Dentist of the Back Roads
House Calls to Neediest Patients Bridge Health-Care Gap

By Mary Otto
Washington Post Staff Writer
Saturday, February 23, 2008; A01

LAFAYETTE, La.

T he cane fields and the bayous of Louisiana's Cajun heartland whir past the pickup's cracked windshield. Gregory Folse is at the wheel. He wears green scrubs. His dental instruments and a grinding tool he uses to repair dentures are stowed behind the seat.

Most of his 1,800 patients are too fragile to go out for dental appointments or denture fittings, so he goes to them, riding a circuit of eight parishes.

They represent a cross section of the region's elderly, poor and disabled: Cajun fishermen, retired farmers and oil field workers, younger people crippled by illness or trauma, frail Hurricane Katrina nursing home evacuees, including one who floated on a mattress for seven hours and lost her dentures. There was a madam, too, but she has gone to her reward.

Many, until he sees them in nursing facilities and isolated homes, have not had an oral exam for years. When Folse looks into a new patient's mouth, he often finds decay, rampant infection, the broken stumps of ruined teeth, even oral cancers.

The pain and disease speak to a lack of dental benefits and dental care.

Evidence links oral disease to heart and respiratory problems, and studies show that the old, frail and poor have the worst dental conditions of anyone in the country.

Most of those who had dental insurance during their working lives lost it when they retired. Medicare, the national health insurance program for senior citizens, does not cover routine oral health or dental services. Private dental insurance is limited and too costly for many. And the price of dental care can overwhelm people on fixed incomes: A pair of dentures can cost hundreds, sometimes thousands, of dollars.

Most of Folse's patients are on Medicaid, the public health-care program for the poor, which offers a scant patchwork of dental benefits.

Even in states that subsidize some care, there is a shortage of dentists who will treat seniors and the homebound and who are willing to accept Medicaid, with its complexities and historically low reimbursement rates.

In Louisiana, for instance, fewer than 50 of about 2,000 dentists provide dentures, said Ward Blackwell, executive director of the Louisiana Dental Association. Fewer than five attempt to meet the broader oral health-care needs of the frail and old in nursing homes.

Folse estimates that he donates more services than he bills to Medicaid. But he draws deep satisfaction from his work -- and sometimes a sack of crawfish along the way.

In Abbeville, Folse pulls up to a little house with crawfish traps stacked out front. He's here to adjust Elaine Sherman's dentures. He washes his hands at her kitchen sink.

"So you were hurtin', Sweetheart?"

* * *

When a nursing home has a small beauty shop that offers water, good light and a little quiet space, Folse, 47, tries to set up there. In the beauty shop at the River Oaks Retirement Manor in Lafayette, southwest of Baton Rouge, there are also bingo supplies and a priest's vestments.

He checks the chart of his next patient. The 74-year-old man suffers from dementia and is delusional. Sometimes such appointments "can get pretty wild," the dentist says.

But he thinks that everything, not just dental school, but also his years as a cowboy and his experience riding along with his country doctor grandfather, Phillip Robichaux, prepared him for this work.

A nurse gently but firmly brings the patient. His gum disease is advanced, and some of his teeth are so loose he could swallow them or inhale them. A timely $100 extraction can save $50,000 worth of surgery, hospitalization and complications.

"Those are bad. I'm going to take those out for you," Folse says. At first, the man balks.

"How bad?"

"They are real loose."

"Not to me."

"I want to take 'em out. I don't want them to make you sick. They are infected."

Folse does not take no for an answer. He leans in, projecting calm authority. He doesn't wear a mask or safety glasses. He leads by example and nonverbal cues. When Folse opens his mouth, the patient opens his.

He gives the patient shots of local anesthetic.

"Great job," the dentist says. "You are doing a great job."

And slowly, carefully, he draws out the worst of the man's yellow teeth.

"The others are in horrible shape," Folse says. "But these three were life-threateningly loose."

The nursing homes on Folse's circuit pay him a monthly stipend of $6 a patient. He serves as their medical director. With an office manager who keeps track of the caseload and a young part-time dentist and hygienist, Folse provides exams, responds to emergencies and tries to meet the overwhelming need he sees.

"It's way worth the money we pay," River Oaks' director, Guy Sarver, says.

Sarver sees an irony in the lack of Medicaid dental coverage for the old and poor in Louisiana and many other states. "They'll pay for eyeglasses or penile implants. But they won't pay for teeth."

Dental benefits vary by state and often by year, based on budgetary decisions. Louisiana covers only dentures.

Maryland's dental services for senior citizens under Medicaid are confined to emergency and trauma care. In Virginia, adults are limited to medically necessary oral surgery and extractions when infections compromise their health. The District recently introduced a comprehensive dental package for adults. A few states offer nothing.

* * *

In 1965, when President Lyndon B. Johnson signed the Medicare and Medicaid bill into law, neither program included routine dental care.

In Medicare's case, "the justification was this is a routine service you don't need insurance for," said Marilyn Moon of the Silver Spring-based American Institutes for Research. Adult dental coverage was later made optional under Medicaid. But lawmakers have remained reluctant to expand benefits, given the program's spiraling costs.

Private dental insurance is expensive as well. A plan for AARP members in Lafayette, for example, offers annual premiums starting at $424.20. The bulk of Folse's patients, before entering nursing homes, lived on fixed Social Security incomes of less than $1,000 a month.

Folse estimates that adding a dental guarantee under Medicaid for the aged and disabled would cost $700 million a year. He advocated for such a provision, and a bill was introduced in Congress in 2005. It never moved past the committee level.

Last year, galvanized by the death of a 12-year old Prince George's County boy, Congress tried to include a dental guarantee for the children of the working poor in an expansion of the State Children's Health Insurance Program. The expansion was vetoed twice by the president and shelved.

Benefits for seniors and the disabled never entered the discussion.

* * *

The twice-divorced Folse lives on a farm north of Lafayette. His hay crop this year will help pay the bills. He also sells a baling machine called the Bale Band-It. When he drives his circuit, he sometimes gets "hay calls" from people who want to buy hay or from Bale Band-It customers.

"Sometimes a bale will bust, and it's not the Band-It's fault," he says. "You gotta know what to do."

Folse drives 40,000 to 50,000 miles a year. He never uses a map.

He was born farther south, down in Raceland. His grandfather, the country doctor, was a big influence. So was his father, a livestock auctioneer. Folse worked cattle to pay his college bills. He thought about going to veterinary school, but then he found dentistry. The idea just hit him one day.

"Senior year, we did a rotation in nursing homes. The residents really inspired me," Folse said. "They had so much need."

After graduation, he worked in a nice office with regular healthy patients. But he started visiting nursing homes on Fridays, his day off. He was overwhelmed again by what he saw and how he felt treating the frail, the deranged, the forgotten, the truly grateful.

He thought, "This is really what I want to do."

"Nine hundred patients with severe gum disease or abscess. Half of my patients. I take everybody that has swelling. Everybody in pain. Everybody that's got loose teeth. And I help them as best I can. With funding. Without funding. The family pays some, the nursing homes. Sometimes no one pays. It doesn't matter. I do it."

The rewards are often intangible.

"I had a patient in a wheelchair. She had a stroke. She was so happy to get her dentures. She reached down and grabbed her purse. She reached inside. She found a piece of bread. " 'Here doc,' she said. 'Take it.' I didn't want to take her last piece of bread. No telling how long it had been at the bottom of her purse.

"We have to give out of being wealthy. She gave to me out of her poverty."

* * *

Sixty miles northwest of Lafayette, at a nursing home in Pine Prairie, Folse gets help from a young dentist, Wendy McCurdy, who heard him lecture at the Louisiana State University School of Dentistry and was intrigued by the challenges of his work. "My mother has worked with special-ed kids all my life," McCurdy says.

They set up in the beauty shop. A little sign outside the door reads: "Haircut $6, Shampoo and set $7. . . . Wash and blow dry $3."

"Come on in, Sugar Plum," Folse calls to the first patient.

A line quickly forms at the door.

He finds troubles no one else would, says Sandra Book, nursing facility administrator: "Some of these people are in pain, but they can't tell you. Without an exam, you can't tell if they have a big old ulcer in their mouth."

At a nursing facility in the town of Eunice, they are also waiting.

"Hey, Mr. Teethman!" shouts one fellow.

A woman stops Folse in the hallway. Her root tips are exposed. She wants them pulled. Another is impatiently awaiting her dentures. "My teeth. Where are they?"

On his way to his next place, Folse stops at a cemetery to visit the grave of a fragile old woman who died recently from complications of a facial abscess. She had many medical issues, but an infection in her mouth finally overran her body's defenses.

"This is an example of oral health being a matter of life and death," he says. "Over the past seven or eight years, I've seen oral health contribute to the death of at least one or two a year."

In many cases, an oral cancer proves fatal. Other times, it's pneumonia, which can be linked to bacteria in the mouth. "I see pneumonia patients all the time. I know oral health, and oral hygiene is a significant factor in that disease," Folse says.

* * *

He's driving past fields of sugar cane and scrub woods to deliver a pair of dentures to a retired retail clerk in St. Martinville.

Smoke from a cane field curls in the blue sky. Driving over a coulee, a drainage canal. The sun is setting. A hawk is on the wire. Driving over a black bayou with a shrimp boat.

"I can't forget to stop at the lab to get that repair," he says.

Over the Vermillion River, the sky is changing from blue to black. There is a line of dark clouds on the horizon over the rice fields.

In Abbeville, Elaine Sherman is feeling better now that her dentures have been adjusted. She and her husband fished today.

"I have gumbo and crawfish ¿touff¿e and fried garfish balls," she says. "Homemade bread and pecan pie."

He stays for dinner.