Mouths wide shut (continued) BY TANYA WHITON
	Mercury-amalgam fillings Recent evidence suggests that mercury amalgam fillings may pose health risks, and consumers need to be aware of the fact that, unless they ask questions, in a low-cost setting, these amalgam fillings are often the cheapest, and therefore the most common, solution to a problem. At Community Dental, John Eppich says, "People come in to us, and say, ‘I’ve got this problem, I need it fixed, what’s the cheapest way I can get out?’ " Eppich himself says he doesn’t believe amalgams are causing that much damage, and that they are the best ones to use because they are very durable. But the legislature has insisted that Community Dental keep their patients informed about potential health risks. In Canada and several countries in Europe, according to a brochure put out by the Bureau of Health, limits are recommended on the use of mercury amalgam for pregnant and nursing women, young children, and people with kidney problems, based on evidence that too much mercury can damage the kidneys, nerves and brain, especially the brains of developing infants. — T.W.

Southern Maine has no such program. Debbie Keefer, Oral Health Program Coordinator for Portland, has gotten funding for a brand new clinic to serve the city’s homeless population, and she can’t find a dentist to run it. John Eppich, Executive Director of Community Dental, a nonprofit that runs five of the 15 clinics statewide that offer services to low-income people, is desperately in search of dentists for his program. "There are 445 practicing dentists in Maine," he says. What this means is that some areas of the state have one dentist per every 3500 to 4000 people.

Nickerson points out that in addition to a general lack of practitioners, "Dentists as a population are aging ¾ people are retiring out of the field. When there’s a supply-and-demand problem, people with few resources have the hardest time."

Another significant problem with access to dental care is the need to, as Mary Jude puts it, "put the mouth back in the body." Eppich echoes her statement. "Somewhere along the line, insurance companies separated the mouth from the body," he says. The result of this division is that practically (and professionally) dental care is considered a separate field. For people without insurance, or with limited resources, it is possible to get care for pressing "medical" health concerns ¾ but not for dental-health problems. Jude points out that "you can go in [to the hospital] if you’re having a heart attack, or if you have high blood pressure. You can’t go in with dental problems, unless you have pain."

A more subtle manifestation of the separation between the mouth and the rest of the body is the conception of dental care that accompanies it — the idea that taking care of your teeth is a luxury. This misinformed idea is more widely held than you might think, and it persists, in spite of the fact that without adequate care, people are at high risk for infection and pain. And more alarmingly, there are documented links between poor oral-health and cardiovascular disease, the exacerbation of diabetes, and premature and low birth-weight babies. Yikes.

Judith Feinstein says that "in our culture, dental care is something people look on as discretionary ¾ it’s a choice." For those of us without a lot of discretionary funds, the options seem to be, Feinstein says, "to go less often, or put it on a credit card." And at "safety-net clinics" (like Community Dental) "if you come in at the top of end of the [income] scale ¾ if your income qualifies you to pay $85 instead of $92 ¾ that still may be something you can’t afford."

Coupled with the generally unarticulated notion that dental care is a luxury is a much more familiar obstacle: fear. The two combined can keep otherwise health-conscious people in a state of neglect and denial. Who, after all, loves to go to the dentist? Fear of the dentist is so pervasive, it seems cliché ¾ which means it’s overlooked as a real problem.

Jude, who is also chair of the Maine Dental Access Coalition, says that in a recent needs-assessment survey, fear was the number one reason people gave for not accessing care. Not lack of income, shortage of dentists, or the idea that dental care is discretionary. Nope. Fear. "It’s terrible," she says, "if you can sit in the waiting room and hear a drill. Clinics need to be low barrier." She starts talking about soft colors, separate waiting areas, and soothing music ¾ not the sorts of amenities that federally funded and nonprofit health services can usually invest in.

In Southern Maine, the only real option for restorative care is Eppich’s program. "We treat most of the people who are challenged by cost, access, and lack of providers," Eppich says. Community Dental is the largest nonprofit dental outfit in Maine, with clinics in Portland, Saco, Sanford, Auburn, and Farmington. Last year, Community Dental handled 23,000 patients visits. Around 50 percent of its patients are eligible for MaineCare, and some 60 percent of that group are kids. But for adults, MaineCare only covers emergencies. This means that a sliding scale applies to preventive and restorative care, with four levels of fees ranging from full cost to cost calculated according to income level, using federal poverty guidelines. But unlike federally qualified health centers (FQHCs), Community Dental uses federal poverty guidelines but must bill per procedure.

Eppich does a price breakdown for me to clarify how the numbers work, based on a single person and ranging from level C (100 percent of federal poverty guidelines) to level A (200 percent of federal poverty guidelines). A set of four bitewing X-rays can cost from $17 to $39. A panorex (whole mouth) X-ray can cost from $34 to $77. A mercury amalgam filling for three surfaces can cost from $75 to $115. And a composite filling for the same cavity can cost between $90 to $135. These numbers represent a substantial saving when compared to private-practice dentistry, and Eppich insists there is no difference in quality. "They [private-practice dentists] might have the new equipment, but we provide quality dentistry."

The glitch? Community Dental operates on a first-call/first-booked basis, with patients competing for open appointments. Each month, about 500 people call, and the clinic can serve only 200. On or around February 15, for example, Community Dental will book the entire month of March. Anyone who misses that window has to call back the following month to try for a spot in the next lottery.

"I think it’s a terrible system," Eppich says, obviously frustrated by the limitations his clinic faces in serving a needy population. "But it’s the best we can do right now. There’s no maximum [wait time], that is one of the flaws. You can call and just be shut out." He gives an example: "Let’s say Bruce Springsteen is coming to Portland, and tickets are gone in 15 minutes. The people who didn’t get tickets the first time aren’t first in line to get tickets when more go on sale."

In other words, get ready to camp out. Another friend, a married mother of two, tells me she recently gave up on the competitive scheduling option and is "paying through the nose" to go to a private-practice dentist. But she speaks highly of the team at Community Dental, saying that, once you do get in, they offer quality care.

The only other venue providing low-cost restorative care in the Portland area is so limited that Public Health Director Nate Nickerson cautions it is not really an option at all. The Portland Free Clinic, designed to serve people without insurance who earn up to 200 percent of the federal poverty level, will occasionally refer patients to a Volunteer Dental Clinic, which operates every other Tuesday night from 6 to 9 p.m. "I wouldn’t go to the Free Clinic in order to get oral health [care]," Nickerson says. "The worst scenario is when people come in with expectations we can’t meet."

So, back to the private sector. Though several of the people I spoke with held out the vague possibility that private-practice dentists will sometimes provide services at less than full cost, or provide a payment plan, private practitioners, understandably, don’t broadcast this option. Eppich is careful to point out that vilifying private-practice dentists is not the way to approach the access problem. Dentists do, after all, have six-figure loans to pay back after being graduated from dental school. Keefer is hoping that the brand new clinic she’s overseeing for homeless citizens will at some point be available for others in need of care, too, but first, she’s got to staff it.

I’d hoped, when I set out to write this piece, that I could find some workable solutions for low-income folks in need of dental care. According to Mary Jude, 35 percent of the elder population in our state are without any teeth at all. Of course, as in "medical" health care, preventive maintenance is the best way to ward off tooth troubles. In addition to UNE’s program (which, Alan Conant reminded me, is not designed to replace visits to the dentist), the Reiche School hosts a program three half days a week where low-income folks can get their teeth cleaned for a mere $5.

From now on, when I encounter people who are uncertain as to what career path to pursue, I’m going to urge them to please, please go to dental school. Then come back to Maine. We want to keep our teeth.