Six-year-old Mychael Greene doesn't like the look of the hooked tool that dentists use to scrape plaque from teeth, or the sour taste their latex-gloved hands leave in his mouth. But his mother, Shawn Greene, made sure her son opened wide during a recent checkup at the University of Maryland Dental School in Baltimore.
Her reason: the death earlier this year of Deamonte Driver, a 12-year-old Prince George's County boy who died after an infection from an abscessed tooth spread to his brain. Deamonte's Medicaid coverage had lapsed, but even with it, his mother said, it was difficult to find a dentist who would see her children.
Advocates and politicians have latched onto Deamonte's death to publicize inadequacies in dental care for the nation's poor - especially children. Democrats in Congress are using the case in a push to improve dental care for poor children covered by Medicaid and the State Children's Health Insurance Program.
And in Maryland, health officials have convened a Dental Action Committee that will make recommendations on Medicaid reimbursement rates and other issues. Medicaid and SCHIP provide health care benefits for about 400,000 Maryland children and young adults up to age 21.
"The system is broken and it needs a complete overhaul," said Laurie Norris, a staff attorney with Baltimore's Public Justice Center who has worked with Alyce Driver, Deamonte's mother. Norris has joined with Dr. Norman Tinanoff, who oversees the state's largest dental clinic for the poor at the University of Maryland Dental School, to push for improved oral health services.
They testified at a May 2 hearing before a House Oversight and Government Reform subcommittee, which is also taking a closer look at the delivery of dental care to poor children.
"We have people [on Medicaid] who say they can't find a dentist," said Tinanoff, referring to the relatively small number of dentists in the state who will see Medicaid patients.
Medicaid is a federal-state program that pays for health care for low-income families with children, the disabled and the elderly. In Maryland, seven managed care organizations provide health care to Medicaid recipients.
Of Maryland's 5,500 dentists, only about 900 are enrolled in the Medicaid program, according to state officials, and of those it's unclear how many are accepting new Medicaid patients or are even still practicing. Tinanoff's own survey found that only about 170 dentists were willing to take on new patients.
Part of the problem, according to Tinanoff, is that the state still lags behind others in reimbursement to dentists for treatments provided to Medicaid patients. Maryland ranked lowest in the nation in 2004 for reimbursement levels for restorative procedures, such as repairs to infected teeth, according to a survey by the American Dental Association.
And there are other barriers. Parents of children covered under Medicaid can have a difficult time navigating the system of managed care organizations that serve Medicaid beneficiaries. In Deamonte's family's situation, his mother required help from Norris and several others to secure an appointment for another son, DaShawn, who was diagnosed last fall with six rotting teeth.
Deamonte's health crisis started in mid-January, when the boy, who had not complained of any oral pain, began to experience intense headaches. What was first diagnosed as a sinus infection turned out to be a brain infection, and after two brain surgeries, the extraction of an infected tooth and nearly two months in the hospital, Deamonte died, unexpectedly, on Feb. 25.
"Deamonte's death was an enormous tragedy," said state Health Secretary John M. Colmers, who has met with advocates and dentists in recent months to come up with new ways to provide dental care to poor and low-income residents. "It was heartbreaking."
Colmers has convened a Dental Action Committee that will begin meeting this month and will report to him in September with a list of proposals - including a possible increase in reimbursement rates for dentists who treat Medicaid patients, as well as new education programs that will stress the importance of good oral health.
State Medicaid officials are also considering creating "dental homes" for poor children that would serve as the first stop for oral health needs.
In addition, the state is moving ahead with a plan to expand the existing network of community dental clinics - a proposal that until recently had been on hold because of a lack of funding. "We have to address this obvious need," Colmers said, adding that he will seek the $2 million needed to start the clinic expansion from the recently formed Community Health Resources Commission, an executive committee that has a $15 million budget.
"I want some real action," he said.
Deamonte's death has also sparked action on Capitol Hill, where elected officials are debating reauthorization of SCHIP, a $40 billion, 10-year program that provides health-care coverage to about 6 million children. Some politicians have seized the moment to propose large increases for oral health services and have used blown-up images of Deamonte to illustrate the need.
In March, Sen. Benjamin L. Cardin, a Maryland Democrat, co-sponsored the Children's Dental Health Improvement Act of 2007, which would authorize $50 million in financial incentives and planning grants to states to improve their Medicaid payment rates to encourage more dentists to participate in the program, and $40 million to beef up dental staffs at public clinics.
Cardin and his co-sponsor, Sen. Jeff Bingaman, a Democrat from New Mexico, hope their bill will be folded into the new SCHIP program.
Last month, Rep. Albert R. Wynn, whose district includes Prince George's County, introduced a bill that, among other things, would offer grants to communities to hire dental health coordinators who would connect needy children and their families with dental services. Rep. Elijah E. Cummings, a Baltimore Democrat, introduced "Deamonte's Law," a bill that would provide money to expand dental services at health clinics and fund training in pediatric dentistry.
"A silent epidemic of dental disease is plaguing our children, and our inability to address this issue has had horrifying effects," Cummings said in introducing his bill. "I simply cannot comprehend how, in this country where we have achieved so much progress, we so thoroughly failed this little boy."
Fewer than one in three children in Maryland's Medicaid program received any dental service at all in 2005, the latest year for which figures are available. And while state officials have been working to improve services, barriers, including missed appointments and a lack of awareness among some populations, continue to frustrate administrators and advocates alike.
"There's a real problem, and this population is difficult to deal with because they don't keep appointments," said Susan Tucker, executive director of the state's Office of Health Services.
Managed care organizations are also offering help in addressing the problem. One idea is to require proof of dental check-ups for school registration, much as inoculations against chicken pox and measles must be certified.
"We are looking for ways to make sure our clients have the most up-to-date information in the most easily accessible form," said Steven Matthews, a spokesman for UnitedHealthcare Medicaid plan, which provides dental services in Maryland, referring to lists of dentists the group provides to beneficiaries.
As a result of Deamonte's death, the state is now trying to get a clearer picture of the dentist-to-Medicaid patient ratio, Tucker said. In addition, the state intends to work with managed care organizations to make sure Medicaid patients find a dentist.
"We want them to get more than a list [of names]," she said.
Tinanoff and other oral health advocates have lobbied state officials in recent years to increase reimbursement rates to dentists who treat Medicaid patients. While they have had some success, the discrepancies between the cost to the dentist and reimbursement are still great. Indeed, a 2004 survey by the American Dental Association ranked Maryland 39th out of 50 states regarding reimbursement rates for diagnostic and preventive procedures.
For example, the state pays Medicaid dentists $9 for dental sealants, while the cost to dentists is roughly $40, according to Tinanoff. "It is unreasonable to expect a high number of dentists to participate in Medicaid when the rates do not cover overhead costs," he said in his May 2 testimony before the congressional subcommittee.
Tinanoff is also working with Baltimore Health Commissioner Dr. Joshua M. Sharfstein on a pilot program that would allow physicians to give children fluoride varnishes, which drastically cut down on cavities, during regular medical checkups.
"Even with the dental school here, there are not enough resources for the incredible dental problems that exist," said Sharfstein, who is trying to secure $250,000 to fund the pilot. "We are interested in really increasing the amount of prevention."
A healthy mouth - that's what nudged Shawn Greene to bring her son to the University of Maryland recently. But the Windsor Mill mother, who works two jobs and still can't afford adequate dental coverage for her family, said there was something else, too. Deamonte's death haunted her.
"That actually scared the heck out of me," said the 38-year-old woman, who also brought her daughter, Chazmin, 14, to the clinic. "I am just trying to keep on top of their dental health - that's a priority for me."