Teeth get taken for granted. People postpone or can't afford trips to the dentist, and health insurance policies often omit dental benefits. Now years of collective neglect -- like a nagging toothache -- have reached a crisis in Maryland.
The state's Medicaid dental benefits are among the worst in the nation. A new study has found that more than half of the cavities in privately insured Maryland children aren't treated.
People in large rural areas of the state have no fluoride in their drinking water and wind up with lots of cavities.
The state ranked 27th nationwide in the number of people getting oral cancer, according to a 1993 study, but so few patients were screened and diagnosed that Maryland ranked fourth in deaths.
"There is a tremendous crying need," said Dr. Pat Higgins, president of the Eastern Shore Dental Society.
Experts say that, unlike medical care, dental care is seen as expendable, and benefits are often optional in health insurance coverage.
But the toll is great.
When cavities in children's primary teeth aren't fixed, there are serious consequences for their permanent sets of teeth, ultimately affecting chewing and speech.
Some cavities go untreated for so long that the infections eat away the gums and eventually force the underlying bone to recede.
Considered among the most excruciating pains that human beings endure, toothache was a major cause of suicide before painkillers were developed, dentists say.
Maryland children who aren't getting treatment are distracted in school by throbbing abscesses.
When Higgins organized Eastern Shore dentists in February to donate their services, one teen-ager was so desperate that he rode his bicycle through a snowstorm to get a root canal.
The uninsured improvise, rubbing alcohol on their sore teeth, drinking whiskey or trying to pull out the offenders themselves.
Some people are landing in hospitals with dangerous infections.
At Johns Hopkins Hospital, Dr. Steven Ashman, director of oral and maxillofacial surgery, said he has admitted at least two patients whose abscesses drained into their necks, causing life-threatening conditions.
"They can't get to a clinic or dentist for care, so they end up here, usually in pain and with abscesses," Ashman said.
"They take up the health care system at its most expensive end."
For the 467,000 poor and disabled Marylanders on Medicaid, this is particularly true.
When the state cut off dental benefits to adults in February 1993, researchers tracked a 21.8 percent increase in these patients showing up at the University of Maryland Medical Center's emergency department.
The rise occurred at the same time that fewer Medicaid patients overall were going to the emergency department, according to a recent University of Maryland Dental School study.
But the only treatment adults can get in the emergency room is painkillers and antibiotics.
The teeth causing the problem can't be pulled out, since even that basic service is not covered.
Nine states give no benefits
According to a 1995 national survey by the American Dental Association, eight other states in the country have no benefits for adults. The other 30 that responded to the survey all offered some dental benefits.
Maryland children on Medicaid do have dental benefits, but few dentists serve them because the state provides such paltry fees.
On average, they say they are paid about 20 percent of what it costs to provide the care.
Only 22 percent -- 41,911 of the 190,000 children in the state's main Medicaid program -- got dental care in fiscal 1995, according to a report by the state Department of Health and Mental Hygiene.
Another 75,000 children on Medicaid are in managed care, but their dental treatment is unknown.
Now, the inspector general's office of the U.S. Health and Human Services Department is looking into whether Maryland is violating federal law because its low payments to dentists discourage them from seeing the children.
Advocacy and other groups have already used court action to force three states to increase their payments to dentists.
Maryland's policies have left their mark.
Children eligible for Medicaid had 30 percent more cavities than the average child in the state, and 70 percent of their cavities go untreated, according to a study by Dr. Mark Wagner, professor of pediatric dentistry at the University of Maryland Dental School.
During the 1994-1995 school year, Wagner and his team examined 3,500 children in kindergarten and third, sixth, ninth and 12th grades.
He discovered that even among those with private insurance, dental care didn't seem to be a priority. Fifty-five percent of the cavities in children with private insurance had not been treated.
Wagner believes that may stem partly from parents' mistaken impression that baby teeth don't need attention.
Overall, among Maryland children, 45 percent of the tooth decay had been treated, compared with 79 percent nationally, according to Wagner's study.