For Too Many Md. Children, Too Few Trips to the Dentist

On a recent day at the busy Walnut Street Dental Clinic in Hagerstown, Md., Ilaya Rajagopal treated an 18-month-old who had six cavities and lectured the child's mother, in his gentle way, about the damage caused by putting a baby to bed with a bottle.

The dentist also taught a 3-year-old how to brush. He installed a wire space-maintainer for a girl who lost two teeth to decay. He extracted a boy's tooth after discovering an abscess.

An abscess, he said, "is like a time bomb, ticking."

Tooth decay is the most common childhood disease in America, five times as common as asthma, research shows. And it is especially common among the poor.

In February, a 12-year-old Prince George's County boy, whose Medicaid coverage had lapsed, died after bacteria from an untreated dental abscess spread to his brain. The death of Deamonte Driver cast a new light on the failures of the state and federal Medicaid system to provide dental care to poor children. Fewer than a third of Maryland's nearly 500,000 Medicaid children were seen by a dentist last year, a statistic that is typical of the problem nationwide.

The Driver family's poverty, periods of homelessness and problems with transportation, phone service and mail delivery complicated the search for care. But the obstacles are shared by many other families navigating the Medicaid system.

Patients in rural areas, such as Western Maryland and the Eastern Shore, often travel miles to find care. In urban areas, including Prince George's County, dental offices might be closer by, but there are other barriers.

Across the state, there is a chronic shortage of dentists skilled in treating children and willing to deal with Medicaid's paperwork and reimbursement rates. Dentists who do accept Medicaid patients struggle against a culture of poverty in which the urgency of treatment is sometimes not understood or is eclipsed by other needs.

When children are not seen for routine checkups, cleanings and sealant applications, small problems become bigger and increasingly difficult to treat, resulting in pain, problems eating, sleeping and learning, illness and, in rare cases, even death.

"One abscess is all you need," Rajagopal said.

Obstacles to Participation

Rajagopal, a dental fellow from the University of Maryland, is working a two-year stint at the Hagerstown clinic, which receives a federal grant to provide care to the poor. He is nearly alone in serving Medicaid children in Washington County, the gateway to Western Maryland's Appalachian region.

Only six dentists in the county billed Medicaid for more than $10,000 last year. And only 26 percent of the 14,000 county children enrolled in Medicaid last year had a dental visit, according to a study by the state Dental Action Committee, a panel of health providers, insurance officials, health officials and children's advocates convened after Deamonte's death.