ANNAPOLIS – TLC Community Health Center’s two dentists handle a patient load nearly double that of the average dentist and receive dozens more crisis calls about children with so much tooth decay they need surgery.
It takes eight months to get an appointment.
“We are so overwhelmed. We need help,” said Joan Robbins, executive director of the health center serving Somerset, Wicomico and Worcester counties.
The Eastern Shore health center’s case isn’t unique. Maryland’s rural counties can’t recruit or retain dentists to care for Medicaid patients because dentists are flocking to suburban higher-income areas where their work is more profitable.
Poor urban children face the same shortage, but have better access to care than rural children do.
“There is a shortage of dentists, period,” said Dr. Harry Goodman, director of the Department of Health and Mental Hygiene’s Office of Oral Health. “But in rural areas it is worse.”
The Eastern Shore’s nine counties have one dentist for every 2,100 patients enrolled in HealthChoice, the state’s Medicaid manager. Somerset County is the worst in Maryland, with one dentist serving every 8,099 clients. Western Maryland isn’t must better – counties there have one dentist for every 1,808 recipients.
Montgomery County, one of the state’s most affluent areas, has the state’s best ratio: one dentist for every 777 HealthChoice patients, according to the study by Dr. Gary A. Colangelo, dental director of CareFirst BlueCross BlueShield. The state’s average is one dentist per 1,329 recipients, while the nation averages a dentist for every 1,600 Medicaid clients. It is not necessarily greed pulling dentists away from these areas, but “financial reality,” said Dr. Mark L. Wagner, Dental School professor at the University of Maryland at Baltimore.
The problem is rooted in what dentists say are paltry Medicaid reimbursements and cumbersome reporting processes that discourage them from treating the poor or from locating their practices in rural areas where low- income patients abound.
“There certainly isn’t a financial incentive” to care for Medicaid patients, “just altruism,” said Goodman. Adding to the problem is the fact that dental education is expensive, entailing heavy loans.
Carolyn Brown is a junior at the University of Maryland Dental School. She wants to serve these patients, but will graduate with nearly $100,000 in debt. She said she can’t afford to deal with Medicaid’s meager compensation.
“We graduate with willing hearts and skilled hands, but have no opportunities,” she said. “It is just not worth the time and expense to go through all of that (Medicaide) rigmarole,” only to lose money.
HealthChoice covers 50 percent of dentists’ patient expenses, not enough to pay overhead, she said.
Children suffer the most, since HealthChoice provides full dental coverage only to those under age 21. But the dentist shortage isn’t entirely to blame, said Jacob Frego, director of the Eastern Shore Health Education Center.
Rural Medicaid populations are difficult to reach, he said. Unaccustomed to keeping appointments, patients neglect crucial follow-up care and often have no transportation.
The consequences of poor or unavailable care are great, dentists say.
Allegany County’s health department sends at least two children a week to the emergency room because their teeth have rotted into their gums, said dental program director Leslie Stevens.
Stevens said she knows one boy who has been waiting a month to have his rotten teeth pulled, but he can’t get into Kernan Hospital in Baltimore until late April. He is in so much pain that he drops in regularly for painkillers, she said.
Speech pathologists who deal with children with cleft-lip and cleft palate disorders also see the result of dentist scarcity.
“I often hope a child doesn’t need dental care, because chances are we aren’t going to find a local dentist,” said Pat Landis, a volunteer speech pathologist in Washington County and Johns Hopkins Hospital.
That’s the tangible side to a 1995 DHMH study that found 60 percent of Maryland’s school-aged children have rotten teeth – 10 percent more than the national average. Most of that decay is untreated.
Children in Western Maryland and the Eastern Shore topped the state for tooth decay, the study found. Allegany, Cecil and parts of Dorchester don’t add fluoride, a cavity reducing agent, to their water, contributing to rampant tooth decay, the study said.
Legislation passed after the study has been only incrementally effective in meeting the goal of getting 70 percent of HealthChoice children to the dentist once a year by 2005. The state reached 17 percent in 1999.
The waiting list of children needing surgery at the University of Maryland’s Dental School isn’t getting any shorter, Wagner said.
A recent study by the Maryland Healthy Schools Coalition found 40 percent to 60 percent of the surveyed HealthChoice children in Worcester, Wicomico and Somerset County public schools have untreated dental decay. Each child averaged four to six rotting teeth.
Tooth trauma isn’t limited to children, said Frego, but hits all ages, especially the elderly.
“We have got to keep in mind that there is another end of the population with dental needs,” he said. “It is really another chapter of the problem.”
Poor elderly on Medicare have no dental coverage, he said. And only a few of HealthChoice’s eight managed care companies provide basic dental coverage for adults over 21.
And adult patients’ dental problems are rarely simple, said Dr. Sarah Leonhard, director of Greater Badin Health Services, a Southern Maryland health center. They come in with thousands of dollars worth of capping, crowning and cleaning work.
“If they can’t pay for it, they do without and eventually they lose their teeth,” she said. “We pull a lot more teeth than we want to.”