Dental Decay: The Hidden Health Crisis

Last Spring, following the death of twelve-year old Deamonte Driver of Maryland whose untreated tooth infection spread to his brain, I wrote about the national epidemic of dental disease and the lack of access to dental care faced by the poor and working class. Last month, an article in The New York Times painted a horrifying picture of the state of dental care, where bootleggers sell dentures that would otherwise be unaffordable to many people missing teeth; where low Medicaid reimbursement rates perpetuate a dearth of participating dentists; where untreated cavities are a leading cause of kids missing school, people use Krazy Glue to reattach broken teeth, or swish rubbing alcohol to treat an infection, "burning the gums and creating ulcers."

Currently, Medicaid only covers pulling teeth to treat infections -- not root canals or dentures -- which can certainly dim the job prospects for someone trying to earn a living in our economy.

"Try finding work when you're in your 30s or 40s and you're missing front teeth," Jane Stephenson, founder of the New Opportunity School in Berea, Kentucky told the Times.

According to Maryland Senator Ben Cardin's staff, dental decay is now the most common chronic childhood disease in the US, affecting twenty percent of children aged 2 to 4, fifty percent of those aged 6 to 8, and nearly sixty percent of fifteen year olds. It is five times more common than asthma among school age children, and nearly 40 percent of African-American children have untreated tooth decay in their adult teeth. Improper hygiene can increase a child's adult risk of having low birth-weight babies, developing heart disease, or suffering a stroke. Eighty percent of all dental problems are found in just 25 percent of children, primarily those from lower-income families.

In March, in response to Driver's death, Cardin cosponsored the Children's Dental Health Improvement Act of 2007 along with Senator Jeff Bingaman, who had pushed similar legislation for seven years. The bill called for $40 million annually for five years to help community health centers hire dentists to serve poor children. It also would have awarded $50 million in grants to help states improve dental services to children enrolled in Medicaid or the State Children's Health Insurance Program (SCHIP). At the time, Cardin said on the Senate floor: "It is outrageous today that in America, a young boy can die because his family can't find a dentist to remove an infected tooth. It is not enough simply to mourn Deamonte's death. We must learn from this failure of our health-care system and take action to make sure it never happens again."

The dental bill was folded into the CHIP bill. The final version of CHIP -- passed by Congress and vetoed by President Bush -- didn't contain the grants sought by Cardin and Bingaman but it did guarantee dental coverage to kids and also established minimum standards of care. Senator Cardin explained the dilemma he and his colleagues faced: "When things get tight in state budgets, one of the first things they cut is something that's not mandated, so when we had to choose between grants to cover dental benefits or a guarantee of dental care, the latter was a greater, immediate priority. We know now that dental care is vital to a child's overall health -- experts tell us that it impacts many other aspects of their health as well. Not to mention it's an indicator of one's ability to get ahead and thrive," he said.

Cardin, Bingaman, and their allies were successful in passing $5 million in grants in the Labor Health and Human Services bill to help states reach poor kids but clearly -- as indicated by the initial grant request -- the need is far greater than that. Even Cardin said of the CHIP bill, "There is more work to do ... . We still have to improve reimbursement for dental providers [so more dentists will participate in Medicaid], and get grants to the states to allow them to offer dental wraparound coverage for those who may have health coverage, but no dental insurance."

A Cardin spokeswoman also said that this is the best that Democrats were able to achieve at this time. "Clearly healthcare in the US needs help. We need to fix the system as a whole and Democrats in the Senate are trying to make changes that reflect those priorities."

Indeed, improving reimbursement rates and the availability of dentists is necessary in order for poor kids to avoid long waiting lists and get the timely services needed. (One dentist, for example, told the Washington Post that an abscess "is like a time bomb, ticking.") When Driver passed away nearly a year ago the state Senate initially responded with legislation to provide $2 million annually over the next three years to expand dental clinics for the poor. But it was determined at the time that the funds were not available, causing State Senator Jamie Raskin to tell me, "We always have enough money for things we don't need -- like funding the war in Iraq, or boondoggle projects that will make developers a lot of money. But when it comes to things we do need -- like dental care for kids -- suddenly there's no money."

According to the Washington Post, less than one-third of nearly 500,000 Maryland children on Medicaid saw a dentist last year, "a statistic that is typical of the problem nationwide." But things are looking a little better in the state now. After Driver's death, Maryland Department of Health & Mental Hygiene Secretary John M. Colmers created a Dental Action Committee to make concrete recommendations on what could be done to increase access of dental care providers for lower-income people. One of the key recommendations was a $44 million grant to raise Medicaid reimbursement rates equal to the median charges in the Atlantic region. Maryland Governor Martin O'Malley's proposed budget -- released yesterday -- requests $16.1 million, including $14 million to increase Medicaid reimbursement rates ($7 million from the state, matched by the federal government); $1.4 million for two new dental clinics in regions that currently don't have them; and $700,000 for a mobile dental clinic to serve the school system. Colmers said they hope to phase-in the $44 million Medicaid allotment over 3 years.

"We're not going to solve these problems overnight," Colmers told me. "This is a substantial down-payment towards reaching our goals."

Raskin agreed. "You feel the difference between having Democrats and Republicans in state office on an issue like this. The Democrats really feel that the maldistribution of dental care is a scandal and are willing to pay to get dental care to poor kids. Budget times are tough but this is an excellent use of targeted funds," he said. "The Democrats feel very passionate about this. I talk to constituents who tell me that the quality of dental care people receives has become a very good predictor of how well they will progress in the work force and how well they will do in life. Dental care is key to individual opportunity in America."

Although there has been much talk about healthcare reform in the presidential campaign, there has been little mention of dental care. The Obama and Edwards campaigns declined to comment for this article. Ann Lewis, Senior Advisor at Hillary Clinton for President, pointed to a recent speech Senator Clinton delivered in Iowa where she made her commitment to dental coverage clear -- and it happened to touch on Deamonte Driver's death: "I want to cover dental care. And in the congressional plan, which I open up to everybody ... there are more than 250 plan choices. Most of them cover dental care. One of the things we are finding out is all of the connections between dental problems and heart disease, between dental problems and other systemic conditions. So, if we don't cover dental care, you're going to miss a lot of the problems that will then get very expensive ... I talked about the story of a young boy, 12-years old, living in Maryland ... had a toothache. [His mother] couldn't find a dentist to take him because they didn't have any money for a dentist. They called every dentist they could get and some were very sympathetic, but they said, 'Well, we already have our full compliment of charity patients. We can't take anybody else.' Turned out he had an abscess. The abscess burst, so he ends up in Johns Hopkins Hospital. They tried to save him. He dies. The hospital incurred $300,000 worth of medical care trying to save him because his mother couldn't get a $60, $70, $80 ... dental visit. So that's the kind of story that underscores the unfairness of the system, but also the importance of covering dental care, and I intend to do everything I can to make that happen."

It's good to see some Democrats on the Hill -- and in the statehouses -- working so hard to craft a sane and humane response to this epidemic. Much remains to be done, but there are good people who will keep this on the radar and continue this fight.