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Pulling Teeth: How Medicaid is Failing the Poor at the Dentist’s Office

We are losing a lot of really good teeth.

“We” is our community of lower-income adults and children who depend on a broken Medicaid dental care system that short-changes their oral health and by extension, their long-term overall health.

“We” also refers to the dental professionals whose responsibility it is to save teeth, but who every day witness how the system causes immediate and long-term consequences of sub-standard dental benefits for those of limited means.

“We” are also the private practice dentists for whom Medicaid reimbursements are so low that we must limit, pick, choose and ration the care for the poor, so as not to seriously compromise our practices financially.

However, the underlying failure is within our health care policy and with the Medicaid naysayers who have drawn a bright red line between benefits for those who can afford care and those who cannot. This includes dental care, where harsh paywalls segregate the poor from those with even modest dental care benefits.

This lack of dental care for lower-income Americans guarantees oral health problems at a far higher rate than for their neighbors with traditional dental health benefits. Poor oral health is associated with heart disease, nutritional deficits, digestive problems, depression, social and employment difficulties, as well as addiction disorders arising from acute and chronic pain relief habits.

Medicaid’s paltry coverage of dental care for the poor is a shameful reflection on our political leaders’ failure to recognize that better dental care can help prevent costly long-term health concerns. In fact, sensible levels of dental benefits for the poor would be a positive, proactive investment in sustaining overall health and preventing expensive, reconstructive care later.

Here’s an example of how Medicaid dental coverage fails: A patient experiences pain in the mouth, sensitivity to heat or cold, pain in chewing, swelling or other kinds of  tenderness. He comes to our dental office and learns that he has a strong tooth, but needs root canal treatment to save it. The tooth itself is strong, and could serve for many years; it’s the underlying nerve tissue that’s compromised – and is easily treated. Yet the root canal treatment is not reimbursed by Medicaid (along with other tooth-saving treatments like crowns). Unless the patient can afford to pay out of pocket, which is rare, the only alternative is to extract the tooth. This is the beginning of a landslide of deficits including the shifting of other teeth, leading to a multitude of future problems including additional tooth loss. Dental disability follows.

I am the clinical director of a community-based dental health practice that accepts traditional insurance as well as MassHealth. Our professional staff is trained and equipped to provide excellent preventive dental care and treatment for anyone. This care is on par with sophisticated private and teaching dental practices: we operate with state-of-the-art dental equipment, highly trained dental professionals and dental residents. We welcome any patient who walks through our door – because that is the moral and ethical calling of the dental profession – and of all medicine – or it should be.

While proposals for mid-level dental providers could improve access to care among those patients who face limited availability of dental services, that initiative alone does not answer Medicaid’s failure to cover important and appropriate services, causing the unnecessary loss of good teeth.

Dental health awareness, preventive care and good health habits are vital for all populations, but reaching those of limited means is even more essential. Mandated child dental care and education through school-based programs are badly needed. It’s our job to stay engaged with patients to help maintain their routine dental care throughout their lifespan, a most important preventive strategy. Community leaders should also be advocating for Community Water Fluoridation, the safest and most effective public health program for preventing tooth decay, especially in children and in the elder population. Yet many communities reject this important preventive measure.

It’s true that not all patients – and parents – are aggressive about early (and on-going) dental hygiene and preventive care. Although we invest heavily in educating patients about oral health, there are patients whose lifestyles are detrimental to their own well-being – and that of their children. This can be said of all socio-economic levels in our country, but oral health problems have a unique niche among the poor.

The rationing of dental care for poor adults must better reflect common-sense decision-making and sound professional judgment focused on preserving oral health. We can no longer shun patients or aid in the removal of otherwise good teeth due to unacceptable reimbursement rates or non-reimbursement. We must advocate for more equity in oral health care – for the benefit of all of our patients’ overall well-being and for our overall community health.

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Dr. Ronald Maitland, a professor of dental medicine at Tufts University and New York University, is clinical director of the dental residency program at Community Health Programs Neighborhood Dental Center/ Berkshire Medical Center in Pittsfield, Mass.

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