Medicaid-Only Clinics Fill Teeth in Economic Gaps

Tooth decay is a disease. That is what Dr. David Krol, chair of the department of pediatrics at the University of Toledo, tries to impress upon his patients.

“It is an infection in the mouth that can be passed from caregiver to child—most often, mother to child,” he said. “This is important, and something that I'm not sure everyone understands.”

For families who have private dental insurance plans and who keep up with appointments and take care of toothaches and cavities right away, Dr. Krol's warning may not be something they need to think about.

But for families on Medicaid, getting a dental checkup isn't quite so simple. Many dentists don't accept Medicaid at all because of historically poor reimbursement rates.

Often, any dental clinics that do accept Medicaid patients are few and far between, or perform a limited range of services, and patients can expect long wait times for an appointment.

Small Smiles is a national organization of dental clinics that are run by FORBA (For Better Access), a management company based in Pueblo, Colo., that counteracts those unfortunate trends. The 52 Small Smiles clinics in 17 states accept nothing but Medicaid-qualified patients.

That makes it the largest provider of Medicaid dental services in the country, according to Dr. Aldred Williams, the lead dentist at Small Smiles of Washington.

On the inside, this Small Smiles looks like many of its private-practice counterparts in the affluent suburbs surrounding the District of Columbia. There is a spacious waiting room filled with toys and decorated with colorful professional murals, plus a television.

The examination rooms are also bright and inviting, and there are plenty of them—nine treatment rooms, plus separate consultation rooms, hygiene rooms, x-ray rooms, and doctor offices. They, too, are outfitted with high-tech, top-of-the-line equipment.

Dr. Williams—or “Dr. Al,” as his colleagues call him—is happy to give a tour. In a Medicaid-only setting, one might expect a bare-bones, cost-cutting setup.

But Dr. Williams, a retired military dentist who received a commendation for emergency service at the Pentagon on September 11, 2001, proudly shows off his clinic's themed Winnie the Pooh and sports rooms, on which no expense has been spared.

In high contrast to the inside décor, the Small Smiles of Washington building exterior is a converted nightclub that used to be called “The Black Hole.” Dollar stores and pawnshops abound up and down the stretch of Georgia Avenue where the clinic is located. A security guard, employed by the clinic, circles the block.

But this is a perfect location for Small Smiles. Its patients, after all, aren't coming from the wealthy suburbs. This is their neighborhood dentist.

And in fact, the neighborhood's high concentration of Medicaid-qualified patients enables the clinic to stay financially afloat despite Medicaid's poor reimbursement rate. The sheer volume of billing—anywhere from 60 to 90 visits per day (up to 150 appointments, as many as 40% of which are canceled or result in no-shows, for which Small Smiles charges no punitive fee)—brings in just enough revenue.

The place is busy, but not overwhelmed. Five front-office personnel, five dentists, 12 assistants, and three hygienists keep the clinic running smoothly. The average wait for an appointment at Small Smiles is just 2 weeks, and the practice accepts walk-ins and emergency cases.

Its staff—although not necessarily trained as pediatric dentists—is fully qualified to perform complicated pediatric procedures as well as routine cleanings.

Dr. Williams said in an interview that they are paid a competitive wage, and although turnover is high, advantages like regular working hours and FORBA's handling of reimbursement and human resources lure new graduates and former retirees, like himself, to the clinic.

Often, area clinics send their developmentally disabled or autistic patients to Small Smiles, which is trained and equipped to treat these special needs children.

At its opening last November, there were already 1,000 confirmed patients. Todd Cruse, vice president of development and government affairs for FORBA, said in an interview that last year there was a total of 697,000 patient visits at Small Smiles clinics around the country. (For locations, visit www.smallsmilesusa.com

In areas without a clinic like Small Smiles, “It is difficult for many low-income families to find or afford a dentist,” said Dr. Krol, who listed multiple problems that can arise following lax dental care. “Imagine trying to concentrate in school with a toothache, or trying to eat when it hurts to chew. If a child isn't eating, think of how hard it is to get the calories needed to grow.”

“In older children, especially older adolescents, I sometimes see periodontal [gum] disease. We are learning that gum disease may have effects on diabetes, heart disease, and preterm birth,” he said in an interview.

The mouth and the teeth also can be indicators of systemic diseases, said Dr. Krol. “Problems such as anemia, leukemia, Crohn's disease, and others can manifest themselves in the mouth. In addition, some children are more susceptible to problems if they have dental or oral disease.

“Children who are undergoing bone marrow transplant and chemotherapy can have significant problems if they have oral fungal infections or mucositis, and children with heart problems can be especially at risk for problems if they have dental disease.”

Martha Ann Keels, D.D.S., division chief in pediatric dentistry at Duke Children's Hospital in Durham, N.C., pointed out that more serious problems can occur in conjunction with dental disease.

“We recently had a child die at Duke of a brain abscess caused by his untreated dental caries,” Dr. Keels said in an interview.

“He had Down syndrome and a cyanotic heart condition in addition to severe gastroesophageal reflux disease. He was on Medicaid and had been on a waiting list to be seen for several months. His infection spread from his teeth to his brain. By the time he got to Duke, it was too late for me to be able to fix his teeth and rectify his brain abscess.”

At Small Smiles, Dr. Williams told a similar story of dental caries out of control. “The worst case involved an 18-year-old who presented with a substantial radiographic abscess subjacent to a lower molar. The infection was rapidly spreading through the soft tissue of the neck from the angle of the mandible, approaching the midline of the neck,” he said.

“This is ultraserious because once the infection hits the midline there is a direct path to the heart.”

In this case, however, the clinic intervened in time to refer the patient to nearby Children's National Medical Center. “Children's immediately put the patient on massive amounts of IV antibiotics, with good result,” Dr. Williams reported.

The Small Smiles dental clinic in Washington had 1,000 patients pre-enrolled when it opened in November 2006.

Dr. Williams with his commendation for service on 9/11 at the Pentagon. Denise Napoli/Elsevier Global Medical News

Mouth 'Is Part of Our Responsibility' in Well-Child Visits

So how can pediatricians and family physicians ensure that their patients' mouths stay healthy?

“At every well-child visit [a physician] should be asking about how patients take care of their teeth, if they have a dentist, and looking at the teeth and the rest of the oral structures to see if there are problems that need to be referred to the dentist,” said Dr. Krol. “The mouth is a part of the body. There is no reason why the mouth should be separate. It is part of our responsibility, just like the heart and the lungs.”

Dr. Keels pointed out that many physicians feel too unfamiliar with the mouth to know whether what they see there is normal or unhealthy.

“Certainly, large brown or black holes in the teeth should be easily recognizable as severe caries. It is the subtle findings such as white spots or dental defects that should trigger the doctor to help find a dental home for the child so aggressive prevention strategies can be employed to reverse the disease process,” she said.

“There are also other red flags such as [a] toddler's consumption of juice or frequent carbohydrate snacking, lack of adequate toothbrushing and flossing, and/or a family history of dental disease.” These things all warrant referral to a dentist, Dr. Keels said.

But what if patients lack access to dental insurance, or are on Medicaid and are having trouble finding a provider? “[Physicians] can help families find a dentist by knowing where the dentists are that see children, see children on Medicaid, or see children who may not have insurance,” said Dr. Krol.

“They can also find ways to build a relationship with dentists who will see needy children when requested by the physician.”

Dr. Keels agreed. “Many of my Medicaid recipients have special needs, such as cerebral palsy, autism, or cleft lip and palate. These families have so many challenges to deal with, as many times it is their child's illness that resulted in the family's need for Medicaid. We have to be creative and come up with techniques to help make oral hygiene successful. That takes time to get to know each child and their unique issues.”

Tooth decay is a disease. That is what Dr. David Krol, chair of the department of pediatrics at the University of Toledo, tries to impress upon his patients.

“It is an infection in the mouth that can be passed from caregiver to child—most often, mother to child,” he said. “This is important, and something that I'm not sure everyone understands.”

For families who have private dental insurance plans and who keep up with appointments and take care of toothaches and cavities right away, Dr. Krol's warning may not be something they need to think about.

But for families on Medicaid, getting a dental checkup isn't quite so simple. Many dentists don't accept Medicaid at all because of historically poor reimbursement rates.

Often, any dental clinics that do accept Medicaid patients are few and far between, or perform a limited range of services, and patients can expect long wait times for an appointment.

Small Smiles is a national organization of dental clinics that are run by FORBA (For Better Access), a management company based in Pueblo, Colo., that counteracts those unfortunate trends. The 52 Small Smiles clinics in 17 states accept nothing but Medicaid-qualified patients.

That makes it the largest provider of Medicaid dental services in the country, according to Dr. Aldred Williams, the lead dentist at Small Smiles of Washington.

On the inside, this Small Smiles looks like many of its private-practice counterparts in the affluent suburbs surrounding the District of Columbia. There is a spacious waiting room filled with toys and decorated with colorful professional murals, plus a television.

The examination rooms are also bright and inviting, and there are plenty of them—nine treatment rooms, plus separate consultation rooms, hygiene rooms, x-ray rooms, and doctor offices. They, too, are outfitted with high-tech, top-of-the-line equipment.

Dr. Williams—or “Dr. Al,” as his colleagues call him—is happy to give a tour. In a Medicaid-only setting, one might expect a bare-bones, cost-cutting setup.

But Dr. Williams, a retired military dentist who received a commendation for emergency service at the Pentagon on September 11, 2001, proudly shows off his clinic's themed Winnie the Pooh and sports rooms, on which no expense has been spared.

In high contrast to the inside décor, the Small Smiles of Washington building exterior is a converted nightclub that used to be called “The Black Hole.” Dollar stores and pawnshops abound up and down the stretch of Georgia Avenue where the clinic is located. A security guard, employed by the clinic, circles the block.

But this is a perfect location for Small Smiles. Its patients, after all, aren't coming from the wealthy suburbs. This is their neighborhood dentist.

And in fact, the neighborhood's high concentration of Medicaid-qualified patients enables the clinic to stay financially afloat despite Medicaid's poor reimbursement rate. The sheer volume of billing—anywhere from 60 to 90 visits per day (up to 150 appointments, as many as 40% of which are canceled or result in no-shows, for which Small Smiles charges no punitive fee)—brings in just enough revenue.

The place is busy, but not overwhelmed. Five front-office personnel, five dentists, 12 assistants, and three hygienists keep the clinic running smoothly. The average wait for an appointment at Small Smiles is just 2 weeks, and the practice accepts walk-ins and emergency cases.

Its staff—although not necessarily trained as pediatric dentists—is fully qualified to perform complicated pediatric procedures as well as routine cleanings.

Dr. Williams said in an interview that they are paid a competitive wage, and although turnover is high, advantages like regular working hours and FORBA's handling of reimbursement and human resources lure new graduates and former retirees, like himself, to the clinic.

Often, area clinics send their developmentally disabled or autistic patients to Small Smiles, which is trained and equipped to treat these special needs children.

At its opening last November, there were already 1,000 confirmed patients. Todd Cruse, vice president of development and government affairs for FORBA, said in an interview that last year there was a total of 697,000 patient visits at Small Smiles clinics around the country. (For locations, visit www.smallsmilesusa.com

In areas without a clinic like Small Smiles, “It is difficult for many low-income families to find or afford a dentist,” said Dr. Krol, who listed multiple problems that can arise following lax dental care. “Imagine trying to concentrate in school with a toothache, or trying to eat when it hurts to chew. If a child isn't eating, think of how hard it is to get the calories needed to grow.”

“In older children, especially older adolescents, I sometimes see periodontal [gum] disease. We are learning that gum disease may have effects on diabetes, heart disease, and preterm birth,” he said in an interview.

The mouth and the teeth also can be indicators of systemic diseases, said Dr. Krol. “Problems such as anemia, leukemia, Crohn's disease, and others can manifest themselves in the mouth. In addition, some children are more susceptible to problems if they have dental or oral disease.

“Children who are undergoing bone marrow transplant and chemotherapy can have significant problems if they have oral fungal infections or mucositis, and children with heart problems can be especially at risk for problems if they have dental disease.”

Martha Ann Keels, D.D.S., division chief in pediatric dentistry at Duke Children's Hospital in Durham, N.C., pointed out that more serious problems can occur in conjunction with dental disease.

“We recently had a child die at Duke of a brain abscess caused by his untreated dental caries,” Dr. Keels said in an interview.

“He had Down syndrome and a cyanotic heart condition in addition to severe gastroesophageal reflux disease. He was on Medicaid and had been on a waiting list to be seen for several months. His infection spread from his teeth to his brain. By the time he got to Duke, it was too late for me to be able to fix his teeth and rectify his brain abscess.”

At Small Smiles, Dr. Williams told a similar story of dental caries out of control. “The worst case involved an 18-year-old who presented with a substantial radiographic abscess subjacent to a lower molar. The infection was rapidly spreading through the soft tissue of the neck from the angle of the mandible, approaching the midline of the neck,” he said.

“This is ultraserious because once the infection hits the midline there is a direct path to the heart.”

In this case, however, the clinic intervened in time to refer the patient to nearby Children's National Medical Center. “Children's immediately put the patient on massive amounts of IV antibiotics, with good result,” Dr. Williams reported.

The Small Smiles dental clinic in Washington had 1,000 patients pre-enrolled when it opened in November 2006.

Dr. Williams with his commendation for service on 9/11 at the Pentagon. Denise Napoli/Elsevier Global Medical News

Mouth 'Is Part of Our Responsibility' in Well-Child Visits

So how can pediatricians and family physicians ensure that their patients' mouths stay healthy?

“At every well-child visit [a physician] should be asking about how patients take care of their teeth, if they have a dentist, and looking at the teeth and the rest of the oral structures to see if there are problems that need to be referred to the dentist,” said Dr. Krol. “The mouth is a part of the body. There is no reason why the mouth should be separate. It is part of our responsibility, just like the heart and the lungs.”

Dr. Keels pointed out that many physicians feel too unfamiliar with the mouth to know whether what they see there is normal or unhealthy.

“Certainly, large brown or black holes in the teeth should be easily recognizable as severe caries. It is the subtle findings such as white spots or dental defects that should trigger the doctor to help find a dental home for the child so aggressive prevention strategies can be employed to reverse the disease process,” she said.

“There are also other red flags such as [a] toddler's consumption of juice or frequent carbohydrate snacking, lack of adequate toothbrushing and flossing, and/or a family history of dental disease.” These things all warrant referral to a dentist, Dr. Keels said.

But what if patients lack access to dental insurance, or are on Medicaid and are having trouble finding a provider? “[Physicians] can help families find a dentist by knowing where the dentists are that see children, see children on Medicaid, or see children who may not have insurance,” said Dr. Krol.

“They can also find ways to build a relationship with dentists who will see needy children when requested by the physician.”

Dr. Keels agreed. “Many of my Medicaid recipients have special needs, such as cerebral palsy, autism, or cleft lip and palate. These families have so many challenges to deal with, as many times it is their child's illness that resulted in the family's need for Medicaid. We have to be creative and come up with techniques to help make oral hygiene successful. That takes time to get to know each child and their unique issues.”

Tooth decay is a disease. That is what Dr. David Krol, chair of the department of pediatrics at the University of Toledo, tries to impress upon his patients.

“It is an infection in the mouth that can be passed from caregiver to child—most often, mother to child,” he said. “This is important, and something that I'm not sure everyone understands.”

For families who have private dental insurance plans and who keep up with appointments and take care of toothaches and cavities right away, Dr. Krol's warning may not be something they need to think about.

But for families on Medicaid, getting a dental checkup isn't quite so simple. Many dentists don't accept Medicaid at all because of historically poor reimbursement rates.

Often, any dental clinics that do accept Medicaid patients are few and far between, or perform a limited range of services, and patients can expect long wait times for an appointment.

Small Smiles is a national organization of dental clinics that are run by FORBA (For Better Access), a management company based in Pueblo, Colo., that counteracts those unfortunate trends. The 52 Small Smiles clinics in 17 states accept nothing but Medicaid-qualified patients.

That makes it the largest provider of Medicaid dental services in the country, according to Dr. Aldred Williams, the lead dentist at Small Smiles of Washington.

On the inside, this Small Smiles looks like many of its private-practice counterparts in the affluent suburbs surrounding the District of Columbia. There is a spacious waiting room filled with toys and decorated with colorful professional murals, plus a television.

The examination rooms are also bright and inviting, and there are plenty of them—nine treatment rooms, plus separate consultation rooms, hygiene rooms, x-ray rooms, and doctor offices. They, too, are outfitted with high-tech, top-of-the-line equipment.

Dr. Williams—or “Dr. Al,” as his colleagues call him—is happy to give a tour. In a Medicaid-only setting, one might expect a bare-bones, cost-cutting setup.

But Dr. Williams, a retired military dentist who received a commendation for emergency service at the Pentagon on September 11, 2001, proudly shows off his clinic's themed Winnie the Pooh and sports rooms, on which no expense has been spared.

In high contrast to the inside décor, the Small Smiles of Washington building exterior is a converted nightclub that used to be called “The Black Hole.” Dollar stores and pawnshops abound up and down the stretch of Georgia Avenue where the clinic is located. A security guard, employed by the clinic, circles the block.

But this is a perfect location for Small Smiles. Its patients, after all, aren't coming from the wealthy suburbs. This is their neighborhood dentist.

And in fact, the neighborhood's high concentration of Medicaid-qualified patients enables the clinic to stay financially afloat despite Medicaid's poor reimbursement rate. The sheer volume of billing—anywhere from 60 to 90 visits per day (up to 150 appointments, as many as 40% of which are canceled or result in no-shows, for which Small Smiles charges no punitive fee)—brings in just enough revenue.

The place is busy, but not overwhelmed. Five front-office personnel, five dentists, 12 assistants, and three hygienists keep the clinic running smoothly. The average wait for an appointment at Small Smiles is just 2 weeks, and the practice accepts walk-ins and emergency cases.

Its staff—although not necessarily trained as pediatric dentists—is fully qualified to perform complicated pediatric procedures as well as routine cleanings.

Dr. Williams said in an interview that they are paid a competitive wage, and although turnover is high, advantages like regular working hours and FORBA's handling of reimbursement and human resources lure new graduates and former retirees, like himself, to the clinic.

Often, area clinics send their developmentally disabled or autistic patients to Small Smiles, which is trained and equipped to treat these special needs children.

At its opening last November, there were already 1,000 confirmed patients. Todd Cruse, vice president of development and government affairs for FORBA, said in an interview that last year there was a total of 697,000 patient visits at Small Smiles clinics around the country. (For locations, visit www.smallsmilesusa.com

In areas without a clinic like Small Smiles, “It is difficult for many low-income families to find or afford a dentist,” said Dr. Krol, who listed multiple problems that can arise following lax dental care. “Imagine trying to concentrate in school with a toothache, or trying to eat when it hurts to chew. If a child isn't eating, think of how hard it is to get the calories needed to grow.”

“In older children, especially older adolescents, I sometimes see periodontal [gum] disease. We are learning that gum disease may have effects on diabetes, heart disease, and preterm birth,” he said in an interview.

The mouth and the teeth also can be indicators of systemic diseases, said Dr. Krol. “Problems such as anemia, leukemia, Crohn's disease, and others can manifest themselves in the mouth. In addition, some children are more susceptible to problems if they have dental or oral disease.

“Children who are undergoing bone marrow transplant and chemotherapy can have significant problems if they have oral fungal infections or mucositis, and children with heart problems can be especially at risk for problems if they have dental disease.”

Martha Ann Keels, D.D.S., division chief in pediatric dentistry at Duke Children's Hospital in Durham, N.C., pointed out that more serious problems can occur in conjunction with dental disease.

“We recently had a child die at Duke of a brain abscess caused by his untreated dental caries,” Dr. Keels said in an interview.

“He had Down syndrome and a cyanotic heart condition in addition to severe gastroesophageal reflux disease. He was on Medicaid and had been on a waiting list to be seen for several months. His infection spread from his teeth to his brain. By the time he got to Duke, it was too late for me to be able to fix his teeth and rectify his brain abscess.”

At Small Smiles, Dr. Williams told a similar story of dental caries out of control. “The worst case involved an 18-year-old who presented with a substantial radiographic abscess subjacent to a lower molar. The infection was rapidly spreading through the soft tissue of the neck from the angle of the mandible, approaching the midline of the neck,” he said.

“This is ultraserious because once the infection hits the midline there is a direct path to the heart.”

In this case, however, the clinic intervened in time to refer the patient to nearby Children's National Medical Center. “Children's immediately put the patient on massive amounts of IV antibiotics, with good result,” Dr. Williams reported.

The Small Smiles dental clinic in Washington had 1,000 patients pre-enrolled when it opened in November 2006.

Dr. Williams with his commendation for service on 9/11 at the Pentagon. Denise Napoli/Elsevier Global Medical News

Mouth 'Is Part of Our Responsibility' in Well-Child Visits

So how can pediatricians and family physicians ensure that their patients' mouths stay healthy?

“At every well-child visit [a physician] should be asking about how patients take care of their teeth, if they have a dentist, and looking at the teeth and the rest of the oral structures to see if there are problems that need to be referred to the dentist,” said Dr. Krol. “The mouth is a part of the body. There is no reason why the mouth should be separate. It is part of our responsibility, just like the heart and the lungs.”

Dr. Keels pointed out that many physicians feel too unfamiliar with the mouth to know whether what they see there is normal or unhealthy.

“Certainly, large brown or black holes in the teeth should be easily recognizable as severe caries. It is the subtle findings such as white spots or dental defects that should trigger the doctor to help find a dental home for the child so aggressive prevention strategies can be employed to reverse the disease process,” she said.

“There are also other red flags such as [a] toddler's consumption of juice or frequent carbohydrate snacking, lack of adequate toothbrushing and flossing, and/or a family history of dental disease.” These things all warrant referral to a dentist, Dr. Keels said.

But what if patients lack access to dental insurance, or are on Medicaid and are having trouble finding a provider? “[Physicians] can help families find a dentist by knowing where the dentists are that see children, see children on Medicaid, or see children who may not have insurance,” said Dr. Krol.

“They can also find ways to build a relationship with dentists who will see needy children when requested by the physician.”

Dr. Keels agreed. “Many of my Medicaid recipients have special needs, such as cerebral palsy, autism, or cleft lip and palate. These families have so many challenges to deal with, as many times it is their child's illness that resulted in the family's need for Medicaid. We have to be creative and come up with techniques to help make oral hygiene successful. That takes time to get to know each child and their unique issues.”