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.