Kimberly Bright was driving home from work recently when a tooth that had been bothering her for months went from being a painful annoyance to an acute emergency.
The shooting pain forced her to detour to Frederick Memorial Hospital's emergency room.
"The pain is radiating across the left side of my face," said Bright, who works as a home health care worker. "It's my wisdom tooth and I want it out."
Bright's infected molar was removed by Jordan Hicks, a fourth-year dental student at the University of Maryland who was staffing a new dental clinic across the street from the hospital.
The University of Maryland School of Dentistry and the hospital have opened the Monocacy Health Partners Dental Clinic in a unique arrangement that school officials hope will serve as a model for providing dental care to low-income adults, who often still lack coverage even as access to health insurance has been vastly expanded in recent years under the federal Affordable Care Act. Last year alone more than 1,200 people seeking relief for a terrible toothache came to Frederick Memorial.
The dental school operates other clinics, but Monocacy Health Partners is the first that's affiliated with a hospital, an arrangement that officials hope will draw patients away from the emergency room and help better integrate dental care with health care.
They also hope it creates a sustainable financial model that can be replicated in underserved areas across Maryland and the country.
Generally there are few options for adults. For example, the Community College of Baltimore County School of Health Professions operates a Dental Arts Center in Dundalk that has a dental hygiene clinic offering preventive oral health services at reduced rates. School officials report more than 18,333 patient visits since the clinic opened in 2008, and $5.8 million savings in dental fees for patients from spring 2009 through spring 2016.
About half of adults have some level of gum disease, according to the U.S. Centers for Disease Control and Prevention. Much of it would be preventable with proper hygiene and professional care.
Mark Reynolds is dean of the University of Maryland School of Dentistry. Poor oral health not only causes pain, he said, but can inhibit nutrition and speech and lead to problems with self-esteem, relationships and employment.
He said there also are well-established links between oral health and other chronic health problems, such as heart disease, stroke and diabetes.
"I see dentistry as an important portal to the health care system," Reynolds said. "We shouldn't be providing care in isolation ... or only in emergencies."
Historically, dental care has existed outside the health care system, said Julia Paradise, an associate director of the Kaiser Family Foundation's commission on Medicaid and the uninsured. There was little acknowledgment of its connection to overall health.
Paradise cited several reasons. Some dentists wouldn't accept private insurance. Fewer would take those on Medicaid, the state-run health program for the poor. Medicaid programs around the country have cut dental benefits during tough budget times.
The situation has changed with the Affordable Care Act, Paradise said, but mostly for children. Medicaid began covering comprehensive dental care for children and pregnant women, whose oral health can affect their babies. Under the health care law, private health plans sold on state and federal exchanges are required to cover dental services for children.
Medicaid still is not required to cover adults. Kaiser surveys show some states provide full benefits, but 32 states — including Maryland — cover only limited dental services, and four cover none.
Medicare, the federal health plan for seniors, does not offer dental coverage.
"It's not like these people can always fork over even $50 for a visit or care," Paradise said. "And if they haven't had dental care throughout their lives, they are more likely to have extensive needs."
An estimated 47 million Americans still have only limited access to dental care across the country, according to Kaiser. Roughly 830,000 each year turn to emergency rooms, which provide painkillers and antibiotics rather than dental treatment.
Federally backed health care centers are beginning to fill the gaps with sliding-scale dental care for low-income adults who come in for general health care services.
In 2014, Kaiser found, more than three-quarters of these health centers provided dental care, and about 15 percent of visits were for dental services. Health departments and nonprofits and dental schools also are providing some services, Paradise said.
Bright, a Medicaid recipient, said she takes her four children for preventive care because it's covered. She doesn't get preventive care herself because it's too expensive. She said she brushes her teeth twice daily to protect against cavities and other dental problems.
The last time she saw a dentist was two years ago, when she needed a different wisdom tooth pulled. Medicaid covered the extraction because she was pregnant.
The bill from the Frederick clinic for the latest molar was $40.
Bright plans to return to the clinic soon to have a cavity filled, and will also likely need another wisdom tooth removed at some point.
To get the state-of-the-art, five-room clinic running, the hospital needed about $200,000 for capital improvements to the building and about $160,000 for annual operations, according to Jim Williams, the hospital's senior vice president of population health and ambulatory services. State bonds and community grants covered some of the costs.
Williams expects some of the costs to be offset by savings in the emergency department. Sliding-scale payments by patients will also help.
The clinic is now seeing only those patients with acute problems, not providing preventive care such as cleanings. Those services will be added over time, Williams said. Eventually, officials expect 1,800 people per year to use the clinic.
Patients who need other medical services or help finding health insurance or a primary care doctor will be referred back to the hospital, which shares records with the clinic.
The dental school will contribute students, who are required to do two volunteer stints at community-based health centers and clinics for two weeks, and will tap school staff and volunteer dentists from the community for oversight.
Hicks, the student dentist who saw Bright, presented the case for extracting Bright's wisdom tooth to Jeff Rajaski, a Frederick dentist and dental school instructor. Rajaski confirmed the molar had to go.
Hicks had extracted at least 26 other teeth — a near mouthful — in the dental school's Baltimore clinic. He said time in the clinics is helping him build confidence before he graduates and heads out on his own next year, likely back home near Augusta, Maine.
He said he became interested in dentistry at age 16, when his dentist told him about the shortage of providers in many areas of the country, a problem that's expected to worsen as the nation's dentists age and retire.
Like many in medical fields, Hicks wanted to help.
He expects practicing in his home state to be rewarding. Already, he said, it's gratifying to solve dental problems and relieve pain.
Bright liked that part, too. It had been nearly two months, and over-the-counter painkillers could no longer restrain the ache.
About 20 minutes after climbing into an exam room chair, Bright clutched some post-procedure instructions, gave the staff a gauzy smile and headed out.