By George Terwilliger, MD

In first of this two part series about dental care, I explained the causes and treatment of dental pain. The upshot is that most dental problems are preventable through good diet, regular brushing and flossing, and getting regular professional dental care. Dental problems that bring people to the ED usually are not very amenable to the skill set of emergency departments. Most dental pain needs the services of a dentist or an oral surgeon.

Current law states that emergency departments and urgent care centers in Vermont must evaluate every patient who shows up, regardless of ability to pay. However, there is no similar requirement for dentists and oral surgeons.

George Pierce Terwilliger, MD
George Pierce Terwilliger, MD

Vermont has an irregular policy toward funding comprehensive dental care for its citizens who need assistance to secure routine or emergency dental care. Unfortunately, this sometimes makes getting needed dental treatment difficult, particularly for adults.

For children and pregnant women there is at least some funding for both preventive and emergency care. Children enrolled in Dr. Dynasaur have good coverage for a wide range of dental problems and can usually find a dentist who accepts this insurance. Pregnant Vermont women now have full dental services at participating dentists if they are enrolled in Dr. Dynasaur or Medicaid. This coverage extends for 60 days after delivery. This new program is considered very effective at preventing problems not only for these mothers, but also in young children ages 2-5 years of age. The bacterium that causes cavities is contagious; mothers with poor dental health are more likely to pass this on to their young children.

There is a problem with the above insurance. Both the children’s benefit and the pregnant women services are paid well below the typical dental office cost of providing the care. This has lead to dentists and oral surgeons often raising dental fees to the rest of their patients. Vermont has often tried to modestly budget increased rates for dental care only to fall back to level funding. There has never been a cost of living increase in reimbursement for dental services.

Adults are a different story and therein lies the most critical gap on dental services. For most adults in Vermont with Medicaid, there is a reduced reimbursement rate with total services limited to a maximum of $510 per year. This dramatically restricts the type of care and the frequency of care for adults with financial need.

Adults with Medicaid dental limits and those without dental insurance at all are often unable to afford needed dental treatments. Many dentists and oral surgeons don’t accept Medicaid’s below cost payments and require the patient to come to the appointment with a payment plan in place. There are many dentists in the Brattleboro area and many of them will work out extended payment arrangements for those who require extensive care. There are many fewer oral surgeons. They have offices in Brattleboro, Bennington, Greenfield, MA, and Keene, NH. Some will work with you to set up payment plans.

Recognizing the local adult need, some volunteer efforts are being made to close the gap in dental care. There is the United Way-sponsored Free Adult Dental Care Day, held each May, in which local dentists and oral surgeons take care of many types of problems with no fee to the patient. There is also a free clinic, the Brattleboro Walk-in Clinic, which provides basic primary dental care. This is located at 81 Belmont Ave and is open Tuesday evening from 5:30 to 7:00 PM. This limited service is by appointment only using volunteer dental staff and dentists. You must inquire at the clinic personally for more information. These are just short-term answers for a few patients provided by volunteers. It is not an oral health delivery system but it probably does help patients who otherwise might later end up in the Emergency Department of your hospital.

It is heart-breaking to see patients in the ED in whom we not only cannot provide needed dental care, we can’t provide necessary follow-up due to lack of insurance or scant financial resources. In fact, we have seen a few very sick patients who required hospitalization and urgent surgery due to repeated failure to have necessary dental care. While prevention is certainly the best way to deal with these problems, such talk certainly falls on deaf ears when in crisis.

What can you do?

  • Write your legislators, both state and federal, asking them to introduce or support bills seeking to improve dental coverage, especially for a comprehensive approach to adult care at a more reasonable reimbursement rate.
  • Encourage your dentist or oral surgeon to accept Medicaid and provide sliding scale payment plans for uninsured people.
  • When you get a dental appointment, make sure you show up. It is difficult for dental providers to make urgent appointments. Do not cancel at the last minute. Try to be on time for your appointment.
  • Give to the Brattleboro Walk-in Clinic
  • Give to the United Way of Windham County
  • Limit the sweets your children consume and have them brush immediately after consuming them. Just say no to soda! Do not let children sleep with bottles of milk, formula, juice or other sweet liquids. Doing so is a major factor in cases of severe tooth decay in children requiring surgery.
  • Of course, it should go without saying, “Take good care of your teeth!”

George Terwilliger, MD, is the Site Director for the Emergency Department at Brattleboro Memorial Hospital.

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