Dental care hard to find for moms-to-be
Editor’s Note: This article originally appeared in the Milwaukee Journal Sentinel. It is being reprinted as part of a partnership between the Community Journal and Journal Sentinel to help address a critical issue in our community.
When Michelle Hamberlin learned she was pregnant in April, it gave her one more reason to seek treatment for a broken, abscessed tooth and swollen gum.
Dental infections during pregnancy can pose a risk to both mother and baby, experts say.
But for Hamberlin, 21, deciding to see a dentist was one thing.
Finding one was another. “I called everyone listed in the book,” said Hamberlin, one of more than 4, 700 pregnant women in Milwaukee County in July eligible for dental coverage through Badger- Care Plus, the state’s Medicaid program for pregnant women and families.
“They had a three-month waiting list, or their numbers were disconnected, or they said they weren’t tak- ing my insurance.” The Journal Sentinel found a similar result: Calls to all 55 dental clinics in the city listed on the state BadgerCare Plus website found only eight that were accepting new adult BadgerCare patients enrolled in the managed care organizations that administer the program. And most were booking new patients two to three months out.
Dentists say the low participation is due to the state’s Medicaid reimbursement – which, at about 40% of the billed amount, ranks fifthlowest in the country and often does not cover a dentist’s costs. The amount is less for those in a managed care organization, as are more than 90% of BadgerCare Plus patients in Milwaukee County. Hormonal changes during pregnancy make the gums more susceptible to swelling and infection, and some studies point to a link between gum infections and premature birth. For that reason, the state Department of Health Services recommends pregnant women see a dentist.
Yet just 35% of all Badger- Care Plus patients in Milwaukee County did so during the year that ended June 30, 2010, said department spokeswoman Stephanie Smiley. A breakdown of dental visits by pregnant patients was not available.
The lack of dental access points to a flaw in the Badger- Care Plus program at a time when state and local officials are striving to improve the health of low-income pregnant women in Milwaukee. More than two months after she began looking, Hamberlin still hadn’t found a dentist. By then, she was 14 weeks pregnant and in constant pain. Pieces of her tooth were breaking off in her mouth.
Link to preterm birth? Dentists emphasize the need for good oral hygiene and dental care before and during pregnancy.
In addition, a number of studies have found that pregnant women with periodontal disease – a more serious form of the gum infection gingivitis – are more likely to have a preterm or low birthweight baby.
Preterm birth caused 53% of infant deaths in Milwaukee during 2005-’08, according to the Milwaukee Health Department’s 2010 infant mortality report.
But because periodontal disease is more common in people with other risk factors for preterm birth – such as smoking or diabetes – not all researchers agree gum infections themselves are a cause. In addition, while treating periodontal disease during pregnancy has been shown to be safe, not all studies have found doing so lowers preterm birthrates.
Bryan Michalowicz, a dentist with the University of Minnesota, authored a study of 823 pregnant women with periodontal disease who lived in Minnesota, Kentucky and New York City’s Harlem.
About half the women were randomly selected to receive periodontal treatment during pregnancy. The rest were treated after giving birth.
The study, published in 2006 in the New England Journal of Medicine, found no significant difference between the rate of preterm birth or low birth weight between the groups.
“I think it’s fairly well settled that treatment of periodontal disease doesn’t affect these birth outcomes,” said Michalowicz.
Although several other large clinical trials showed similar results, researcher Marjorie Jeffcoat of the University of Pennsylvania strongly believes there is a link.
She did a study of 322 pregnant women with periodontal disease that found those whose disease was successfully treated during pregnancy had significantly lower preterm birthrates.
She attributes her findings to the study’s methods. Jeffcoat and colleagues selected only patients who had moderate to severe periodontal disease in the first place, and then measured preterm birthrates in women whose disease was effectively treated.
This year, Jeffcoat published another study of lowincome, mainly African-American women with periodontal disease who refused dental care. The study found that those who rinsed twice daily with an alcohol-free antibacterial mouthwash had preterm birthrates that were about one-quarter those of women who rinsed with just water.
Jeffcoat is now planning a larger study of the mouthwash that will enroll women in several cities. She stressed that no matter the results, using mouthwash shouldn’t take the place of going to a dentist.
“We know we need to study (the link between periodontal disease and preterm birth) more,” said Monica Hebl, a former president of the Wisconsin Dental Association. “But studies continue to strengthen the idea that women should consider a periodontal evaluation as part of their prenatal care.” Dental access problems The state’s dental access problems are well-known. As the Journal Sentinel reported two years ago, statewide, more than 300, 000 children in the BadgerCare Plus program didn’t see a dentist in 2007.
Of the dentists in Milwaukee County certified to bill the state’s Medicaid programs, including BadgerCare Plus, 42% submitted claims totaling less than $10,000 in the year that ended June 30, 2010, Smiley said. That suggests many dentists have few patients covered by BadgerCare Plus or Medicaid.
In 2008, a report by the state Legislative Audit Bureau found that the managed care organizations that administered Medicaid dental benefits in four southeastern Wisconsin counties had not fulfilled their contractual requirement to maintain an adequate number of providers or timely access to care. Despite a recommendation to pursue alternatives, the department expanded the model to include two more counties in southeast Wisconsin, a move the Wisconsin Dental Association opposed.
Health services deputy secretary Kitty Rhoades said she didn’t know why the department didn’t act on the bureau’s recommendation. But with a $1.8 billion deficit in the Medicaid program, she said, it was unlikely the state would increase the reimbursement for dentists. Instead, the department is trying “creative solutions” to improve dental access in southeastern Wisconsin, Rhoades said.
Under its current contract, beginning in 2012, if managed care organizations fail to meet certain benchmarks, the department can withhold up to 0.25% of what it pays them to provide services.
For example, 34.8% of adults continuously enrolled in BadgerCare Plus must use dental services in the year that ended June 30, 2011. That percentage increases to 38.3% this year and 42.1% the year after.
“It’s kind of the beginning of pay for performance,” Rhoades said. “Here’s what I hired you to do, and if you don’t get it done, you don’t get all your money.” Prevention important Preventing oral disease is key to overall health, dentists say. And that not only includes improving access to dental care, but making changes at home.
“We can’t drill and fill our way out of the problem,” said Hebl, a dentist at Burleigh Dental in Milwaukee, which treats Medicaid patients on Thursdays. “We have to educate people on the front end.” Jorelle Alexander, dental director of Milwaukee Health Services, agreed.
“We need a paradigm shift,” she said. “Most of the resources have been focused on fixing the problem, when we need to work with (people) to prevent it.” Milwaukee Health Services offers six support groups a year to provide health information to low-income pregnant teens and young women who aren’t already receiving prenatal care. Alexander teaches each group about oral hygiene during pregnancy and caring for babies’ teeth, said program director Jill Denson.
After birth, many young mothers and fathers graduate to parenting groups, where they get more hands-on teaching.
Women in the groups are screened for urgent dental problems and receive priority for treatment at Milwaukee Health Services. They’re typically seen within a week, Alexander said, while normal wait times for dental care there run four to six weeks.
Michelle Hamberlin’s abscessed tooth needed to be removed by an oral surgeon. But in her case, that took intervention by Katy Murphy, a public health nurse who works with Hamberlin through the city’s Empowering Families of Milwaukee program.
Murphy called Southeast Dental Associates, which administers Hamberlin’s BadgerCare dental benefits. “I said, ‘I’m a public health nurse, and I’m sitting with this client, and she has signs of infections, she’s in pain, and she’s pregnant,’ “Murphy said. “It took those three words – infection, pain, pregnant.
Otherwise they’ll say, ‘we’ll put them on the wait list.’ “Hamberlin, whose baby is due Dec. 6, was equally frustrated.
“It shouldn’t be so hard,” she said. “If it wasn’t for Katy (Murphy), I wouldn’t have had my tooth pulled, and it’s not Katy’s insurance. It’s my insurance.”