Uninsured, underinsured patients in Missouri remain desperate for dental care

Wednesday, May 29, 2013 | 6:00 a.m. CDT; updated 4:57 p.m. CDT, Tuesday, September 17, 2013
Missouri residents of all ages who are uninsured or underinsured are struggling to get dental care. Free clinics at schools and other locations have been providing some relief for those in need of care.

COLUMBIA — The first time one of Mike Mahnken’s teeth snapped in half, he was biting into a chocolate-covered strawberry from a box his mother had given him. He heard a crack and felt a piercing pain in his mouth. 

The pain was so sharp, he thought he was dying. He pulled the truck he was driving over to the side of the road and waited for his eyes to stop watering.

Horse show to benefit Family Health Clinic dental

Back in the Midwest after a two-year break, the Calvary Episcopal Charity Horse Show will be held Thursday-Saturday at the Central Missouri Events Center, 5212 N. Oakland Gravel Road.

The “Church Show,” which donated over $250,000 to charitable organizations in its 19-year history, will benefit the Boone County Family Health Center, providing dental health care for the medically underserved; the Food Bank for Central and Northeast Missouri, and Doctors Without Borders.

According to the show's website, Toni Knight Utoft will judge all divisions of the show. Qualifying classes will be offered for the UPHA Challenge Cup Finals, the Saddle & Bridle Shatner, Working Shatner, Hunter Classic and Pleasure Medallion Finals, the Good Hands Finals, and the MHSA Medallion Finals.

Organizers are urging exhibitors to bring one jar of peanut butter per class entered to donate to the food bank.

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The tears stopped, but the pain didn't.

Mahnken has lived with mouth pain since he was 17. He's now 29, and though some days are better than others, the pain is constant.

“It kind of feels like people are taking knives and shoving them up through my mouth to the top of my head," he said. "And sometimes it'll shoot down my neck.”

Mahnken's teeth break and chip because they're brittle, but he isn't sure whether it's because of an antibiotic he took as a child or the amoxicillin he took as a young adult, which has been linked to damaged tooth enamel. Dentists have told him it's a genetic problem. Mahnken took care of his teeth — he always brushed as a kid. Now, he says he would have all of them pulled and get dentures if he could. However, he can't, as he's still too young. Dentures would eventually wear his gums and his bone down so that it would be impossible to keep them in his mouth.

The dentists he has seen have estimated it would cost $50,000 to fix his teeth: $30,000 to pull his bottom teeth, do root canals and get crowns for his top teeth, and $10,000 to get a permanent denture. He has insurance through his job at Hubbell Power Systems in Columbia, where he operates a machine lift in the warehouse, but it only covers up to $1,500 worth of procedures. At that rate, it could take Mahnken more than 50 years to fix his teeth.

Without the money, or the credit score he needs for a $50,000 loan, he is forced to live with the pain. One dentist Mahnken saw put it this way: “We’re talking about a brand-new fully loaded Suburban here. Do you think you would just give one of those away?”

A troubled system 

Mahnken’s struggle to find dental care is not unusual in Missouri. 

The facts are bleak:

Missouri ranks 41st in adult oral health care nationally, according to data collected during the 2010 Behavioral Risk Factor Surveillance System Survey, based on the percentage of adults who reported a dental visit in the past year.

The Missouri legislature cut dental care from the services that Medicaid covers in 2005. Only pregnant women and people who are blind are covered for dental care through Medicaid, which is called MO HealthNet in Missouri. However, a pregnant woman who makes more than $21,257 per year, or a person who is blind who makes more than $11,490, is ineligible. As of December 2011, just 48,738 adults in Missouri with Medicaid were eligible to receive full dental coverage. 

Children who have Medicaid can receive care, but only 10.8 percent of dentists in Missouri participate in the MO HealthNet program.

For uninsured adults, some clinics will allow payment on a sliding-fee scale based on their income. But waiting lists can be months, or even years, long.

“The system has issues,” said Gary Harbison, the Missouri Coalition for Oral Health executive director. “If you want to get oral health care, you’re going to meet some challenges depending on what area of the state you’re in and what your finances are and your health coverage is like, and at the same time, there are people who don’t understand that oral health is essential to their overall health.”

In Columbia, getting dental care isn't like winning a lottery; it actually is a lottery — one of the only ways an uninsured adult or adult with Medicaid can get dental care.

The Columbia/Boone County Department of Health and Human Services runs the dental lottery. To be entered, a person who doesn't have Medicaid must make a copayment of $2.50 to $5 to receive a dental assessment by a nurse practitioner. If the person is eligible, he or she will pay just $10 for treatment, but this includes only fillings and extractions. The department can take only 13 to 15 people per month.

“This is the best we can do, and this is a blessing compared to not having anything at all," said Vivian Doughty, a social services specialist at the department. "We feel lucky to have our program since very few adults have dental coverage."

Aside from the lottery, the other option for uninsured people in Columbia who need dental care is the Family Dental Center. And eligible low-income patients must pay on a sliding scale — so a patient who makes $11, 490, 100 percent of the federal poverty level, or less might pay $50 to have a tooth pulled. For adults who qualify for Medicaid because they are pregnant or blind, there are a couple more options in Columbia.

There are nearby clinics in Richland, Jefferson City, Salisbury, Sedalia and Linn that provide basic dental care at a reduced rate or on a sliding scale, according to the Missouri Dental Association. And there is the University of Missouri-Kansas City Dental School, which provides dental care at a reduced rate. To get dental care at a dentist’s office that doesn’t offer reduced rates, it might cost more than $175 to get a tooth pulled.

Even dentists agree it's not easy for an uninsured or underinsured adult to find dental care.

That's why roughly 1,775 people lined up in the rain outside of the Show Me Center in Cape Girardeau on May 3 and 4. They waited for treatment at a large-scale dental clinic, called the Missouri Mission of Mercy, which provided free cleanings, fillings and extractions. Some people camped outside the arena for days. Many stood in line for eight or 10 hours. 

“There just aren’t resources,” said Debra Howenstine, a faculty member at MU's School of Medicine, the medical director for the Columbia/Boone County Department of Public Health and Human Services and an attending physician at Family Health Center. “I’m really frustrated at this point. I don’t think in my lifetime oral health will improve in Missouri. And there is not a quick, easy plan.”

Saying 'ahhh' in the ER

When Karsten Ewald, 49, had dental pain, he had to search for a year for a place to get a tooth pulled before he finally found a dentist in Centralia who would do it for a reduced cost. When you have dental pain, it's impossible not to think about it, he said.

“Some people say it’s the worst pain you will ever experience because it’s right in your face, and it’s right in your head, and you can’t escape it,” Ewald said. “It’ll drive you mad, so you really become motivated to do something about it. And if you have a pair of pliers, you think, man, if I could do that.”

Ewald has three jobs — he is an art instructor at Paquin Tower, a construction worker and a potter — but he doesn't have dental insurance. He has never had a job that offered the benefit. All of his molars have been pulled, except for two on the right side, because he couldn’t afford fillings. Now, he can’t chew on the left side of his mouth. He thinks about his teeth constantly.

“I think about how wonderful it would be to have a beautiful, straight set of teeth,” Ewald said. “It affects your personality. I don’t smile as much as I would like to, and I’m a very happy person. It is just reality, and I’ve tried to get beyond it.”

At the Family Health Center, Howenstine estimates about 90 to 95 percent of the patients she sees do not have dental coverage. And they haven’t for most of their life.

“I bet over half of the people that I see have big open cavities, some of them decayed off to the gum line,” said Howenstine, who works extensively with underserved patients. “I see many, many people losing their teeth at young ages because of periodontal disease.”

As a physician, the most she can do is prescribe antibiotics or pain medication. Without dental care or an insurance provider that covers dental care, many people turn to the emergency room. But the situation there is the same  — physicians are not dentists and can only treat the immediate problem with pain medication.

A study of Kansas City emergency room visits from 2001 to 2006 found an increasing trend of people using hospitals to get dental care. During that period, the percentage of dental-related emergencies increased from 13.1 to 19. The average charge for a visit was $360.

“Emergency rooms are not set up to provide oral health care,” Harbison said. “That whole process is going to cost more than regular preventative dental care would cost, which would have kept people out of the emergency room in the first place.”

Lacking leadership

One of the problems health care advocates cite with oral health care in Missouri is the lack of a dental director. There is no leader and hasn't been one for 10 years. A dental director might be able to obtain federal funding, establish a dental sealant program in high-risk schools, update a state oral health plan and push for its implementation, Harbison said.

In 2009, an oral health task force associated with the Missouri Department of Health and Senior Services released a statewide oral health plan. Almost none of the plan's goals have been reached.

“The fact that work has not really progressed on the goals of the plan I think is reflective of the fact that we don’t have a dental director,” Harbison said.

One of the goals on that list was to reinstate a dental director.

The job of a dental director has largely been left to the Missouri Coalition for Oral Health and the Missouri Dental Association, Harbison said. But these groups lack authority in the state system.

During this year’s legislative session, Rep. Donna Lichtenegger, R-Jackson, introduced House Bill 613, which would have reinstated a dental director in Missouri. The bill got only as far as a public hearing. Harbison said. Lichtenegger also introduced House Bill 467, which would have required public water systems to notify the community 30 days before discontinuing fluoridation. It didn't pass either. Both bills can be reintroduced during the next legislative session.

The Missouri Coalition for Oral Health did achieve one of its goals this year: It helped organize the Oral Health Issues and Development Committee. Lichtenegger, a registered dental hygienist, is the chair of the committee with co-chair Rep. Jeanne Kirkton, D-Webster Groves. The committee aims to encourage members of the House and Senate to consider oral health care a higher priority, Lichtenegger said.

“We need to get the word out there for how important (oral health) is,” Lichtenegger said. “As leaders, we should help our districts realize that there are programs out there that they can use to help their constituents.”

Waiting, calling, waiting

Four days. Two weeks. One month. A year. Five years. Any one of these could be the length of a wait for dental care.

Keith Novinski, 47, waited two years for an appointment at the Family Dental Center and then gave up. Six months ago, he was reminded he was on the waiting list when he felt a jarring pain in his tooth. Novinski remembers calling the dental center again and asking the woman on the phone when he might get a call back.

“She said, 'Well, we have a really long waiting list and there are people who have been on this waiting list for a year or two,' ” Novinski said. “She told me to call back on the following day so I could come in if anyone were to cancel their appointment."

Novinski called for several days with no luck. And he couldn't find another dentist in Columbia who would take an uninsured patient. So he went to the Internet and searched for home remedies on YouTube. He found two videos that suggested swishing with salt water and making a paste of cloves. For now, it's working for him.

Long waiting lists aren’t surprising. Publicly funded clinics are commonly overbooked because they do not have the dentists they need to serve the uninsured, and the dentists are not reimbursed at a high rate, Lichtenegger said.

Steve Long, the director of planning and development at the Family Health Center and Family Dental Center, said the dental center’s priorities are patients who have already established care with the Family Health Center or Family Dental Center, children, senior adults, people with chronic illnesses and emergency cases. Waiting times for appointments vary depending on these factors. The center's goal is not urgent care, but instead, it is to fix immediate problems and then develop a longer-term treatment plan.

The Family Dental Center focuses on providing care to children; 64 percent of its patients are under the age of 20, while just 14 percent are uninsured adults, said Gloria Crull, the organization's chief executive officer. That's because the center hopes to fix any dental disease and teach good dental habits early in life, which might prevent costly dental care in adulthood.

Adults who are in the prioritized categories might have to wait for an appointment, but they will get one eventually. For adults who are not in these categories, they must call every day to check for open appointment times, Crull said. The center stopped using a waiting list because it got too long — it was filled with hundreds of names and people who might have to wait months.  

"It wasn't fair," Crull said. "It left them thinking they would get an appointment when it was quite clear that we couldn't keep up with the demand. In fact, we were overwhelmed — there are only so many dental chairs."

Long said some of the Family Dental Center's limitations are created by the clients it serves. People miss appointments without calling to cancel, which leaves open slots in its schedule.

“If more people would come when they make an appointment, we would get more done," he said. "We end up with open spots, so we’ll tell people: If something opens up and you can come if we call you and you can come right then. Probably the biggest limitation is the patients themselves.”

There are limits on the number of uninsured and Medicaid patients the center can accept, Long said. One of the reasons the center must set these limits is because uninsured patients pay just a fraction of the cost of their care, based on their income. And it doesn’t help that Medicaid reimbursement rates are lower in Missouri than other states. 

The 2011 Medicaid dental reimbursement rate for dentists serving Medicaid patients was 39 percent, according to the Department of Social Services. The reimbursement rate for treating Missouri children with Medicaid in 2010 was about 46.7 cents to the dollar, compared to the national average of 60.5 cents to the dollar, according to data from The Pew Center.

“We’re a business,” Long said. “We are a nonprofit, but as a business, we have to balance our books, so we can’t spend more money than we take in. So there is a limit to how much charity work we can do and how many people we can serve who pay us little for our care.”

'Lost hope'

"Soul-crushing." That's how Mahnken describes his search for dental care.

He estimates he's on 10 waiting lists in Missouri and California, where he lived for a year. For eight years, he's been calling and emailing dentists, and searching for payment plans.

“I was at the point where I would have been cool with someone just taking a baseball bat and knocking all of my teeth out,” he said. “Then I would have had to get the dentures. Because the dentists wouldn’t do it.”

His teeth are always on his mind, Mahnken said, whether he's talking or eating. His favorite food is mashed potatoes because they won’t break his teeth and they don’t hurt to eat. Anything cold creates a sensation like a dagger in his jaw, he said. Crispy bacon is out of the question; he broke a tooth once eating bacon in a salad.

Mahnken has practiced speaking in a way that doesn’t show his teeth. His smile is false, he said. It is designed to obscure his teeth. He avoids going out into large crowds or socializing with people. When he is in a lot of pain, the smallest thing can irritate him, and he will lash out.

“It makes me feel horrible, and it makes me feel ashamed,” he said.

He’s grown accustomed to waking up every morning with pain in his mouth and head.

“It’s almost become normal to me,” he said. “I’m not sure how it would feel if I didn’t feel it. I’ve felt it for so long.”

Mahnken has given up trying to fix his teeth, he said. But his family and his best friend, Jamie Ketcher, have not. She has sent more than 30 emails to dentists in multiple states.

She recalls a day that her friend was collapsed on the floor, in agony. “We had had plans to go do something and it was just the whole weekend that he couldn’t go out," she said. "That was around the time I started sending out emails.”

The dentists who have responded to the emails have told her they can’t help if she can’t pay. Or they have directed her to dental contests and dental clinics that can only pull Mahnken’s teeth. As a last resort, Ketcher started an online fund for people to make donations to fix Mahnken’s teeth. So far, the fund has collected $717. When people in Mahnken’s family have some extra money, they donate it to the fund.

Mahnken's mother, Teresa Martin, wishes she would win the lottery so she could  help her son. It's hard for her to see her to see him in pain and not be able to do anything about it. Like Ketcher, she has called dentists for years asking for help.

“Up until this fund, I felt like a failure,” Ketcher said. “I tried so hard, and it makes you feel really low that you can’t help someone. My best friend is going to end up dying from this because nobody wants to help. Up until I started the fund, I lost hope.”

Getting kids' teeth on healthy track

At Southern Boone Primary School in Ashland last month, children filed into the library, lined up in front of three dental hygienists and opened their mouths to have a fluoride varnish swiped across their teeth with a tiny brush.

It was the second year the Southern Boone School District had done a varnish application. About 200 of 350 students from both the primary and elementary school participated with their parents' permission. Earlier in the year, a dentist came to the schools to do a dental screening. The dentist checked the children’s teeth, talked to them about brushing, and gave them a score that indicated whether they needed to see a dentist. The state provided the supplies, but all of the work was donated.

Columbia Public Schools has one dental screening and two fluoride varnish programs every year at the preschool and elementary level. The program relies on local dentists and dental hygienists, as well as the Family Dental Center, Lori Osborne said in an email. She is the health services coordinator for Columbia Public Schools.

After the dental screenings, it’s up to the school's nurse to call parents and make sure their children get the dental care they need, said Robin Bullard, director of nursing services for the Southern Boone School District.

“You’ll see them back in the office with tooth pain, saying, I can’t do my work because my tooth hurts or I can’t concentrate,” Bullard said. “It’s the same if someone comes to school hungry. You can’t sit and concentrate if you’re hungry. If you’ve got a tooth that’s really hurting, you just can’t concentrate."

It can be hard to find a place that will accept children who have Medicaid coverage, Bullard said. This is part of the reason half of the children in Missouri with Medicaid coverage did not receive dental care in 2009. 

Matt St. George, the dentist who oversaw the Ashland fluoride varnish application last month, said the fluoride varnish program helps prevent cavities. It also can make parents aware that their child might need to see a dentist. 

But that's easier said than done, he acknowledged.

Rural areas in Missouri don’t have many dentists, let alone dentists who will take Medicaid. People will drive 45 miles to come to his office in Fulton, he said.

“When I went to dental school, not too many kids were going back to small towns — they were going to the big cities,” St. George said. “I grew up in a town where there was one dentist, and it took three months to get in to see them. That’s just an access to care thing and not that parents are not caring about their kids’ teeth.”

In Columbia, it's easier for children to get dental care. Michael Todd, a private practice dentist at Mid-MO Dental Center, accepts children who have dental coverage through MO HealthNet. He says access to dental care for children in Columbia has improved over the past 17 years. But in other areas of the state, access is a problem.

To solve part of this problem, there is the Ronald McDonald Care Mobile, known as the Tooth Truck. It is a mobile dental office that travels to schools or after-school programs in the Springfield area. The services are free and the Tooth Truck will take any child who qualifies for free or reduced lunch, has Medicaid or has no private dental insurance and has not been to the dentist in the past year. The truck has served over 14,500 kids since 2002, said Sarah Cimino, the full-time general dentist who works on the Tooth Truck.

Cimino sees kids who fall between the cracks because their parents don’t qualify for Medicaid. She also sees kids whose parents qualify, but might not have easy access to dental care. There are plenty of Medicaid providers for children in Springfield — that is not the problem. But some dentists only take a limited number of children with Medicaid. Children's parents might lack transportation or might not be able to leave work to take them to the dentist. There is also a lack of education about dental health, Cimino said. 

Tooth decay affects children in the United States more than any other chronic infectious disease, according to the Centers for Disease Control. Parents can help prevent decay by brushing their children's teeth with fluoride toothpaste, taking them to the dentist, feeding them nutritious meals and limiting their consumption of sugary drinks, according to the American Dental Association. 

Not all parents know to do this, Cimino said. She notices a generational lack of education about oral health. An example is "baby bottle decay," which occurs when parents put their children to bed with bottles containing milk or fruit juice. Parents will tell her, "Oh well, it’s just a baby tooth," "I don’t floss my teeth, so I don’t know why I should floss theirs," or "I lost all of my teeth at 20, so my child is probably going to lose theirs as well."

The Tooth Truck can have an impact on the whole family, not just the child, she said. Cimino has known some parents who started flossing because their child, after going to the Tooth Truck, told them how important it is.

"We’re trying to break those barriers and get through to parents," she said. "And educating the child is a great step."

She tells parents: "That's very unfortunate what happened in your situation, but your child is not doomed to the same results because of that. What can we do to work through that?”

Supervising editor is Katherine Reed.

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Richard Montgomery May 30, 2013 | 3:23 a.m.

@Mike Mahnken
Mike, I was one of the people quoted in this article. I know how you can get your dental work done professionally and as inexpensively as you're ever likely to get it done elsewhere: through the University of Iowa's College of Dentistry and Dental Clinics. For a greatly reduced bill you have your dental work done by University of Iowa Dentistry student working under the close supervision of a dentist who is also a professor of dentistry at the university. After trying in vain for 3 years to have my dental work done at the waste of space known as the Family Dental Center, I'll be going to the University of Iowa to have my dental work done. It's located in Iowa City, Iowa, which is in southeast Iowa. It's a 4 hour drive from Columbia. The hardest part of the whole experience is getting to Iowa City and finding the clinic. So, if you decide to have your dental work done there, allow plenty of time ahead of your appointment to locate the clinic so you aren't late for your appointment. You may even want to arrive in Iowa City the day before your appointment to make sure you know where the clinic is located. Anyway, below is a link to their website. Good luck to you. Keith Novinski

(Report Comment)
Ellis Smith May 30, 2013 | 6:25 a.m.

Due to the prohibition about naming local or other businesses, I won't name names, but one very good dental practice in Columbia, Missouri consists of two dentists who are both University of Iowa Dental School graduates. I wish I were close enough in distance to Columbia to still be one of their patients. University of Iowa's Dental School and Dental Clinic are known nationally.

Go Hawks!

(Report Comment)
Ellis Smith May 30, 2013 | 7:15 a.m.

PS (to previous post):

Getting from Columbia to Iowa City, Iowa is now much faster and far less stressful than it used to be.

Take I-70 to Kingdom City
Take US 54 NORTH (portions 4-lane divided) to MO 19 NORTH
Take MO 19 NORTH (2-lane) to US 61 (4-lane divided) NORTH
Take US 61 NORTH to MO 27 NORTH
Across the Des Noines River MO 27 becomes IA 27 (4-lane divided)
US 218 joins IA 27; both go straight north to Iowa City

Where IA 27/US 218 cross I-80, west of Iowa City, the highway becomes I-380 and continues north to Cedar Rapids and Waterloo. An Iowan would probably think going to Cedar Rapids would be a good thing. But Waterloo? Not so much. Poor old Waterloo gets no respect. :)

(Report Comment)

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