Dr. Philip Higgins, chief dental officer at Penobscot Community Health Care’s Dental Center in Bangor, winces a little when he hears people talk about lack of access to dental care in Maine.
“Access to care is not the issue. There are barriers to care,” he said, standing in a room filled with dental stations, patients and their hygienists at the clinic on Union Street.
If access to clinics were the prime dilemma, a solution would be more obvious: more providers, more clinics. It may be harder to get to a dentist in a rural area than an urban one, but Higgins knows of about 20 clinics for low-income individuals that are all accepting patients. Penobscot Community Health Care, for example, sees anyone who walks through the door.
The barriers, especially to preventive care, are complicated and varied — cultural, educational, financial. They also have real consequences for the state’s health and wealth. As lawmakers and members of many expert panels over the years have debated reform measures, Penobscot Community Health Care, which has another location in Old Town, has been working on the ground to implement them. The clinic should measure, and the state should watch to see, how the reforms change oral health in the greater Bangor area and beyond.
The center, which also provides medical care, has become a first line of defense for the poor seeking care. It’s the largest federally qualified health center in Maine and the third or fourth largest out of the approximately 100 in New England. Federally qualified health centers are “safety net” providers in underserved urban and rural communities. Penobscot Community Health Care’s budget in 2013 was $60 million, with less than 4 percent coming from federal grant money for operations.
Most of the patients don’t have the ability to pay. At the dental center, 44 percent are eligible for MaineCare, the state’s version of Medicaid. Another 24 percent self-pay or use the clinic’s sliding fee program, which offers free or discounted care to the underinsured or uninsured. The remaining 32 percent have commercial insurance.
What are Maine’s dental problems that need addressing? First, Maine spends more money fixing oral health problems than preventing them. For those between 15 and 44 who are uninsured or have MaineCare, the No. 1 reason they go to the emergency room is not for something like physical injury but, rather, untreated dental disease, according to the Muskie School for Public Service. The high use of emergency rooms is a problem not just because it’s more expensive but because they can’t treat the underlying dental disease. And oral infections don’t just cause pain and school or work absences. They are linked to diabetes, heart disease and stroke.
But if you have a bad toothache, and your gums won’t stop bleeding — something that happened to one of Higgins’ patients — you’re not going to wait until you can schedule an appointment with your dentist. You’re going to the emergency room. And that’s just what Higgins’ patient did before he was referred back to Penobscot Community Health Center’s dental center. If he’d known the center would have seen him, he could have saved the visit and expense. The center has walk-in care — 8 a.m. to 4 p.m., Monday through Friday — precisely because it’s trying to reduce the number of people who show up at the emergency room. The service started in 2010.
Of course it would have been even better if the patient hadn’t required emergency services at all and had previously received consistent preventive care. The problem, however, is that the people most likely to need preventive care can’t get coverage for it under MaineCare. MaineCare covers expensive extractions but not cleanings. It should, dentists agree. Otherwise the cost snowballs; covering preventive care should be cheaper in the long run.
But even if MaineCare covered one cleaning per year, it wouldn’t solve the whole problem. People would still need to act on the fact that cleanings are worth it. They’d need to hold their dentist appointments, and they’d need to brush and floss regularly at home. Experts call it “oral health literacy.”
It’s hard to change social behavior, especially among those who have to miss work and travel far to get to the dentist and who don’t know others who get their teeth cleaned regularly. Many of the center’s patients are “pain oriented,” Higgins said, meaning they come in when they have pain, instead of taking steps to prevent the pain in the first place.
“The real challenge is getting people to buy into care when they don’t think they have a problem,” Higgins said.
Some dentists have tried incentives to get people to follow through. Other providers have opted to home in on one or two attainable goals for their patients. Dental practices have developed public ad campaigns and fliers with easy-to-understand language and pictures.
As for Penobscot Community Health Care, one thing it’s doing is changing its intake process, so a patient’s first appointment is longer and focuses on both a restorative and preventive diagnosis. The center also offers dental hygiene services through a clinic located at Brewer Community School to underscore prevention at an early age. Opened in 2012, it’s the only school-based health center in Maine with a dentist on staff, said Director of Communications and Medical Education Sarah Dubay.
Prevention also starts long before school — with infants. Sheila Brijade, Penobscot Community Health Care’s pediatric dental residency director, emphasized early education for parents is key. They should bring their babies to the dentist within six months of the eruption of the first tooth — or by one year of age — to talk about what to expect. It’s a comfortable visit, Brijade said, meant to prepare parents for the oral care ahead and avoid complicated rehabilitation when the baby grows up.
Other good things for parents to know? Don’t let your child take little sips of juice from a sippy cup all day, as the consistent contact with sugar increases the risk of tooth decay. Also, don’t put your baby to sleep with a bottle of milk. The fluid stays in the child’s mouth as he or she sleeps, leading to decay. Believe it or not, baby teeth are important. They are space holders for permanent teeth, and if children lose them early to rot, it could cause problems later when the molars push through. Also, starting kids out right with brushing and flossing is just a basic way to form healthy habits.
There are other challenges for providers, such as the fact that clinics can’t bill for services provided by externs, who are dental school students guided by a supervisor. In addition, for many years, policymakers worried there weren’t enough dentists being drawn to the state. So Penobscot Community Health Care started a residency program in 2008 where dentists come to gain experience after they complete dental school. The pediatric residency program began in 2011.
So far, out of about 20 people who have completed the programs, eight dentists have remained in Maine, and most have gone to serve in public health dental practices, Dubay said.
One of them, David Miller, 27, started as an extern at the center while at Tufts University. He’s been on staff as a dentist for about three months. Originally from Florida, he said he never dreamed he’d end up in Maine.
After much time spent discussing problems, his view was refreshingly positive. He’s up for the challenge. He likes seeing a variety of patients, he said. “Working in a big clinic is fun and exciting.”
It’s a view on which Maine needs to capitalize — the will to see problems differently and to address them head on, with enthusiasm.