Poor, Sick And Cut Off From Dental Care

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Mike Bush eats only one meal a day to avoid chewing (Photos: Dianne Finch)
Mike Bush eats only one meal a day to avoid chewing (Photos: Dianne Finch)

Mike Bush is 45, unemployed and struggling with paranoid schizophrenia. But he has an even more pressing problem at the moment: lunch.

Bush's teeth are so bad that he eats only one meal a day to avoid chewing.

“I shy away from meats and things. I told my dad that I’m running out of teeth to chew with. No big deal," he said. "I’m probably going to end up with dentures.”

Bush, who lives in Bedford, Mass. started seeing a dentist three years ago for the first time in decades.

But his timing wasn’t ideal. In 2010, just after getting his initial dental exams and cleanings, MassHealth, the state's program for low-income residents, cut its budget dramatically. Critical dental benefits were eliminated from the plan: fillings, crowns, root canals, and dentures were no longer covered. Extractions, for better or worse, were spared.

The problem isn't isolated to Massachusetts. In states across the country, adult dental services provide an easy target for cash-strapped lawmakers looking for cuts, according to a 2011 report by the Institutes of Medicine, “Access to Oral Healthcare for Vulnerable and Underserved Populations.”

One reason, the report points out, is that Medicaid requires dental coverage for children, but not for adults. It referred to a February 2011 letter to states from the U.S. Department of Health and Human Services reminding them that Medicaid savings can be achieved via adult dental cuts.

“While some benefits, such as hospital and physician services, are required to be provided by State Medicaid programs, many services, such as prescription drugs, dental services, and speech therapy, are optional,” the HHS letter said.

So, many states are scaling back on the adult programs. Others are already moving to restore certain dental services after struggling with some unintended consequences due to earlier cuts.

Heading To The ER Instead Of The Dentist

For example, some states that track dental-related emergency room visits are seeing much higher costs. And physicians unable to treat dental problems are generally handing out opiate painkillers and antibiotics, according to Centers for Disease Control data cited in The New York Times.

Dental problems are sometimes perceived as less important, or somehow distinct, from overall wellness and good health, studies show.

But the 2011 IOM report advised governments and universities to integrate oral health into overall health programs in order to improve access to services and remove disparities.

“The enduring separation of oral health care from overall health care has marginalized issues related to oral health,” the report said.

An elderly woman on MassHealth exhibits the results of poor, erratic dental care over the years.
An elderly woman on MassHealth exhibits the results of poor, erratic dental care over the years.

An aside: I know this from personal experience. A close relative who is mentally ill and on MassHealth has black front teeth due to multiple, untreated cavities and old fillings that are falling out. After waiting two years for a dental appointment, she recently had the two most painful teeth pulled, though they could have been saved with fillings. (She also has 40-year old fillings that need replacing, but has no disposable income to pay for treatment.)

Another close relative, an elderly woman, also on MassHealth, has been trying to get dentures for several years because she only has five teeth left. She can't afford care, though, and today I'm taking her to my own dentist for an emergency appointment, paying out of pocket, because her teeth became so jagged they were stabbing her in the tongue.

As for Mike Bush, even though he is now going to the dentist, he can't afford the treatment. He's done his best to keep from breaking his decaying teeth. And after the last dental visit he learned he needs six fillings, and something has to be done about his 10 missing teeth – mostly molars.

His gums hurt when he chews, he says, but he’ll live with it until he can find a way to pay for the dental work.

“If I hit the lottery, I’d get implants,” he said.

Requesting The "Soft Menu Option"

Carrie Endicott, the director at Elm Brook Place, a rehabilitation facility for the mentally ill in Bedford, said that all of the dental cuts have had profound impact on the members’ nutritional health - and on their ability to get jobs.

“People come here for vocational reasons to get back into the job market and you know it’s hard to go on an interview when you are missing half of your teeth," she said. "They are self conscious about smiling.”

Endicott added that salads and raw vegetables are often left untouched. “It’s tough. Members have asked for a “soft menu option” for people who can’t chew...You can’t push raw vegetables on people who are missing half their teeth,” she said.

The Mentally Ill More Likely To Suffer

About 20% of Masshealth subscribers are physically or mentally disabled adults – not including those living in nursing homes.

People suffering from mental illnesses are 3.5 times more likely than the general population to go without teeth, and also have significantly higher rates of tooth decay, according to a 2011 meta-analysis published in the British Journal of Psychiatry.

Mark Etheridge has learned to conceal the fact that he has no "uppers."
Mark Etheridge has learned to conceal the fact that he has no "uppers."

Mark Etheridge, 47, suffers from Bipolar disorder.

At Elm Brook, he’s discovered a passion for cooking. Another thing he's learned: how to conceal the fact that he has no “uppers.”

“I stick my tongue out to kind of hide it a little bit when I smile,” he said.

A Fix In The Works
After intense lobbying by consumer advocacy groups like Health Care for All, and complaints from dentists and patients, Massachusetts lawmakers devised a plan to partially address the problem.

Last month, the state Senate passed an amendment to reinstate some of the dental services that were cut from MassHealth in 2010. If the Senate amendment survives, an infusion of $7.2 million would be added back to cover anterior fillings.

State Representative John W. Scibak of South Hadley said that by addressing front teeth as a first step, it would at least help people who are interviewing for jobs.

This won’t get Etheridge his uppers, and Bush will have to wait for his molars.

Coverage for cleanings and extractions will continue, but anything beyond those services would require out-of-pocket payments.

Pulling Teeth Instead of Filling Cavities
Scibak supports full reinstatement of services, and views the amendment as a first step toward that goal. He says the current system of emergency-room dental care is not only expensive but it’s also bad medicine, with the wrong specialists working on the wrong problem.

“Clearly if you go to the emergency room for a dental problem, A: It’s going to cost far more than if you saw a dentist. And B: In many situations the person in the emergency room may not be able to address your problem other than perhaps giving you pain medications or treating what may be a localized infection,” said Scibak

He says he’s heard from dentists and constituents that some of the 700,000 adults on MassHealth are having teeth pulled that could be saved with fillings, while others use hospital emergency rooms for tooth pain and infections. While the overall number of poor patients seeking out such services because they can't pay for more appropriate dental care is unknown, a spokesperson for Health Care for All says in the last two months alone, the nonprofit has received 71 calls specifically about problems related to dental care.

Elm Brook’s Endicott said her clients' bad teeth continue to haunt her. She told the story of one man she has known for 17 years:

“While we were having lunch together one of his teeth just snapped and fell out of his mouth," she said. "Then another one chipped...his mouth was disintegrating while we were having lunch. And to look at his teeth now they, I mean they are just kind of like stalagtites; they're just a fraction of normal teeth.”

Dianne Finch is a freelance journalist and multimedia producer in Rockport, Mass. She'd like to thank Leslie Johnson for helping with reporting at Elm Brook.

This program aired on June 22, 2012. The audio for this program is not available.

Rachel Zimmerman Twitter Reporter
Rachel Zimmerman previously reported on health and the intersection of health and business for WBUR. She is working on a memoir about rebuilding her family after her husband’s suicide. 




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