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

The Walnut Street clinic sometimes has a waiting list of as many as 400 names. People have to keep calling the office if they want their children to become patients.

"My sister . . . told me to try to get in. They are the only ones who accept Medicaid," said Christina Boward, a waitress who takes her two children to the clinic for routine care. The only other place she knows to take them is in Baltimore, 100 miles away, an expensive and difficult trip for the single mother.

Prince George's, Maryland's second-most-populous county, has 85,000 Medicaid children. Only 25.5 percent of them had a dental visit last year, the Dental Action Committee found, and only 52 dentists in the county billed $10,000 or more to Medicaid. According to a congressional inquiry begun after Deamonte's death, seven dentists provided most of the care.

In 2006, three brothers, prosthodontist Rahim Tofigh and pediatric dentists Amir and Hamid Tofigh, billed for one-third of the dental services provided by United Healthcare, a managed care organization serving Prince George's Medicaid children, the congressional inquiry found. Even so, Rahim Tofigh said, he found the Medicaid bureaucracy burdensome and the fees low.

"I cannot even hire a root canal specialist or an oral surgeon who is willing to see patients under the current fee schedule," said Tofigh, whose specialty involves implants and reconstructive dentistry. "In fact, my periodontist [gum specialist] stopped seeing medical-assistance patients due to the difficulty of getting reimbursed for his services."

The state's reimbursement rates for many dental procedures are far below the median fees charged by dentists in the region.

Maryland's Dental Action Committee has called for an additional $40 million a year -- about half state and half federal funds -- to raise reimbursement rates to the median as a way of encouraging more dentists to treat poor children. The committee also has recommended a broad restructuring of the state's Medicaid program.

Following criticism from Congress, United Healthcare officials said they have focused their efforts on reaching out to patients who have gone for years without a dental visit and on expanding their provider network to make it easier for patients to find dentists. United Healthcare has also funded a new pediatric dental fellowship at the University of Maryland and has begun working with other academic institutions to expand community dental services in Prince George's.

And Prince George's Health Department dental clinics will again see Medicaid children. Treatment of those children was discontinued for a decade to concentrate on serving people without any dental coverage.

"We are expanding to include Medicaid children as patients," said Prince George's Health Officer Donald Shell. "No child with a dental need will be turned away."

Social Complications

Reaching Medicaid families can be a challenge, health providers said.

Some parents face language barriers. Others are unaware of what services are necessary or available or how to find them. Some are likely to miss appointments or delay care until the patient is in pain.

Arphine Ackerman, who presides over the small and busy waiting room of the federally funded Choptank Community Health System dental clinic, which serves poor families in Cambridge, Md., said the parents who call the office often do not seem to grasp the urgency of getting care, even for a serious problem such as an abscess.

"They say my kid has a marble, a gumball, a bump," she said.

Ackerman and Connie Richardson, who manages the office at the Walnut Street Dental Clinic in Hagerstown, both expressed frustration over missed appointments.

"I'm not above making people feel guilty," Richardson said.

Yet Richardson said she tries to remember the challenges poor families face. "Their lives are way different from ours," she said. "Transportation is a huge problem. They don't call because they don't have time on their cellphones. We have to be compassionate."

In Prince George's, the county has hired a program chief for dental health services, a post that has been vacant for five years, to help focus the effort to reach needy families.

The county, which operates a dental clinic in Cheverly and a school-based clinic in Oxon Hill, recently opened a third clinic, for adults and children, near the Suitland Metrorail station. De'Andre Ferguson, 9 months old, was the first Medicaid child to visit the clinic.

His mother, Keyana Ferguson, said she knew her baby should have a dental checkup by his first birthday but was worried about finding a dentist. She said she was happy and relieved to hear about the clinic, which is close to her home.

Dentist Bridget McGuire gently examined the baby's mouth as he sat quietly on his mother's lap. She told Ferguson how to use a damp washcloth to clean his gums after he drinks a bottle and how to gently brush his teeth once they emerge.

Then McGuire congratulated De'Andre on getting off to such a hopeful start.

"You look absolutely perfect."