Editor’s note: Sunday Citizen reporter Ulrika Gerth has spent the past six weeks researching the plight of people who cannot afford regular dental care, to be presented in a series of stories.
Today: Along with an overall look at the issues, we profile one woman’s efforts to get care for her and her sons.
Amid fluoride rinse and teeth whitening strips at Wal-Mart sits a home remedy for cavities. It costs $2.66 and is applied with a tiny stick.
The instructions say it is only for temporary use but Dave Rooney of Somersworth [EM] uninsured and behind on some bills [EM] put the white material on his aching tooth, over and over again. The infection festered.
There are thousands of people like Rooney in New Hampshire. They have no dental benefits, little money and a staggering need for dental care. Their pain is felt across the state, in emergency rooms, overcrowded community health centers and in phone calls to emergency referral hotlines.
Every day, an average of between two and five people walk into each emergency room in the state with tooth infections so severe some require antibiotics intravenously.
Four hundred people are on the waiting list of Ammonoosuc Community Health Services to receive vouchers to local dentists. And another 200 were waiting for a referral to any of the 17 volunteer dentists of SeaCare Health Services before the nonprofit organization last year decided it could handle emergency cases only.
“There was no way we could keep up,” said Dental Coordinator Jasper Salach of SeaCare, which serves low-income uninsured in 21 Seacoast towns. “I think all centers are looking to creatively limit the amount of people they see without turning away the emergencies.”
The dental center of Families First in Portsmouth is closed to new adult patients except for emergencies. So is the Dental Resource Center in Laconia, and the Capital Region Family Health Center in Concord is only a handful of new dental patients away before the wait exceeds two months and no more people will be accepted.
“It’s overwhelming,” said Deb Bergschneider, dental clinic coordinator at the Concord center. “Because we serve the uninsured, we see the lower level of the community and the need is just astronomical. … By the time they get to us, their mouths are bombed out. They are all emergency situations. It’s a severe, severe, problem. It’s sad.”
It does not take more than a scratch on the state’s glossy surface to find people fighting dental infections instead of perfecting blinding smiles and straight lines of teeth. Some live in beach rentals in the winter and campgrounds in the summer, some live at the housing authorities and some live next door. Some suffer from disabilities or long-term illness. Most are the working poor.
“In the last 30-40 years, oral health has improved tremendously,” said Skip Homicz, president of the New Hampshire Dental Society, citing statistics from the national health objectives, Healthy People 2010. “The number of people over 55 wearing dentures has been cut in half. The number of people who has not seen a dentist in the past year has been cut in half. That said, a segment of the population has not participated [EM] 20 percent of the population has 80 percent of the problems.”
Cases in point
They are people like Margaret Lynch, 48, at the Rochester Housing Authority, who suffers from the early stage of periodontal disease after going 10 years with undiagnosed diabetes. She recently took out a $175 loan from the Holy Rosary Credit Union to have a tooth pulled and fears not having any teeth at all.
Jean Eisenstat, 50, also at the Somersworth Housing Authority, cannot recall when she last was able to afford a dental examination and rather spends her limited income on her four children’s teeth because they have the future ahead of them. Three front teeth dangle as she speaks. She recalls as shocking the moment her teeth began to fall out.
Like 48 percent of New Hampshire residents [EM] or 618,000 [EM] they have no dental insurance. Although an unknown number can pay for dental care out of pocket, a Granite State family of four making $39,000 a year, or just over two times the federal poverty level, will have no disposable income to spend on dental care, according to a 1999 study by the Josiah-Bartlett Center for Public Policy. The median household income in the state is $49,000.
The problem is almost identical, if not worse, in Maine, where 58 percent have no dental insurance and the median household income reached $37,600 in 2003, according to the Census.
The approximately 40,000 adults on New Hampshire Medicaid and 212,000 adults on Mainecare struggle too, as the public assistance covers only emergency extractions and pain relief. Both states cover comprehensive dental care for children.
Some people, like Michelle Brock, 38, a Portsmouth mother on Medicaid, have nowhere to go. Dependent on cancer specialists for survival, she cannot enroll at community health centers in the area, as they require patients to sign up with their primary doctors to gain access to dental care. Supporting herself and two teenage boys on $600 a month from Social Security, she said she is unable to pay cash at a dental practice.
So, many people wait to seek care until there is an emergency, until a dull toothache turns into head-splitting pain.
“I’m horrified,” said Salach. “Some are pulling their own teeth. They take pliers and wiggle them out. When you’re in extreme pain you take extreme measures. Some take a whole bottle of Anbesol (oral pain relief) and dump it on the tooth. It’s pretty desperate. Teeth are something you don’t think about until there’s pain. They may look clean and all of a sudden you have pain and need a quick fix.”
The problem starts early. Although New Hampshire has one of the lowest rates of uninsured children in the country at 5 percent and the 58,200 children on Medicaid [EM] called New Hampshire Healthy Kids Gold [EM] have dental benefits, tooth decay runs rampant.
“Even by age 1, it’s too late for some children,” said Homicz. “People don’t get into dental disasters overnight. It’s a slow and insidious road.”
Some parents let their toddlers fall asleep with a bottle of milk or juice, a practice so common the destructive result has got its own name, baby bottle tooth decay. During hour after hour of bathing in sugary drinks, the teeth rot away, requiring restorative surgery for as much as $10,000, according to New Hampshire Dental Director Margaret Snow. In school, tooth decay continues, supplied by soda from vending machines.
Dental Hygienist Michelle Bouchard, who travels to schools aboard the mobile dental van of Exeter Healthreach, has been in classrooms where seven out of 10 children have untreated decay. Her experience is in line with statistics showing tooth decay remains the leading chronic childhood disease, five to eight times more common than asthma, at number two.
“You can start all the dental clinics you want but with no prevention you’ll never stop oral health problems,” said Wendy Frosh, director of the New Hampshire Coalition for Oral Health Action.
The coalition is one of many statewide efforts spurred by the U.S. surgeon general’s call for action in 2000.
In the report, Oral Health America, the surgeon general called for the first time attention to the “silent epidemic” of dental and oral diseases among the poor of all ages, ethnic minorities and the disabled. It focused on the connection between oral health and general health, how periodontal disease may be associated with heart and lung diseases, stroke, diabetes and premature babies.
“Too many people have disconnected the mouth from the rest of the body,” said Tricia Brooks, president of New Hampshire Healthy Kids, which provides low-cost insurance to the state’s uninsured children. “Forget about self-esteem and not being able to find a job. You can get sick. We need to make sure people see that connection.”
Fueled by the report, New Hampshire’s health foundation, the Endowment for Health, made oral health one of its themes between 2001 and 2005, and has so far pumped $2.8 million into everything from the public awareness campaign Watch Your Mouth, scheduled for this summer, to the Coalition for New Hampshire Oral Health Action, in collaboration with the Department of Health and Human Services.
The coalition established a statewide plan in 2003 that builds on the recommendations from the surgeon general. The plan boils down to eight goals and 78 strategies to fulfill a vision that residents will “have the opportunity to achieve and maintain oral health through access to an effective system of health services which promotes appropriate health behaviors.”
Efforts to improve access to dental care received an extra sense of urgency in early 2004 when a U.S. District Court judge approved a consent decree that details how the Department of Health and Human Services must run its Medicaid dental program for the next five years. Bound by the decree, the DHHS must spend $1.2 million a year [EM] that may be matched by federal Medicaid dollars [EM] to eliminate the issues that got it into legal trouble six years ago.
The decree was the result of a class-action lawsuit against the department in 1999, charging it failed to provide dental care to Medicaid recipients under 21.
At the core of state- and privately funded efforts is spreading the word on the simple formula that can virtually wipe out dental disease: a daily regimen of flossing, brushing, fluoride rinse, a healthy diet and no smoking.
Dental hygienists teach it in school-based dental education across the state, community health centers stress it to their prenatal patients and soon the campaign “Watch Your Mouth” will kick off.
“It makes this problem a community problem, not a bad parent or a bad dentist’s problem,” said Homicz of the campaign. “It puts it out there as a community issue. If we can make you as a private citizen see this is important enough to write a check for $50 or tell you legislator ‘Hey, we’ve got a problem out there.'”
Shortage of bodies
Oral health education is also deemed crucial in solving an equation where the numbers at this time do not add up: a growing population demanding more services from a decreasing number of dentists. The average age of New Hampshire dentists is around 50 and, according to a recent survey by the Bi-State Primary Care Association, “a high percentage” is looking at retirement options.
“I’m the newest guy on the block and I’ve been here for 15 years,” said Eric Hirschfeld, a dentist in Conway.
“It’s going to get worse because we’re not producing enough dentists,” said Edward Thibodeau, assistant dean for admission at the University of Connecticut Dental School, of the nationwide shortage of dentists facing rural areas, including the Lakes Region, the North Country, and most of Maine.
The Endowment for Health has allocated $78,600 to the Bi-State Primary Care Association to expand the New Hampshire Recruitment Center to include dentists and develop a group of “dental ambassadors” who will sell the state to dental school students.
But the association will soon have to look for funding elsewhere and so will many others, including the new dental clinic of Avis Goodwin Community Health Center [EM]that started in November last year with support from the endowment and other private contributors [EM] and the Statewide Sealant Project that has targeted schools with students at high risk for dental disease. In July the endowment will award the last oral health grants and move on to other health issues in the state.
“The biggest problem is sustaining the efforts,” said Lindsay Josephs, program specialist for the Endowment for Health.
“In the end it’s the responsibility of the grantees to meet cost. It’s very scary for them and scary for us who fund them. Can you meet cost by taking care of the uninsured and Medicaid children? Hopefully we’ve raised awareness in the community that they can raise money themselves. We’re all nervous about that.”
The most recent addition of dental centers for the low-income uninsured will open in June at Wentworth-Douglass Hospital in Dover. The hospital saw 730 uninsured emergency dental patients in 2003, costing over $134,000.
For the past five years, the hospital has contributed $100,000 a year to the Strafford County Dental Coalition to pay for local dentists to treat children and adults. But demand exceeded the limited funding. The new center will provide 5,000 patients visits a year and Dr. Babu Ramdev, who daily sees people with tooth aches, abscesses and severe gum infections in the emergency room, hopes it will take some pressure off his department.
“I don’t think people realize this is a major problem,” he said. “You hear the political candidates talk about 45 million uninsured Americans, but have you ever heard them talk about dental issues?”
Somersworth’s Rooney, 36, never went to the emergency room. Afraid of racking up more bills, he headed to Wal-Mart and bought Temparin Filling Material that, according to instructions, “is designed to repair lost fillings with the same ingredients dentists use.” The pain worsened.
On a message board online he learned about the Strafford County Dental Coalition that referred him to a local oral surgeon who said it would be $650 to have three teeth pulled.
“There was just no way so he told me to bring $50 … and that’s all I’ve had to pay so far,” said Rooney. “He ran a needle into every socket. I got nine shots deep into the roots. I think my head became part of the chair. My girlfriend heard me out in the waiting room.”
With the three extractions Rooney can no longer attach his upper partial dentures, leaving two fangs visible on top. His new job of constructing modular homes comes with dental insurance, but his needs go beyond the scope of the coverage.
“It pays for rewiring dentures but it doesn’t pay for dentures,” he said. “If I can ever raise that kind of money I’ll get them, but I’m behind on everything else.”