Six-year-old Edith Becerra had a toothache, but her mother couldn't find a dentist who would treat her.
Edith's tooth began hurting when a filling fell out. She was having trouble eating, and her mother worried that the pain would worsen, making it difficult for her to do her schoolwork as she began first grade.
“I know what a toothache is, and I know she's going to have problems in school if they don't attend to it now,'' said Evelia Becerra, speaking Spanish.
Mrs. Becerra, an apple-packer in Erie, Pa., asked a migrant health services coordinator to help her find a dentist quickly.
But only two dental clinics in the area take patients on Medicaid, the government program for low-income families. Mrs. Becerra was told that the earliest possible appointment for Edith is Dec. 28 - four painful months away.
Edith received dental care last week only through the intervention of a kindly stranger who learned of her plight and offered, anonymously, to pay for her care.
Tooth decay, the most common chronic childhood disease, is easily treatable for most young children who can get dental care. But millions of low-income children in America do not have such care, either because they have no dental insurance or because their parents cannot find a dentist who will treat them.
The barriers low-income children face in getting dental care are complex. Many obstacles involve Medicaid, the health program for poor and disabled Americans run jointly by the states and the federal government. Other barriers stem from a growing shortage of dentists, especially in inner cities and rural areas.
When tooth decay goes untreated, festering cavities can hamper growth, hinder learning, and erode self-esteem.
“It is simply impossible for a child to focus and accomplish well in school when they are distracted by a relentless toothache,'' said Burton Edelstein, director of the Children's Dental Health Project in Washington. “The child can't sleep at night, doesn't get a good breakfast, and heads off to school with a toothache. The whole picture is one of a functional disability.''
U.S. Surgeon General David Satcher last year declared that a “silent epidemic'' of oral diseases afflicts the nation's most vulnerable populations - its children, elderly, and many minorities.
Statistics compiled by the federal government and pediatric dental experts offer a stark illustration of oral health problems among poor children.
One fourth of children and adolescents in the United States experience 80 percent of all decay in permanent teeth. An estimated 4 to 5 million children have dental diseases severe enough to impair their ability to eat, sleep, and learn.
“We get kids sent to us all the time by school nurses, and we look in their mouths and their teeth are rotted down to the gum lines,'' said Jack Whittaker, a pediatric dentist in Bowling Green. “They tolerate this because they're used to it. These kids are six years old and the decay has been there two years or three years.''
Dr. Whittaker, one of the few dentists in Northwest Ohio who routinely accepts Medicaid patients, sees children who can only chew on one side of their mouths because the other side hurts too badly. They cry when he touches their aching teeth.
Alba Rodriguez, a Head Start teacher in Erie, Pa., who helps migrant children learn English, says their teeth frequently are in such poor shape that they have trouble speaking.
A University of Pittsburgh survey requested by the Pennsylvania Department of Health found that Northwest Pennsylvania has significantly higher numbers of children with untreated decay than elsewhere in the state.
David Shapter, a pediatric dentist in Erie, Pa., spends one day each week treating children who desperately need dental care. His patients, at an average age of four, already have eight to 20 cavities.
Many children he treats are two years old or even younger. Some are immigrants from Bosnia or Russia who never had dental care. All probably would be denied treatment if it weren't for a special clinic that treats children in Erie, Pa., and surrounding counties who can't find another dentist.
For every child without medical insurance, nearly three lack dental insurance. But even for children with dental insurance, access to a dentist is by no means assured.
Medicaid covers dental care for children, but states exercise wide latitude in administering the program. Low reimbursement rates and burdensome forms have discouraged many dentists from accepting Medicaid patients.
Although they often treat some low-income patients free of charge, only 25 to 35 percent of dentists nationwide participate in Medicaid in even a limited capacity, said Dr. Edelstein, who wrote the child section of the surgeon general's report.
He estimated that only one in four children enrolled in Medicaid received any dental service within the last year.
Dentists frequently lose money when they treat Medicaid patients. Because each dental office is essentially a mini-surgery center, overhead costs are high. Between 65 percent and 75 percent of each dollar dentists charge pays for overhead, and Medicaid reimbursements typically fall well below that.
Equally frustrating to dentists is the time lost filling out complex Medicaid forms for procedures that are often rejected. Medicaid rules frequently appear arbitrary, in some cases specifying that for certain procedures a dentist can only be paid for work in half the mouth on any given day.
“To have to deal with stupid, arcane rules which don't make any sense scientifically or socially is a little ridiculous,'' said Ross Wezmar, a pediatric dentist in northeastern Pennsylvania and chairman of pediatric dental advisers for the federal government's oral health initiative. “Most dentists are going to say, `To heck with this stuff. This is crazy.'”
Dentists also perceive an increased likelihood of missed appointments among Medicaid patients. Dr. Wezmar estimated that 40 percent of his Medicaid patients miss appointments, instead coming in months later when their child has a toothache and swollen face.
Sometimes children's parents do not realize the importance of preventive care, and a child's routine dental visit can become an insurmountable challenge for a parent who would lose a day's wages and may not have transportation.
Joan Durgin, health services coordinator for Toledo Public Schools, said transportation and other access problems are such a barrier for parents that the district this year will offer expanded dental services at several elementary schools.
“If we don't provide these services, they don't have them in many situations,'' Ms. Durgin said. “We're seeing a lot of decay that goes unchecked and a lot of tooth pain which obviously interferes with children's attention and ability to learn.''
A growing shortage of dentists further impedes dental access for low-income children and adults. Retiring dentists soon will outpace graduates from dental schools, and few dentists practice in inner cities or rural areas where the needs are greatest, according to Oral Health America, an advocacy group for improving dental access.
Although dental access has garnered little national attention, some lawmakers are working to narrow the oral health gap between low-income Americans and their more affluent counterparts.
Sen. Susan Collins (R., Me.) learned of the dentist shortage in rural areas from her own dentist in Caribou, a northern Maine town that has about one dentist for every 5,000 patients.
Ms. Collins introduced a bill that would provide state grants to improve access to oral health services in rural and under-served areas. Her bill passed the Senate's health committee this month as an amendment to a broader health care safety net bill.
Sen. Jeff Bingaman (D., N.M.) is drafting a bill that would increase the availability of dental insurance for low-income children and offer state grants to address shortcomings in Medicaid.
In January, the federal government's agency that oversees Medicaid informed states that it would increase oversight activities of their compliance.
“It is apparent that a number of states are not meeting participation goals for pediatric dental services,'' the letter said.
A handful of states have stepped up their efforts to improve access.&tab;
Michigan privatized dental care for children on Medicaid by turning administrative responsibilities over to Delta Dental, a commercial private insurance company. Children in the program, which initially targeted rural counties and is being phased in statewide, are handled the same way as privately covered patients.
“The dentist doesn't know which kids are on Medicaid,'' Dr. Edelstein said. “They get paid the same; they submit the claim the same way; they make the appointment the same way; they have all the same office administration. That's exactly what Medicaid is supposed to be about.''
Preliminary results show a substantial increase in the number of dental providers and in the number of children served.
The Ohio Dental Association and a task force convened by Ohio's health director have recommended adopting the Michigan model in Ohio, where a statewide survey determined that dental care is “the No. 1 unmet healthcare need of Ohioans.''
“The reality is, it costs more money,'' said Paul Casamassimo, a pediatric dentist who chaired the Ohio Dental Association's task force. “The tradeoff is, you get better access to care and get more dentists to participate.''
Some state efforts have met with mixed success. In 1999, Pennsylvania legislators increased Medicaid reimbursement rates for dentists but have not seen a significant change statewide in the number of dentists participating. The rates remain below market standards, Dr. Wezmar said.
“Until you get up to market rate or close to it, nothing's going to happen,'' said Dr. Wezmar, who limits the number of Medicaid patients he accepts to avoid bankruptcy but does treat children up to age 7. They come to see him with swollen gums and mouths in “disastrous'' shape.
“We get people calling all the time,'' he said. “My name begins with `W' and the line [we hear] is, `I've called everybody in the phone book and finally found you.'”