Dec. 18, 2000 -- When her son David was just 1 year old, Linda Van Meenen saw the first signs of decay on his teeth. But when she took him to the dentist, she was told he was too young to be treated, that he wouldn't sit still, and that she should bring him back when he was 2. A year later, she took David to the same dentist, who looked in his mouth and said she had waited too long, and that the teeth were in such bad condition, he wouldn't be able to treat him.
David eventually was referred to another dentist and diagnosed with an uncommon problem: he had been born with no enamel on his teeth. This caused them to start decaying almost from the moment he began to eat. Before he was 5, the boy had received root canals, had all eight front teeth removed, and had most of the remaining others either capped or filled. With both parents unemployed at the time, David's treatments -- costing thousands of dollars -- would have caused them untold financial hardship if not for a state insurance program covering pediatric dentistry. "We could never have afforded all of that if not for the help," says the Lewisville, Ohio, mother.
The Cost of Care
The Van Meenens were lucky: Many state and government aid programs offer minimal dental coverage. Because of this, as many as one in five American children don't receive regular dental care, according to Francisco Ramos-Gomez, DDS, an associate professor of pediatric dentistry at the University of California at San Francisco.
In San Francisco, for example, there are hundreds of practicing dentists, but "if you are under Medicaid and you are looking for a pediatric dentist, there are only three clinics that will accept you as a patient," Ramos-Gomez says. "Less than 1% of dentists in private practice in this country take children that are insured by federal programs. It is a social disparity of tremendous impact."
Over the past few decades, oral health has improved significantly in the United States. Fluoridated community water supplies, healthier diets, and better dental care have combined to dramatically reduce tooth decay and other serious problems. But not everyone has benefited from these gains. And some of those to benefit the least have been kids without dental insurance.
The Office of the U.S. Surgeon General this year released its first comprehensive study on the nation's oral health, and called this lack of dental care a "silent epidemic." Among the report's findings, uninsured children are 2.5 times less likely to receive needed care than children who have dental coverage. And less than 20% of children covered by Medicaid (or Medi-Cal, as it's called in California) had seen a dentist within the preceding 12 months. The report also says tooth decay is the most common chronic childhood disease -- five times more common than asthma. Left untreated, dental decay can impair a child's ability to eat, speak, sleep, and learn.
"Oral health has improved for most people, but now there is a smaller group with much worse problems," says Paul Casamassimo, DDS, MS, president of the American Academy of Pediatric Dentistry and a professor of pediatric dentistry at Ohio State University in Columbus. "While it used to be that all children had some low level of dental problems, today most of the kids are fine, but about 25% of the kids have pretty bad dental problems."
The Politics of Early Care
Part of this problem relates to which services are covered. Some of the major government insurance programs pay only for restorative treatment, but not preventative care, says Ramos-Gomez. Put simply, Medicaid will pay for a filling, but not for the less-expensive checkup and cleaning that would have prevented that cavity. This approach often means that checkups are ignored and dental conditions that start with simple tooth decay can escalate, he says.
But for parents of limited income, even with government insurance programs, visiting the dentist can be a serious financial burden. In addition, even those with insurance can be burdened by the common requirement to pay the bill up front and receive reimbursement later.
As a result, many parents simply put off visiting the dentist, waiting until their children's dental problems become so advanced that they require emergency care. According to the American Academy of Pediatric Dentistry, several recent studies have shown that many parents use the emergency room to obtain primary dental care for their children, even though simple preventive checkups could have headed off the advanced problems often seen under those circumstances, making treatment much less expensive.
Lobbying for Change
To promote better dental health among the country's children, both the academy and the American Dental Association are lobbying Congress to modify government insurance programs to increase payments and cover more preventative work.
As is true in most other medical fields, Ramos-Gomez says many of the current plans have reimbursement levels that are far below the rates sought by dentists. Medicaid often pays only half of such fees, and some state plans pay as little 20%. As long as that remains the case, "there is no incentive whatsoever to take on these patients," he says.
The other side of this issue is educating people not only about the need for preventative care but also that help is available. "Some people don't seek care, even when they would be covered by some of these programs," Casamassimo says. "We have to let them know."
Now age 6, David's adult teeth are starting to grow in, finally filling the gaps left by the earlier removal of his baby teeth. Today he smiles, eats, and talks much like any other child. According to his mother, David's self-confidence has climbed thanks to the dental care he received. And that, she says, is definitely something to smile about.
Will Wade, a San Francisco-based writer, has a 5-year-old daughter and co-founded a monthly parenting magazine. His work has appeared in POV magazine, The San Francisco Examiner, and Salon.
