Big Gaps in Dental Health With ‘Patchwork Efforts’ to Address Access, Affordability

  • Hygenist Janine Reeves of the The HealthHUB School Clinic examines fourth-grader Julia Bowen's teeth at the school clinic on Sept. 9, 2017 at Whitcomb Elementary School in Bethel, Vt. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Hygienist Janine Reeves waves to a teacher before escorting a student to her dental trailer at Whitcomb Elementary School on Sept. 6, 2017, in Bethel, Vt. The HealthHUB School Clinic sees students from South Royalton, Strafford, Chelsea, Sharon, Bethel, Tunbridge, Orange, Washington, Stockbridge, and Williamstown. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Carl Kesseli, of West Lebanon, N.H. is seen by hygienist Sandy Joslin while his wife Sally Kesseli waits for her after her appointment on Sept. 11, 2017 in White River Junction, Vt. Ottauquechee Health Foundation Smiles Program of the Upper Valley provides basic dental hygiene information, oral health screenings, fluoride varnish at in White River Junction, Program coordinator Tonya Hoyt works on her computer during the visit. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Dentist Henry Lemieux examines new patient Eric Olson's teeth as assistant Caroline Sumner takes notes at the Mascoma Community Health Center in Canaan, N.H., on Sept. 12, 2017. Olson, of Canaan, currently does not have dental insurance because his wife recently retired and was paying for the visit from his Health Savings Account. The dental clinic opened on Sept. 1 and accepts patients with with commercial insurance, Medicaid as well as the uninsured. (Valley News - Geoff Hansen) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

Valley News Staff Writer
Saturday, September 23, 2017

White River Junction — Hartford resident Nicole Hopkins, who works as a cashier at a gas station in Hanover and is covered by Medicaid, recently attended a free dental clinic held by the Ottauquechee Health Foundation at the Vermont Department of Health office in White River Junction.

The 34-year-old Hopkins — who is a smoker and has missing and cracked teeth — came to the clinic in hopes that the foundation might connect her to a new dentist who would accept her insurance after her former White River Junction-based dentist, John Holbach, retired this summer.

“There’s not enough places (that accept Medicaid),” Hopkins said.

Community groups such as the Ottauquechee Health Foundation, where a hygienist suggested Hopkins give up soft drinks and take out her lip ring, are stepping up to try to help people like her get the dental care they need.

And they are doing so because Hopkins is far from alone in her oral health issues.

In the Upper Valley, one in six adults is considered to have poor dental health, according to a 2015 community health needs assessment of the Mary Hitchcock Memorial Hospital and Alice Peck Day Memorial Hospital service area in both states.

Of the 429 people surveyed for the assessment who had trouble accessing medical services, more than 38 percent had difficulty accessing dental care for adults, which outpaced the difficulty they had in accessing primary and mental health care. Those with lower incomes were more likely to struggle to find a dentist, according to the report published by the two hospitals.

Family habits, geography, affordability and the lack of interaction between dentists and doctors all play a role in the continuing gap in access to dental care, according to Robin Miller, Vermont’s oral health director.

“There are big barriers in terms of moving the curve on closing the oral health care disparities, but I’m hopeful,” Miller said.

School-based clinics, a new treatment known as silver diamine fluoride that hygienists paint onto cavities to prevent further decay, community water fluoridation, integrating oral health care into primary care, spreading the word that oral health is important to overall health and expanding insurance coverage will all likely play a role in addressing the state’s dental health needs, she said.

“Oral disease is such a complex and multifaceted issue,” said Miller. There’s “not one magic bullet.”

Coverage Caps

One limiting factor in terms of access to dental care is that publicly funded health insurance programs are restricted in the services they cover. Medicare, the health insurance program for people over the age of 65, provides no dental benefit in any state. (The Medicare for All Act of 2017, introduced by U.S. Sen. Bernie Sanders, I-Vt., earlier this month, would expand Medicare to cover everyone and would include coverage for dental, vision and hearing aids, which are not currently covered under the law.)

In New Hampshire, where about 87,000 adults and 96,500 children under age 21 are covered by Medicaid, dental coverage for adults is limited to treatment, primarily tooth extraction, to relieve acute pain and infection.

New Hampshire’s limited Medicaid coverage was a factor for Alex Annunziata, a 36-year-old Hartford High School graduate who is five months sober, lives at the Upper Valley Haven and commutes by bicycle to a job at Cravin’s Country Market & Deli at Dartmouth-Hitchcock Medical Center.

After struggling with dental problems for years, Annunziata had his 19 remaining teeth pulled at Community Dental Care of Claremont in January. Without teeth, his lips curve in. Annunziata, who also has long battled an addiction to opioids, speaks clearly, though, and takes responsibility for the deterioration of his teeth.

“This is all definitely my mistake,” he said in an interview earlier this month. “I should have taken better dental care, been more proactive about it.”

He is now saving up to get dentures.

“Personally, I really feel very bad that our adults get extractions and then no teeth (are) replaced,” said Dr. Sarah Finne, dental director for New Hampshire’s Department of Health and Human Services. “Unfortunately, my job is to administrate what we do have.”

In Vermont, where 96,000 adults and 72,000 children are covered by Medicaid, the program includes dental cleanings, but caps annual dental expenditures for adults at $510, which often doesn’t go far enough.

“You could go in with a dental cleaning (and) be presented with a $3,000 dental treatment plan,” said Miller.

The picture is brighter for children with Medicaid coverage in both states. According to the 2015 community health needs assessment of the Mary Hitchcock and APD service area, of the people who had difficulty accessing medical services, just 9 percent had a hard time finding a dentist for children.

In Vermont, there is no cap for preventive dental care for children up to age 21 enrolled in Medicaid, Miller said. About 55 percent of children covered by Medicaid in Vermont used their dental benefit last year.

The cap is also lifted for pregnant women and for postpartum mothers for 60 days following the birth of their children, Miller said.

New Hampshire children up to age 21 enrolled in Medicaid are also covered by a comprehensive benefit, Finne said. It covers screenings, exams and preventive care without question, but services such as orthodontics and third molar extraction are subject to an additional review by a state official, Finne said. There is no additional coverage for pregnant or postpartum women.

“We only have so much funding,” she said.

Finding a Provider

Many Medicaid recipients do not use even the limited benefit they are allowed. In Vermont, just 25 percent of adults covered by Medicaid used their dental benefit last year.

One reason for this may be that even when a service is covered by Medicaid, it can be a challenge for patients to find a provider. Medicaid reimbursement rates are substantially lower than those of commercial insurers.

As a result, dentists often restrict the number of Medicaid patients they treat.

In New Hampshire, the Medicaid reimbursement rate is less than 50 percent of the cost of the service to the practice, said Sally Bouchard, executive director of the nonprofit Community Dental Care of Claremont, which is one of the few dental practices in the Upper Valley that is accepting new Medicaid patients.

For example, if a filling costs the practice $252 in supplies and staff time; New Hampshire Medicaid will pay $111, Bouchard said.

Medicaid recipients on the Vermont side of the Upper Valley recently lost a key access point when Dr. John Holbach, a White River Junction dentist employed by the Vermont Department of Health Access, retired this summer.

“It definitely for us creates a hole in access in that region because he had been serving Vermont Medicaid patients pretty much exclusively for a long time,” said Cory Gustafson, commissioner of the Department of Vermont Health Access.

Holbach’s retirement left about 520 patients without a dental home, Gustafson said.

The department has been unable to find a dentist to replace Holbach, whose office was co-located with Red Logan Dental Clinic — the only free, restorative dental clinic in the Upper Valley — in White River Junction.

Holbach’s retirement has had a ripple effect on Red Logan’s patients. Red Logan is primarily staffed by dental students who, without a volunteer supervising dentist, cannot do more than offer oral health screenings. Holbach would often act as a fallback supervisor when other volunteer dentists couldn’t be found, said Dana Michalovic, the executive director of Good Neighbor Health Clinics, which includes Red Logan.

To qualify for the free care provided at Red Logan, patients must be at least 21 years old, live within 30 miles of White River Junction, earn less than 250 percent of the federal poverty level and be without dental insurance.

Red Logan, which sees about 630 patients annually, considers adults with New Hampshire Medicaid to be without dental insurance, but does not treat patients with Vermont Medicaid.

Red Logan has a waiting list of 65 patients seeking to be seen and is considering hiring an additional hygienist to do more cleanings, Michalovic said.

“We’re always asking ourselves, ‘How can we see more people?’ ” she said.

Expanding Benefits

Beyond trying to help Holbach’s patients find a new dentist, Gustafson, who was appointed by Vermont Gov. Phil Scott last December, said, “we’re also thinking about, how do we evaluate our dental benefit in general?”

The Vermont State Dental Society also hopes to move the needle on Medicaid coverage for adults, said Vaughn Collins, the society’s director.

He noted that when Medicaid patients have unmet dental needs, they may end up in the emergency room, which is more expensive and doesn’t address the patients’ primary problem.

While many dentists in the Upper Valley do take some Medicaid patients — 70 percent of Vermont dentists accept Medicaid, according to the Dental Society — they often restrict the number they see because Medicaid patients are more likely than others to miss those appointments. The reasons for that include issues relating to transportation, difficulties in taking time off from work, including lost pay, child care issues and other pressing needs that may come up unexpectedly.

The cap on coverage for adults also leaves some dentists feeling that they can’t meet Medicaid patients’ needs, Collins said.

“Some dentists get a little bit skittish about that,” he said.

But, Collins added, increasing Medicaid coverage isn’t the only way to make headway. Community-based public health dental clinics offer expanded cavity prevention through sealants, fluoride varnish, cleanings and oral health education, as does fluoride in drinking water, he said.

Cavities are “almost 100 percent preventable,” he said.

In New Hampshire, policymakers and public health officials are talking about expanding the state’s Medicaid benefit, said Gail Brown, the director of the state’s Oral Health Coalition.

But, those talks are unlikely to lead to any near-term changes, she said.

Brown and other public health advocates are trying not to lose ground they’ve already gained in expanded Medicaid coverage through the Affordable Care Act, for example.

“I think that our primary focus right now needs to be to maintain the health care coverage that we currently have,” she said.

Creating a Philanthropic Network

To help connect patients with dentists who will accept them, Alice Ely, director of the Public Health Council of the Upper Valley, said she’d like to compile a list of which dentist is providing which community service, whether it’s volunteer time or free or reduced-cost care.

“The challenge for many of us is that we don’t have one coordinated system for asking dentists for some sort of donation for the public good,” she said.

With a more strategic approach, Ely said, community groups “might be able to engage dentists more to say, ‘What can you do to help out here?’ ”

Dentists such as Dr. Rebekah Lucier, of Upper Valley Endodontics in White River Junction, are willing to do their part. Upper Valley Endodontics donates root canals for patients referred to them by Red Logan Dental Clinic.

“It’s just a commitment that I’ve chosen to make to the community in which I live,” Lucier said.

Lucier also serves on the board of the state’s Dental Society. She said she’s not alone in her commitment to the community.

“A lot of dentists come into (Red Logan) and volunteer their time,” she said. “We as dentists have a lot of skills and a lot of talents. With that comes a responsibility to take care of people in the community in which you reside.”

School Clinics

In an effort to address the problem at a community level, groups in both states have set up clinics in schools, senior centers, health department offices and other locations commonly frequented by people with unmet oral health needs.

Some of these efforts are long-established, while others are newer and in the process of expanding, such as the new Canaan-based Mascoma Community Health Center, which accepts both Vermont and New Hampshire Medicaid.

The efforts certainly make a difference for those who receive care in this way, but most involved agree that the need continues to outstrip community organizations’ capacity to address it.

“The ideal scenario of course is for everybody to have regular dental care, but the reality is until there is affordable dental insurance for everybody, we sort of have to make due with these patchwork efforts,” said Nancy DuMont, who coordinates Upper Valley Smiles, Alice Peck Day Memorial Hospital’s school-based dental care program.

On a rainy morning earlier this month, 9-year-old Julia Bowen crossed her floral legging-covered legs on a dental chair in a mobile dental office parked outside Bethel Elementary and Whitcomb Junior and Senior High schools as she prepared to have her teeth examined and cleaned.

Wearing red scrubs, Janine Reeves, the new dental hygienist for HealthHub, which provides medical, dental and mental health services in schools in the White River Valley, asked Julia about her teeth. None were loose and she wasn’t experiencing any tooth pain, Julia said.

“How many times a day are you brushing?” Reeves asked.

Julia held up two fingers.

“Do you floss?” Reeves asked.

“Sometimes,” Julia said.

“That’s the part that’s hard to remember to do, right?” Reeves said.

Reeves gave Julia a tooth-brushing lesson, showing her how to look in the mirror to ensure that her bristles hit her teeth in the right spot.

“Jiggle, jiggle, jiggle,” Reeves said. “Point the bristles down toward (your) gums.”

Reeves also took X-rays of Julia’s teeth, cleaned them, applied a fluoride varnish and checked her sealants before sending her back to her fourth-grade classroom, advising her not to eat anything hard or hot at lunchtime to protect the varnish.

Following the visit, Reeves forwarded Julia’s X-rays and notes about her visit to Julia’s parents and HealthHub’s supervising dentist Tara Symancyk, who practices in White River Junction.

Reeves will repeat this with students across the White River Valley and Orange North supervisory unions throughout the school year and into the summer months.

Such community efforts are numerous and growing.

In addition to HealthHub and Upper Valley Smiles, other school-based oral health programs in the Upper Valley include a school-based program in Claremont operated by Community Dental Care of Claremont; the Molar Express, which serves schools, nursing homes and senior centers in Coos and northern Grafton counties; Mt. Ascutney Hospital and Health Center, which provides a school-based program in Windsor Schools; Springfield Medical Care Systems — a federally qualified health center — which last year began providing free cleanings, fluoride varnish and sealants in Springfield, Vt.-area schools.

As federally qualified health centers, Springfield and Gifford Medical Center in Randolph offer financial assistance for dental services to those who qualify.

Since 2007, Upper Valley Smiles has provided 18,293 sealants — thin plastic coating applied to molars to protect them from decay — to children in the Upper Valley, said DuMont.

“That’s a lot of prevention, which we’re really very proud of,” DuMont said.

In addition to providing sealants, the hygienist employed by Upper Valley Smiles also provides basic dental hygiene information, oral health screenings, fluoride varnish and temporary restorations to elementary-age children in Lebanon, Enfield, Canaan, Hartford and Hartland, and in the Richards School in Newport, DuMont said.

School-based dental clinics do make a difference in preventing tooth decay, said Bouchard, Community Dental’s director. Bouchard’s group, through a school-based dental clinic, has helped to bring down the rate of untreated decay in Claremont elementary students from 65 percent to 15 percent over the past eight years, she said.

“We know that we are doing the work, (we) just need to keep pushing,” Bouchard said. “What’s the reason behind that last 15 percent?”

For more serious and permanent restorative work, community groups offering school-based clinics refer children to dentists.

The “goal is always to get those kids into a dental chair eventually,” DuMont said.

That goal isn’t always met, however.

Some parents don’t have reliable transportation to get their child to a dentist; others can’t afford to miss work.

There’s also sometimes an emotional component that can prevent someone from seeking dental care for their children or for themselves, DuMont said.

“Sometimes parents who haven’t been able to get regular dental care for their children are embarrassed,” she said. “There’s a little bit of that. ... It’s complicated.”

Clinics for Adults

It’s a similarly complex task to connect adults like Hopkins, the Hartford resident, with dentists, but Upper Valley groups are trying by beginning to offer place-based dental clinics for adults in schools, senior centers and health offices.

The HealthHub’s Reeves, who started this year, is now offering services to adults — parents, school employees and other members of the community. Those visits will take place during the summer months, as well as during the school year.

“(We’ve) always known that there’s been a need,” said Jane Bennett, HealthHub’s administrator. “We found the right person that was willing to work year round.”

In order to increase the number of patients Claremont Community Dental serves, the clinic is planning to double its office space near Opera House Square from 1,900 square feet to nearly 4,000 square feet in the next year and a half, said Bouchard, the director.

“It’s overwhelming what we could do with more space,” she said.

Another relatively new effort is the Ottauquechee Health Foundation Smiles program, which ran the free clinic Hopkins attended earlier this month. The foundation began offering these preventive screenings — open to anyone over the age of 18 who doesn’t have a regular dentist — in Woodstock and White River Junction in 2015, said Adrienne Sass, the organization’s executive director.

Though the screenings were initially targeted to seniors, the organization has since expanded to others and now holds clinics at the Upper Valley Haven, the White River Junction office of the Vermont Department of Health and the Thompson Center in Woodstock, Sass said.

The foundation soon plans to begin offering screenings in New Hampshire as well, continuing an effort piloted this spring and summer by the Public Health Council of the Upper Valley at the United Congregational Church in Orford, the Upper Valley Senior Center in Lebanon, the Mascoma Senior Center in Canaan and the HIV/HCV Resource Center in Lebanon.

To match a patient with a dentist, foundation employees turn to tools at their disposal, such as the foundation’s Smiles grants, available to help cover oral health expenses once other avenues have been exhausted, said Tonya Hoyt, the foundation’s program coordinator. They also assist patients in getting rides from Stagecoach, volunteer drivers, the Haven staff or through gas cards.

They don’t have all the answers yet. Some patients, because of their various struggles, even miss appointments at the free clinic, Hoyt said.

“It’s a puzzle,” she said.

Valley News Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.