For Those in Need, Service With a Smile
Grant Program Revamps Low-Income Dental Clinic

By Theola S. Labbe
Washington Post Staff Writer
Thursday, June 8, 2006

There are some rotten and missing teeth in the District.

But many of them are finally getting the expert attention they need, thanks to a District-funded program that provides dental care to the city's poor and homeless populations.

Using a $1 million grant from the city, the nonprofit D.C. Primary Care Association distributed money to seven nonprofit primary care centers as part of an effort to expand access to health care in underserved areas, particularly neighborhoods east of the Anacostia River and parts of Ward 5.

Because of the program, Sheri Graves, 41, is no longer ashamed of her mouth. Using the latest in computer technology, her dentist, Ivan Stangel, pointed to an X-ray of two of her teeth, damaged by decay, on a flat-screen monitor. Just a year ago, it would not have been possible for Stangel, whose clinic is operated by the nonprofit So Others Might Eat, to provide the level of service he can now give Graves.

The SOME dental clinic's $100,000 overhaul, completed in February, was the first project funded by the grant to be finished. The clinic's busy schedule since then -- even with 33 percent expanded capacity -- highlights the strong demand for oral health care among low-income and homeless residents. The clinic, at 60 O St. NW, sees 40 to 50 patients a week and has a waiting list of 90 people.

"We hope that SOME is the first in a series of expansions and improvements in dental care to the underserved," said Sharon Baskerville, executive director of the Primary Care Association.

Research by Rebecca Bruno, a health policy associate at SOME, demonstrated why those improvements are needed. From March through July 2005, she surveyed 538 homeless men and women at 35 sites in every ward to determine their dental status. Sixty-one percent were male; 82 percent were ages 31 to 59. SOME also mailed surveys to 18 community-based dental clinics.

The survey found that 79 percent of adults were missing at least one tooth. About 42 percent had mouth pain, and 28 percent had gums that bled easily. Some good news: 84 percent of respondents said they brushed daily.

Based on Bruno's findings, the report recommended that the District do more to improve the dental care of low-income and homeless people.

"The District has failed to provide adequate and meaningful access to oral health care for its low-income and homeless adults, putting their health at risk," her report concluded.

When D.C. Council member David A. Catania (I-At Large) became chairman of the Committee on Health in January 2005, he discovered that the District spent less than $250,000 annually on dental care for Medicaid recipients. "It was really a joke," he said.

Catania and other health advocates say they are pleased that oral health has become a top public health priority in the city and that the important links between dental care and overall physical health are better recognized.

Catania said he became attuned to dental problems by walking parade routes in the city. Along some avenues, the smiles were bright and full. Along others, many smiles were gap-toothed.

He had his staff comb through the Health Department's budget to look for money that could fund dental care initiatives and began an effort to raise Medicaid reimbursement for dentists so that more private providers would accept Medicaid patients.

Medicaid, which is funded by District and federal money, and the locally funded D.C. Healthcare Alliance provided dental benefits before the Primary Care Association grant program. But critics said those benefits were too limited and too few dentists provided care.

Beginning in October, however, the District will fund a comprehensive dental benefit for adults and children on Medicaid, putting the total amount allocated for dental health at roughly $12 million for fiscal 2007. The funding will include the first rate increase for dentists since 1985, Catania said.

He hopes the higher rates will draw dentists to a program they have largely shunned. Of 600 dentists belonging to the D.C. Dental Society, fewer than 40 provide services to Medicaid patients, according to Catania. Those who do, he added, lose money. The council also approved a $225,000 grant to Howard University's College of Dentistry and SOME to develop a program to serve homeless people who may not qualify for Medicaid or the Alliance programs. Aspects of that program will include Howard dental students who will work at the SOME clinic.

"This is a historic moment for dental services in the District," Catania said.

The importance of adequate oral health care goes beyond having a pretty smile. "If you have no teeth, it is very difficult to summon the courage to go ask for a job, to get a job," Catania said.

Stangel has been working on the teeth of the homeless at the clinic for 2 1/2 years. "We have gone from a facility that has been in place for 15, 20 years with donated equipment to a state-of-the-art clinic," Stangel said. "We have a lot of enhanced efficiencies built in the same place."

The renovations added a fourth treatment room to the dental clinic. The SOME facility also offers behavioral services and medical care.

Stangel said the old clinic had no privacy between the dental chairs, which made it difficult to keep details about patients' health confidential, as required by law.

In addition, much of the equipment was old or hand-me-down and on its last legs. In one area, Stangel and his staff kept a bucket to collect water that leaked from a machine that couldn't be repaired.

Post-renovation, "we have an extremely delightful space for patients to come into," Stangel said. Jazz pipes softly from computer speakers, serving as a backdrop for dental appointments.

The dental office now has equipment more advanced than in some private dental offices. There is digital radiography -- computerized X-rays that Stangel can show the patient on a chair-side monitor, pointing out areas on the screen with a wireless mouse and keyboard. The chair-side monitors also have Internet access, allowing the dentist to research information to show the patient during the appointment.

The patients at SOME's clinic often have more advanced illnesses than are seen at the typical dentist's office. "Most patients present with very debilitated mouths -- something I hadn't seen for years before I got here," Stangel said.

Among working middle-class individuals in industrialized nations, tooth decay and cavities are generally declining, "but if you look at low-income and homeless individuals," he said, "oral disease is rampant."

The causes are many: a drug- or alcohol-dependent lifestyle that doesn't include dental appointments, a poor diet, and, in the face of limited public benefits coverage, not being able to afford private dental providers.

Good dental care is important for reasons other than healthy teeth. Several diseases show symptoms in the mouth. For example, Stangel said, for patients who have HIV, the tissue in the mouth -- the cheeks, the area under the tongue and the back of the throat -- can be more susceptible to developing infections.

"It's really a gateway to what is going on to the rest of their bodies," Stangel said. "Someone who's not taking care of their oral environment is not taking care of the rest of their body."

Graves, the patient with the two decayed teeth, was having tooth reconstruction on a recent day, one of several appointments she had had with Stangel to restore her smile.

Stangel asked Graves how she was doing and, after small talk, explained he would work on one tooth and have her come back to complete work on the second.

The dentist began by removing the temporary material that surrounded a brown-tinged tooth. Then he applied three different solutions, including a primer and a resin, to its surface. Next he filled out the tooth with composite material and used an LED light to harden the light-sensitive substance. Finally, he sculpted and shaped the reconstructed tooth, making fine lines so it resembled a natural tooth. The process took about 30 minutes.

Stangel pulled out a mirror and showed Graves the results.

"Oh man, wow!" Graves said. When she first arrived at the dentist's office last year, she said, she held her hand over her mouth when she spoke.

"I'm so excited, it's like brand new again," she said. Next week, the Extra will look at the city's "medical homes" initiative, which aims to ensure that every District resident has a place to go for health care.