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Kids’ tooth-pulling expenses are higher than cleaning costs

With each breath of the gas, she was floating higher, fingers tingling, belly tickling, her worries so washed away that she scarcely noticed the syringe needle slowly descending toward her open mouth.

Six-year-old Madison Salisbury would have a present to put under her pillow for the tooth fairy tonight.

“Are you flying on the magic carpet?” asked Dr. Bridget Boggs Stevens, Madison’s dentist.

Stevens grabbed an elevating tool to pry up Madison’s infected tooth, then reached for a pair of forceps.

“We’re going to wiggle, wiggle, wiggle,” Stevens said. “Won’t that tooth dance with me?”

Madison kept sniffing the bubble gum-scented nitrous oxide through the plastic “piggy nose.” She never flinched.

In seconds, the decayed tooth popped out, and Madison left with a fistful of “High School Musical” stickers and a cheekful of blood-soaked gauze.

Madison, a Putnam County first-grader, is one of thousands of West Virginia children who have their teeth extracted every year at the state’s expense.

And while health officials and lawmakers say prevention is the solution to reversing West Virginia’s widespread oral health problems, the state Medicaid office is pouring tens of millions of dollars into filling teeth and taking them out.

In each of the past four years, West Virginia dentists have billed the state more to pull children’s teeth than to clean them, Medicaid claims data show.

From 2003 through last year, the state was billed more than $15 million for children’s tooth extractions, and $13 million for cleanings.

More than 31,800 teeth were pulled last year alone.

“That’s heartbreaking,” said Gina Sharps, a dental hygienist and assistant director of WVU’s Childhood Oral Health Project. “We’re obviously not doing enough wellness and prevention. Children’s oral health is so important to their overall health.”

The Gazette analyzed more than 3.3 million Medicaid claims submitted by dentists since 2003. Among the findings:

s The state is spending more pulling and filling teeth than on prevention measures, such as cleanings, fluoride treatments and cavity-fighting sealant applications. Last year, the Medicaid office spent $11 million on children’s extractions and fillings, but only $6 million on prevention treatments.

s The number of cleanings, fluoride treatments and sealants all decreased from 2003 to 2006. At the same time, extractions also declined — a positive sign.

s Routine teeth cleanings dropped from 95,566 in 2003 to about 87,971 last year. And they’re on pace to decline even further, to about 86,000 at the end of this year.

A Medicaid spokeswoman said she wasn’t surprised that the state was paying more for “acute dental care” than prevention — a common practice for Medicaid recipients with other illnesses and diseases. The state spends about $32 million a year for children’s dental services.

“A lot of our members access the medical system for crisis, not for prevention,” said Shannon Landrum, executive assistant to the state Medicaid commissioner. “It’s our goal to change that. The governor has directed us to provide the right care, at the right place and the right time.”

Dr. Stevens sees the extent of the state’s oral health problems every day.

The Dunbar dentist treats children with rampant decay who live up to 70 miles away — from Beckley, Parkersburg and Huntington — whose parents say they can’t find a dentist who accepts Medicaid close to home.

Children as young as 2 will show up needing more than half of their primary teeth extracted — and the rest drilled and filled with composite.

They bring her gifts — coffee mugs filled with peppermint candies, paintings of “good teeth” and “bad teeth” — and drop into the dentist’s chair, waiting for the piggy nose and laughing gas that gives them the giggles.

“Children are in terrible pain,” Stevens said. “They can’t eat. It’s absolutely hideous. Just horrific. There’s such a crisis.”

Few Medicaid-covered children see dentist

Most of the 200,000 West Virginia children covered by Medicaid don’t see a dentist, even though they’re entitled to a full menu of dental services.

At last count, about 64 percent of kids with Medicaid weren’t going to a dentist, according to 2003 data from the federal Centers for Medicare & Medicaid.

By contrast, about 95 percent covered by the state Children’s Health Insurance Plan, which provides benefits for low- and middle-income children, visit a dentist at least once a year.

At Stevens’ practice, children with Medicaid routinely miss appointments. Their parents don’t call to cancel. Stevens books three Medicaid children for every 45-minute slot, figuring one child, at most, will show up.

“If everybody shows up, we are doomed,” said Vickie Moonie, a hygienist who works for Stevens. “It’s so crazy.”

Stevens keeps track of missed appointments. Some children covered by Medicaid skip up to a dozen times, and that puts their health in danger, she said.

Stevens often prescribes antibiotics for children who have abscesses before they come in to have their teeth extracted. She schedules their appointments after they’ve nearly finished taking all of their medication. In some cases, the pain goes away, and parents don’t bring their children back in.

Once the pills run out, though, the pain returns, and Stevens has to prescribe a new round of antibiotics and schedule another appointment. The problem never gets fixed.

“We see kids so infected, so swollen,” Moonie said. “They can’t even eat. It’s just neglect.”

Parents of children covered by Medicaid complain that they can’t get a ride to the dentist’s office and can’t find child care. They move from apartment to apartment. Their telephone number changes, and Stevens’ staff can’t reach them to confirm appointments.

Many parents say they can’t find a dentist who takes Medicaid, Stevens said.

“They’re coming to us from all over the state,” she said. “So many providers aren’t taking the medical card.”

‘We lose money’

Nearly 60 percent of West Virginia dentists billed the state for dental services at least once last year, according to Medicaid claims data. However, Stevens and other dental professionals believe the number of dentists accepting Medicaid kids is much lower.

Only about 40 percent of oral surgeons in West Virginia will see patients with Medicaid benefits, according to Dr. Byron Black, who conducted a recent survey.

In fact, Black’s Charleston practice, Mountain State Oral and Maxillofacial Surgeons, is the only oral surgery office that accepts Medicaid in Southern West Virginia, he said.

On a recent morning, a Monroe County family drove their 16-year-old daughter, who is covered by Medicaid, to Charleston, a 2-hour and 30-minute trip. The girl needed her wisdom teeth removed.

“She drove by four oral surgery offices to get here,” Black said.

His office receives more than a dozen calls a day from Medicaid recipients with toothaches and abscesses.

The soonest Black and his partners can see them? March or April.

“We have to tell them we’re booked out,” said Black, who figures his office can see no more than 15 percent of Medicaid patients and stay in business.

The reason: West Virginia Medicaid reimburses dentists at some of the lowest rates in the nation.

The state raised reimbursement fees for fillings and cleanings in 2001, but reimbursement rates for emergency extractions haven’t been increased since 1992.

West Virginia pays dentists and oral surgeons $44 to extract a tooth. Dentists in the surrounding south Atlantic region receive $193 on average, according to American Dental Association data.

A West Virginia Medicaid advisory board has twice recommended raising reimbursement rates for emergency and surgical tooth extractions, but the state Medicaid office hasn’t adopted the proposal.

Last week, members of a legislative committee examining oral health care also recommended a rate hike.

“People just aren’t being seen, and it all comes back to reimbursement,” Black said. “We lose money when we see these patients.”

Children’s health can deteriorate rapidly when they don’t get proper care for an infected tooth. Many wind up in hospital emergency rooms where they’re given prescriptions for antibiotics and pain pills.

“These people become extremely ill,” Black said. “The overall cost to the state of West Virginia is astounding.”

Drilling and filling increase

Erica Lloyd’s older sister told her the dentist was “going to stick a needle” in her tooth, so it wasn’t surprising she was a bit apprehensive when she climbed into the chair at Dr. Stevens’ office.

Then the nitrous oxide started to work its magic, and the 7-year-old felt like a princess.

“I’m feeling giddy,” Erica told Dr. Stevens during a recent visit. “You’re going in circles and circles. I love the piggy nose!”

“You’re on the roller coaster,” said Stevens with a smile, picking up the drill — “Mr. Whistle” — and working on the first of Erica’s two cavities.

Across the state, dentists are drilling and filling more children’s teeth every year.

Fillings increased by 36 percent — from 48,749 in 2003 to 66,362 last year, Medicaid claims data shows.

Last year, the state spent $5.1 million to fill kids’ teeth — $2 million more than it spent to clean them.

“A lot of the kids are 2 or 3 years old, and they need 15 fillings,” said Sarah Ryan, a hygienist who works for Stevens. “It’s disheartening. It’s sad.”

Erica needed only four fillings: two on this day, two later this month.

Her mother must sometimes brush and floss Erica’s teeth at night because she’s not always good about brushing them herself — especially her back teeth. She also chews ice, which can break teeth and sealants, her mother said.

Stevens kept coaxing Erica to breathe through the “piggy nose,” while she was catching “bugs” — or decay — with Mr. Whistle.

Minutes later, both teeth were filled, and Erica gave Stevens a high-five.

“Great job, sweetie,” Stevens said.

Erica sniffed oxygen for a few minutes to clear her head, then slipped out of the dentist chair, heading straight for the stickers and box of prizes.

“Mommy, can I come back tomorrow?” she asked.

To contact staff writer Eric Eyre, use e-mail or call 348-4869.


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