By ALAN CROWELL
Staff Writer Sunday, February 18, 2007

It was not an unusual accident for an active 9-year-old, but because Kristi has no regular access to dental care, it changed her life.

Kristi was able to receive emergency dental care largely because of the intervention of her family physician, Dr. Cynthia Robertson, who spent hours locating a dentist.

A few months after those emergency visits, however, Kristi's grandmother, Pamela Thomas, received a letter from the clinic that stated Kristi needed care for a possibly cracked jaw and her injured teeth.

Years later, those problems still have not been addressed, and Kristi's teeth are crooked and uneven. A front tooth is turning yellow.

"She needs a lot more work on the front teeth and we just can't get anybody," Pamela said. "Nobody wants to accept new patients on medical cards from (the state)."

Kristi is not alone.

There's a nationwide shortage of dentists, one that's especially acute in rural areas like Somerset County. And the problem is made worse by poor reimbursement rates for dental care by MaineCare, the state's Medicaid program.

The result: Children like Kristi suffer from infections and other dental problems that can affect their ability to concentrate in school and even the way they see themselves.

About half of the patients at the Bingham Area Health Clinic, which serves a rural population in a county with the lowest number of dentists per person in the state, have significant dental decay, said Robertson.

"It is heartbreaking. It is more than frustrating," said Robertson.

Medical research has linked dental infections to chronic health problems, including diabetes and heart problems.

Robertson also worries about the self-esteem problems suffered by patients and how they will affect them over a lifetime.

"I had one young woman who is the mother of three say 'I can't go apply for a job because I can't smile,'" said Robertson.

Robertson, who travels to the Dominican Republic every year to provide medical care in isolated villages, said Maine doesn't look especially good in comparison.

"When you look inside the mouth of somebody from rural Maine, it doesn't look terribly different from what you see in the Third World," she said.

Robertson wants to address the problem. She said staff at the health clinic may begin to apply a fluoride coating to children's teeth and a community group is also raising money for a new dental clinic.

The Bingham Health Council, a group of volunteers that also raised the money to build the new health center, has $90,000 so far and needs another $300,000.

A well-equipped clinic, she said, might make it easier to attract a dentist.

An established professional may be drawn to the area for the rural lifestyle. A recent graduate could qualify for federal help in paying back his or her dental school loans by working in an underserved area, she said.

Robert Weyant, chairman of the Department of Dental Public Health at the University of Pittsburgh School of Dental Medicine, said the problem of access to dental care is not unique to Maine.

"Pennsylvania lost 5 percent of their dentists in the past five years, but if you look in the rural areas, they have lost 10 percent," he said.

Nationally, said Weyant, there are probably many rural areas that don't have access and won't get it unless something fundamentally changes in the way dental care is financed.

"We could be in a real crisis," he said.

About 5,000 dentists retire every year, said Weyant, while only around 4,000 begin their careers.

Ironically, even the use of fluoride in public water supplies has played a part in the problem.

Decades ago, as people aged they often lost all their teeth and stopped requiring dental care.

Now, with people keeping their teeth longer, there is increased demand for dental care from the elderly -- another group that tends to have little or no dental insurance.

With the average debt for dental school graduates around $141,000, according to the American Dental Association -- $200,000 or more is not uncommon -- new dentists are under pressure to start their careers in locations where they will make enough money to pay off their debt.

In the year 2000 there were 47.6 dentists for every 100,000 Mainers, compared to the national average of 63.3, according to the Centers for Disease Control and Prevention.

For dentists like Dr. Jonathan Shenkin, that means plenty of patients, but many with insurance that pays only a fraction of the cost of the services they need.

Shenkin, a pediatric dentist who practices in Bangor, said he provides care to MaineCare patients because it is the right thing to do.

To offer care to MaineCare patients, dentists have to charge patients with private insurance more, and that is not fair, he said.

The problem is largely that there is no financial incentive for dentists to provide care to MaineCare patients, particularly the preventative care that is most cost effective, said Shenkin.

MaineCare reimbursement rates for dental care are low.

According to the MaineCare Benefits Manual, MaineCare will pay only $13 toward a checkup for a child, and only $20 toward treatment of a toothache. MaineCare will pay $150 toward the cost of a comprehensive oral exam for a child -- but once, and only once.

Too often, Shenkin said, he can spot his MaineCare patients by their black or missing teeth and red swollen gums.

About 90 percent of the children he takes to the operating room are MaineCare children, he said.

"They are there because they don't have access to early preventative care," said Shenkin.

Shenkin said that a much more cost effective approach is to offer preventative care at the earliest possible age. Early application of fluoride varnish, for example, can reduce decay by 40 to 50 percent, he said.

"If we let these teeth just continue to fall out, the risk of future disease escalates," he said.

In rural areas the situation is dire and not likely to improve, largely because of the difficulty dentists have in getting paid for their services, according to Dr. Wendy Wolf, president and chief executive officer of Maine Health Access Foundation.

"Folks in rural areas tend to be older, have less insurance and be less capable of paying for dental services out of pocket," she said.

Federal health insurance provides little or, in some cases, no reimbursement for dental care.

"I think it is becoming more and more challenging to make your living as a provider in a rural area," said Wolf.

The problem, said Wolf, is not just creating more clinics but finding a way to make sure dentists can make enough to stay there.

"You build it and (patients) will come but there is nobody to open the door," she said.

Alan Crowell -- 474-9534, Ext. 342

acrowell@centralmaine.com