. Weed sees the outreach clinic as evidence that the time has come for universal health care.

Ironically, it’s likely that some of the people waiting in line at that Tultex plant were there for the first time since three years previously, when they’d been laid off.

The Martinsville clinic is just one of 22 Mission of Mercy clinics held in Virginia over the past decade. In that time they have seen over 18,000 patients and provided over $7M in free dental care. It is one of the largest such operations in the nation.

That’s nothing we should be proud of.

At least two companies that have learned how to make the most of the changes in Virginia law. Small Smiles (in Roanoke) and Kool Smiles (in Norfolk, Richmond, Newport News, Virginia Beach, Falls Church and Portsmouth) are each part of national dental chains designed to serve only children receiving public assistance.

The state’s dental fee schedule is unbelievably complex, but the key elements of it are that reimbursement rates to dentists increase in underserved areas and increase as their percentage of FAMIS patients increases. Dental practices set up in the right areas, serving only FAMIS and Medicaid patients, are able to not just break even, but actually turn a profit.

These practices require great volume in order to make money, so there’s a danger that they’ll turn into dental mills. The Virginia Dental Association’s executive director had just that concern, but he checked them out and says he’s happy with the quality of their work.

“First Dentist Trip.” By JBC Russell. Reproduced under the Creative Commons Attribution-NonCommercial-ShareAlike 2.0 license.

Of course, even if the work is mediocre, it’s got to be better than no dental care at all. When the alternative is prying out teeth with pliers, the bar is set pretty low.

It was just a few weeks ago, browsing entries on my blog from years past, that I discovered a pattern in my dental history. I neglect to get a cleaning for years. I finally go when something’s wonky. It’s discovered that I have “pitting,” or a cavity, which I get fixed. Repeat. I have every reason in the world for not getting those cleanings. I had no dental insurance for a long while. I lived in the New River Valley and figured I’d wait until I moved back to Charlottesville. I’m too busy. I forget.

But the truth is that dental care is not important to me, because I have a safety net. So what if I develop pitting? The dentist will drill it out and fix it. There’s no danger of me letting a cavity spread enough to endanger my health; I’m too much of a wimp to withstand any discomfort. Like oxygen or water, healthcare is worthless as long as you have it, but invaluable once it’s gone.

There’s a lot left on the General Assembly’s to-do list. Dental care remains out of reach for thousands of children in Virginia. There is still no program to provide dental care for adults. Dental scholarships are underfunded. Many areas of the state simply don’t have enough dentists to serve the population. Though last year’s improvements are significant, the job is only half done.

A few months ago I made an appointment for a cleaning, my first in six years. It’s coming up in two weeks. I can hardly wait.

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