A student at Hampton Elementary School in Barbourville, KY, gets ready for a free exam through Kids First Dental, a mobile clinic
Photo: Stephen Crowley [1], for the New York Times
Children in rural communities, particularly those who come from families with low incomes, are often victims of neglect who suffer tooth decay, oral abscesses and advanced periodontal disease.
In a rural state such as Kentucky, for example, dental decay is the number one infectious disease in children. Dental pain is the number one excuse for public school absences.
Other states with large rural populations have similar problems. Among North Carolina parents who feel that their children have unmet health care needs, 57% report the unmet need is for dental care -- nearly twice the number reporting lack of medical care (North Carolina Institute of Medicine Task Force on Dental Care [2]). The same study found that lack of dental care, common among low-income and Medicaid-eligible adults and children, often results in severe or persistent pain, inability to eat, swollen faces, and increased susceptibility to other medical conditions.
Federal statutes require [3] Medicaid to offer dental insurance to all children eligible for the program, yet many rural communities find that low-income children do not have access to dental care.
Three of every four school children in the Appalachian coalfields of Southeast Kentucky are eligible for Medicaid or for KCHIP, based upon family income. Despite years of advancement, including the establishment of two Colleges of Dentistry and an impressive water fluoridation program, Kentucky is a national leader in toothlessness. There are fewer than four hundred dentists statewide who are significant providers of services, for an estimated three hundred thousand poor Kentucky children.
Despite free dental insurance, poor rural children do not receive dental exams and treatment [4] for a number of reasons.
*Many children grow up in homes where the adults do not have regular dental treatment, and so the children are not taken to the dentist. A survey in North Carolina found that on average, only 20% of Medicaid recipients visited the dentist in 1998.
*Many dentists do not accept Medicaid because of the low reimbursement rates. One study [5] identified 26 cases, from 21 jurisdictions, of successful litigation forcing states to bring Medicaid reimbursement more closely into line with reasonable and customary charges. California, Arkansas, Connecticut, Illinois, Indiana and North Carolina were among the states forced to improve reimbursement after equal protection claims were litigated.
*There are fewer dentists practicing in rural areas [6] compared with urban centers, and even fewer in rural practice who specialize in pediatric dentistry.
Rural areas have fewer dentists per capita, as shown by this map of Health Professional Shortage Areas; the counties in darker colors need dental clinicians the most, according to the National Health Services Corps
Map: RAConline [7]
Yet, taxpayer funds spent on dental services have clearly positive effects, both immediate and long-range.
Studies have shown that the age of a child's first preventive dental visit has a significant effect on dentally related expenditures; average dentally-related costs are lower for children who receive earlier preventive care. An October 2004 study published in Pediatrics [8] showed that children in North Carolina who had their first preventive visit at age 2 or 3 were more likely to have subsequent preventive, restorative, and emergency visits than were children who had seen a dentist as infants.
"In addition, children from racial minority groups had significantly more difficulty in finding access to dental care, as did those in counties with fewer dentists per population," the study concluded.
Some dentists are beginning to create innovative models for health care delivery, Ed Smith, DMD, is a Barbourville, Kentucky, dentist serving patients in Knox and surrounding counties. Dr. Smith operates a robust practice that synthesizes the high expectations of business and professional patients with the desperate unmet need of the community's low income population.
Through his nineteen years of practice, Dr. Smith has built his work around the complete community of patients, whether they are professors at Union College, teachers in the local schools or underemployed adults with no insurance. He and his partner, Dr. Devert Owens, have seen people who have pulled their own teeth with pliers or tried to replace loosened crowns with Super Glue and women whose teeth had been knocked out in domestic fights. Even though more than 70 percent of the children in Knox County qualify for free or reduced lunches and therefore for Medicaid or KCHIP, few receive regular dental care.
Dr. Smith has formed a partnership with the local Family Resource/Youth Service Center that serves Knox County. After a series of discussions with local social service workers, Dr. Smith decided to take the dental care directly to children at school. He spent $150,000 to buy a used mobile CAT scan unit and outfit it with used dental equipment.
That was the beginning of Kids First Dental, a unique school-based dental program to improve access to dental care, particularly among low-income children.
In the fall of 2005, Dr. Smith parked the van at Lynn Camp Elementary and saw more than 750 children. Children were sent home with treatment plans and a directory of local dentists so that they could make appointments for future dental care. Family Resource Center staff followed up with parents to make sure children received the treatment they needed.
The program has been so successful that Dr. Smith expanded Kids First into a number of adjoining rural counties.
"This system has actually brought some children into my office for the treatment they need," Smith said. "And some of the other dentists in town that I've talked to say the same." The practice was featured in a front-page article in the New York Times [1] last year.
Smith's model is one of several nationally-recognized innovations in the country. To address North Carolina's problems with pediatric dental care, North Carolina Health Choice for Children [9] was formed and has expanded coverage to youths whose family income is slightly above the Medicaid guidelines. North Carolina is also producing health brochures in Spanish and Hmong to better communicate with children of immigrant families.
Washington State has received recognition for its Access to Baby and Child Dentistry Program [10], formed in 1994 by concerned dentists, public health offices and others. In Washington, general dentists who receive advanced training in pediatric care are eligible for higher reimbursement from the state Medicaid program. ABCD has been shown to increase the participation by private dentists in Medicaid.
In February 2008, the Kentucky General Assembly passed a bill that would require children to have their teeth examined before beginning school. Dr. Ed Smith testified before a legislative committee on behalf of the bill, despite resistance from some educators who argued that the requirement might discourage some parents from sending their children to school.
Dentists in Kentucky and elsewhere have asked for studies that determine the true cost of providing dental services to children. Medicaid in many states pays less than 65 percent of the usual and customary costs for services.
"Medicaid providers are excited about the opportunity to participate in cost studies," Dr. Owens said. "It is their belief that reimbursement rates remain inadequate, and that they are losing money by participating in the program, but who continue to believe in the necessity of the program and in its mission."