by Sylvia Onusic

A mother recently walked through the doors of Centre Volunteers in Medicine, the local free healthcare clinic, with her five-year-old girl. The little girl’s four front baby teeth were broken off at the gum line. In each tooth was an abscess, a longstanding infection. Aside from the discomfort, such infections in baby teeth can affect the permanent teeth just below, becoming a much more complicated health issue in the future.

“The parents didn’t want to take the child out of school for treatment but we finally got her in last week,” Dr. Heather Raymond, director of CVIM’s dental services, told Voices. “It broke my heart.”

John Kelly, a local pediatric dentist since 1977, said that “parents routinely ignore children’s abscessed teeth because they don’t cause a lot of pain, but the infection is sitting there constantly flowing into the blood stream. These children become sick children.”

The Pennsylvania Oral Health Needs Assessment and other reports continue to emphasize the association between low income and dental health. Poor children in Pennsylvania have fewer visits to the dentist, more untreated cavities and dental diseases. According to the Pennsylvania Department of Health, “this strongly suggests that access to preventive and restorative dental care, as well as effective preventive oral health education, is lacking for these poor children and their families.”

Centre County is no exception. A study commissioned by the state department of health from 1998 to 2000, found higher rates of caries and untreated caries in the northern districts, north central districts and in the cities of Philadelphia and Pittsburgh. State College is located in the north central district, and school districts sampled for this study were in Centre County and Clinton Counties.

More than 5,000 local children, an estimated one in four, are Medicaid recipients, yet only six dentists in the county accept payments from this government program for low-income residents, leaving many local children without dental care.

A 2008 list of Medicaid dentists provided by Jeffrey Foreman, executive director of the Centre County Assistance Office showed little improvement over 2004 with only one new dentist signing up in four years.

Dentists who accept Medicaid in Centre County include John R. Kelly, Robert L. Kilareski, G. Matthew Kremser, pediatric dentists in State College; Shama Kulkarni, John W. Le Clair, general dentistry in State College; and Jolene Galak-Vaughn, general dentistry in Philipsburg. Diane Ray, who has joined Dr. Kelly’s practice, is an orthodontist who has applied for Medicaid certification. Kelly told Voices that Pennsylvania is slow to certify new dentists—they don’t want to pay.

The Pennsylvania Department of Public Welfare reports that an estimated 40 percent of all licensed dentists in Pennsylvania are enrolled in the Medicaid Program, but only 54 percent of those actually participate in the program. Of those, only half provide 99 percent of all dental services rendered to eligible Medicaid participants.

Yet dentists know better than anyone the dangers to children of delayed or absent dental care.

Tooth decay affects 48 percent of Pennsylvania children by the age of eight, even those who drink fluoridated water, according to the Department of Public Welfare. By age 15, this increases to 50 percent. Thirty-three percent of low-income children have untreated tooth decay compared to only 10 percent of children in higher-income households.

Good dental health involves many factors, including diet and good brushing habits, but children also need to see a dentist regularly. American children routinely develop cavities and tooth mottling (fluorosis). Unattended cavities can lead to abscesses which can lead to extractions.

“Most people are uneducated about the importance of good dental health for children. Dental health is a whole body issue and dental problems cause health problems,” said CVIM’s Raymond. “Caries are an infection of the tooth, and without check this infection may easily spread throughout the body, affecting the blood and body organs.”

“We know that the mouth reflects general health and well-being,” wrote U.S. Surgeon General David Satcher in his 2000 report, Oral Health in America. “New research is pointing to associations between chronic oral infections and heart and lung diseases, stroke, and low-birth-weight, premature births. Associations between periodontal disease and diabetes have long been noted.”

Kelly told Voices that baby teeth are extremely important to the health of the permanent teeth. They maintain space in the dental arch so the permanent teeth have room to come in. Decay in a child’s first teeth often results in premature tooth loss. Loss of the front baby teeth prematurely is not nearly as critical as loss of the molars and eye teeth, which naturally occurs around 10 to 12 years.

In his practice Kelly said he commonly sees two-year olds with an average of 10 decayed teeth. Tooth decay in this age group is caused mostly by the sugars in soft drinks, juices and juice boxes, and by allowing children to go to bed with bottles. The carbohydrates then sit on the teeth during the night and cause decay. The incidence of cavities has decreased over the years in other groups, but not in this population.

While finances are one of the biggest obstacles to good dental care, many local employers, including the area’s largest one, Penn State, require their employees to pay their own dental premiums. With the recession, unemployment is on the rise, and families who do have an income are cutting back. Dental care is one place they might skimp only to pay a higher price later.

The hardest hit families have options, though. Medicaid is one of them.

More than 1 million children were enrolled in the Pennsylvania Medicaid program as of April 2009. Between 1998 and 2008, the number of children enrolled in Medicaid increased by more that one-third, according to the Pennsylvania Medicaid Policy Center at the University of Pittsburgh.

Medicaid is a jointly funded federal-state health care program, primarily for the poor. The federal government provides much funding to states, depending upon how much that state spends on Medicaid. The more a state spends the more reimbursement the state receives. In Pennsylvania, the program is administered by the Department of Public Welfare.

The majority of clients sign up at the local Centre County Assistance Office in State College, according to director Foreman. For children ages one to five eligibility is set at 133 percent of the federal poverty guidelines, an income of under $2030 per month for a family of three; for children 6 and over eligibility is set at 100 percent of the federal poverty guidelines, under $1,526 per month for a family of three.

According to the Public Welfare Web site, children under 19 make up approximately one-fourth of the state’s total population. About 36 percent of these children live in households where the income is at or below 200 percent of the federal poverty level.

Among those eligible for Medicaid, utilization of dental services is low. Only 21 percent of eligible children under 21 received any dental service, and only 17 percent received preventive dental service.

CVIM’s Raymond has taped the 2004 list of dental care providers for Medicaid clients to the wall of her office. It reads: “NOTE: Centre County has a shortage of dentists who accept medical assistance. The following is a list of participating dentists located in nearby counties.” The list names five dentists in Centre County, three in Blair (two are denture clinics only), one in Cambria, four in Clearfield (two for dentures only) and two in Clinton County (one is a denture center).

So why don’t more dentists provide services to clients with Medicaid coverage?

Raymond said more dentists would sign up to accept Medicaid if the government increased the reimbursement amounts.

But Public Welfare is quick to point the finger at other possible obstacles.

“Great strides are being made in Pennsylvania to improve Medicaid recipients’ access to quality dental care,” says the department’s Web site. But “some of this problem may be due to lack of access, but lack of a dental priority in this population could also account for much of this poor showing.”

In an effort to more specifically identify problems of dental access to Medicaid recipients, Public Welfare held two “dental summits” attended by health planners, consumers, advocates, providers and other stakeholders. At the first summit in 1999, attendees expressed “significant concerns about the low reimbursement rates provided to dental providers and the adverse effects reimbursement rates were having on dental provider enrollment,” the department reported. As a result, the government increased its rates.

In November 2001, the department held the second dental summit in Harrisburg to discuss the same issues of access. The Dental Summit Steering Committee was created and is responsible for “prioritizing, developing and implementing recommendations for improving the dental services provided to Medicaid recipients on an ongoing basis.”

Stacy Witalec, press secretary for the DPW, said that no third dental summit is planned.

Still, the Department of Public Welfare “is pleased to report the progress made thus far and looks forward to continuing to work with advocates, policymakers and stakeholders to continue improving the quality of care and accessibility of dental services provided to Medicaid recipients,” it announced on its Web site. But treatment for this group of patients remains a problem.

“Medicaid fees were increased for numerous services,” Witalec said, backed by the department’s official publications. “Affected fees were increased as much as 76 percent.” Public Welfare also expanded the Medical Assistance Transportation Program (MATP) to Medicaid consumers so they can receive money for traveling to a dentist appointment outside of the county.

Despite modifications and fee increases from 2005 to 2008 and a new online system that speeds reimbursements, the number of dentists accepting Medicaid in Centre County remains almost unchanged.

Kelly has been accepting Medicaid for about 30 years, he said.

“Medicaid reimbursements make up 40 to 50 percent of our revenues and we lose 10 to 15 percent on every procedure,” he said. “We reserve 50 percent of our appointment time for Medicaid children.”

Patients routinely come to Kelly’s practice from around the state, driving hours for an appointment. “There is not a single dentist in Harrisburg who accepts Medicaid,” he said.

But while some parents go to great lengths, others don’t make it in. Kelly’s practice of four dentists suffers “23 no-show failed appointments every day from Medicaid patients. And parents often times don’t bother to call.”

That hasn’t dissuaded the dentist though.

“I feel a moral obligation to give back to the community and to take care of people who are less fortunate,” said Kelly.

Kelly said it’s unlikely that properly funding Medicaid will ever become a high priority for legislators.

“It’s a totally political thing,” he said. “This segment of the population doesn’t vote. They have no leverage and no political power. It is hard to get the attention of politicians unless you are a big contributor to their campaigns.”

CHIP

For families who are not eligible for Medicaid but still have trouble making ends meet, there is the Children’s Health Insurance Program. CHIP was created in 1997 as part of federal legislation aimed at providing affordable health coverage for low-income children in working families who make too much to be eligible for Medicaid but don’t make enough to afford private coverage according. A number of Centre County dentists are CHIP providers. The program provides medical and dental care for children up to age 19.

One of Barack Obama’s first acts as president was to sign legislation renewing CHIP through 2013. (Former President Bush vetoed the same legislation twice.) The program currently covers more than 7 million children in the United States and 191,059 in Pennsylvania, according to the Pennsylvania Medicaid Policy Center at the University of Pittsburgh. In April 2009 between 4.5 and 6.5 percent of children in Centre County were enrolled in CHIP. Enrollment across the state more than doubled between 1998 and 2008.

This new CHIP program is significantly different in that it allows states to offer dental coverage to children who are enrolled in private or job-based health plans that do not include dental coverage, according to Families USA, a national nonprofit advocacy group. As long as these children are not otherwise eligible for CHIP, states can enroll them exclusively for dental coverage.

In 2008, there were an estimated 130,000 uninsured children in Pennsylvania. Of these, 13 percent were eligible for CHIP. Families with higher incomes also may be able to apply for the low-cost version of CHIP, where a premium is paid depending on income.

CVIM

Centre Volunteers in Medicine is a local free clinic which provides dental care for children. However, dental director Raymond said, “most low income children usually quality for CHIP or Medicaid-medical assistance (MA) dental services from the state and thus aren’t eligible for services at CVIM.”

Raymond worked in her own practice for eight years before becoming CVIM’s dental director. The organization provided 180 dental visits for children under 18 this year, according to CVIM reports.

Raymond sees children with a lot of needs she can’t meet. For example, she doesn’t have the ability to sedate children, she said.

“We are very limited in our ability to treat these kiddos,” she said. But sometimes she is able to refer these children to local pediatric dentists, Kelly and his colleagues, who provide additional care.

“Dr. Kelly (and his partners) have a big heart, and are very generous with their time and resources. Dentists like Dr. Kelly are filling a great need in the community that would not otherwise be filled,” Raymond said. “I don’t know what we would do with them.”

Still, the needs are great, and CVIM and Dr. Kelly can’t meet them all.

To expand their reach, CVIM joined the national Give Kids a Smile Day held in May. Since 2004, CVIM and dentists Kelly, Kilareski and Kremser have offered eligible children check-ups, X-rays, fillings, sealants and extractions at the event. In recent years, the event has been co-sponsored by Nittany Eye Associates and Albrecht Audiology, who provide eye and hearing health exams to the kids who attend. The Sullivan Schein Dental Company has contributed the dental supplies since the first event.

Ten local dentists as well as volunteers from CVIM and other local organizations, dental assistants, hygienists and other office personnel donated their time to make this year’s event run smoothly. The providers treat an estimated 100 children who are eligible for CVIM services.

Raymond and her colleagues have seen the difference a day makes.

“At this event we see return patients who come back with fewer and fewer cavities, which shows that it is making a difference, even with one day a year,” she said. Putting on the event twice a year is a goal, she said, but depends on resources and the availability of dentists’ time.

Schools and Dental Care

“Children now receive the majority of their dental care during the summer vacation,” says Diane Smith, from Kelly’s office. “Parents don’t want to take their children out of school and it is a burden for them to be absent from work,” she says.

Some Pennsylvania communities provide a mobile service for low income patients. One dental van from the Titusville Area Hospital Dental Clinic serves Crawford, Forest and Warren counties. In the 2008 fiscal year, St. Luke’s Mobile Dental Van in Bucks county traveled to 34 sites, including 17 Bethlehem public schools, and provided care to almost 1,300 children, according to St. Luke’s annual report.

“Although the law provides for the school district to provide treatment if it so desires, this is typically not done in schools for a variety of reasons,” said Penny Kline of the Pennsylvania Department of Health, Division of School Health. “Anecdotally we have heard or are aware that some school districts do provide some treatment to students, although this information is not reported to the department. If a school did provide treatment to students, it is our understanding that they and/or the dentist would be eligible to bill Medical Assistance (assuming they followed Medicaid procedures to do so).”

Section 1414 of Article 14 of the Public School Code, “allows school districts to provide for the care and treatment of the teeth of all children of school age with the district,” and section 1415 “provides for the county board of public assistance to pay the cost of dental care (as defined by the standards, rules and regulations established by the Secretary of Public Welfare).”

When schools do consider their students’ dental health, it is because of mandatory screenings. Article XIV of the Pennsylvania Public School Code requires that all children attending public, private and parochial schools receive certain school health services including dental examinations, upon entry to school and in grades 3 and 7. The school must also institute a program of dental health education.

In 2006-2007 the State College Area School District, part of the North Central District, provided an estimated 1,865 school hygienist evaluations of school children. The majority of Pennsylvania counties reported in 2005 that their school districts, including Allegheny and Philadelphia, have chosen to employ school dentists rather than dental hygienists to perform the examinations.

The State College district employs one part-time dental hygienist to perform all dental services Jeanne M. Knouse, Director of Student Services at the SCASD said. She explained that the district does have three sources of in-house funds which can be used for providing dental care for low income children. She said parents are probably not well informed about these provisions.