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

By Mary Otto
Washington Post Staff Writer
Thursday, December 27, 2007

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.

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."