NOTE: Cincinnati has had fluoridated water since 1979.
The Cincinnati Enquirer
October 6, 2002
Special Report: Cincinnati's dental
Shortage, cost can be torture for poor
By Erica Solvig
They begin gathering shortly before 7 a.m. outside of Cincinnati's six public health clinics. Mothers with crying children. Teenagers unable to eat. Adults robbed of sleep. With throbbing toothaches, untreated cavities and painful abscesses, they stand in line to be seen by a city dentist who won't arrive for another hour.
Each weekday, as many as five dozen patients can be found waiting for the clinics to open.
They are the lucky ones. They are among the 10,000 patients who crowd the clinics every year to have their emergency cases treated by the city's 10 dentists.
Many others - as many as 4,000 - are on a two-year waiting list to be seen. Many of them are children. Most are poor and cannot afford a dentist or lack dental insurance. And hundreds of them are only seeking routine care.
But because the city's dental clinics are so overwhelmed with patients, the only way thousands can see a dentist is if their untreated cavity becomes so severe that an infection sets in or the pain becomes too unbearable.
“When we see children here, they're usually in a devastating condition,” said Dr. Judith Allen of the McMicken Dental Clinic for the homeless in Over-the-Rhine. “This is the Third World. It really is.”
At a time when the dental health of American children has never been better, Cincinnati is experiencing an oral health-care crisis. City and regional medical officials say tooth decay is the city's No. 1 unmet health-care need.
“We cannot meet the demand,” says Dr. Larry Hill, Cincinnati Health Department dental director.
“It's absolutely heartbreaking and a travesty. We have kids in this community with severe untreated dental infections. We have kids with self-esteem problems, and we have kids in severe pain and we have no place to send them in Cincinnati. People would be shocked to learn how bad the problem has become.”
Cincinnati is not the only U.S. city struggling with the issue. Government research reveals that tooth decay is the nation's most chronic childhood disease - five times greater than asthma and seven times greater than allergies.
And in Cincinnati, the problem is only getting worse, a Cincinnati Enquirer analysis found:
The number of urgent dental cases in the city's health clinics has nearly tripled since 1990, jumping from 3,437 to 10,030.
The overall caseload for city dentists is rising. In 1992, dentists handled 24,309 cases. Last year, it was 26,129 - a 7.5 percent increase.
An estimated 43 percent of the city's 8-year-olds living in low-income homes have significant teeth decay. The rate of infection stood at 37 percent in 1996.
Dental pain and infection have become the No. 1 reasons why people go to University Hospital's emergency room.
Nurses at Cincinnati Public Schools made more than 500 dental referrals last school year. That's nearly 100 more than two years before.
Making matters worse, the sour economy is endangering funding for public dental programs. Federal, state and city budgets are being slashed, meaning fewer dollars could be coming to Cincinnati's dental programs.
It's also getting tougher for people to find dental insurance. Nearly 800,000 people - or about 40 percent of Greater Cincinnati's population - lack dental insurance. Thousands more are underinsured and cannot afford the necessary co-payments for dental care. The problem is not limited to Cincinnati's impoverished. Even young college graduates are coming to the city's dental clinics because they lack dental insurance.
“Fixing this problem just continues to get tougher and tougher,” Dr. Hill said. “If you can afford a dentist or have dental insurance, these problems seem unfathomable. But we see children as young as 1 or 2 with serious dental infections.”
Like Cincinnati, other cities are confronted with crowded dental clinics, budget cuts and a long waiting list. The situation has become so severe nationally that the U.S. Surgeon General in 2000 called it “a silent epidemic."
In Kentucky, nearly half of the commonwealth's 2- to 4-year-olds have cavities - twice the national average. In Ohio, roughly 5 percent of all third-graders have never seen a dentist.
Left untreated, tooth decay can infect the bloodstream and cause medical problems throughout the body.
“It's an embarrassing and pitiful situation for a country with the resources and capacity we have for such a thing that has such a preventable solution,” said Dr. Caswell Evans, executive editor of Oral Health in America: A Report of the Surgeon General. “Yet it's often overlooked.”
Nowhere to go
The lack of access to dental care is the primary reason Cincinnati and other cities face a crisis, critics say.
In the past decade, community dental clinics have shut down. For instance, Hamilton County eliminated its dental program in the mid-1990s, forcing patients to scramble to find alternatives.
“We made a decision that a place like Children's Hospital could do this better than (the clinics),” Hamilton County Health Commissioner Tim Ingram said of providing dental care. “We were assured they would be served elsewhere.”
But the dental clinic at Cincinnati Children's Hospital Medical Center, which sees 35,000 patients annually, is so overbooked that it can only open to new patients once a month.
It's a situation that is frustrating for patients like Lashonda Glover, a 27-year-old North Fairmount mother of three. The last time her 9-year-old daughter, Garriesha Humphrey, saw a dentist was at least three years ago.
When she finally got into Children's in July, Garriesha needed two teeth pulled. Doctors say they could have been treated with fillings had care been available sooner.
“You try everywhere,” said Mrs. Glover, a custodial worker. “It's just so hard to get in.”
Other places, like Madisonville, have requested public funds to provide dental services in the neighborhood. But tight budgets - nationally, in Ohio and in Cincinnati - have meant no money has come to the community.
Even if dentists were available, many Ohioans have no means to pay for dental care. More than 4 million Ohioans, about 40 percent of the state's population, do not have dental insurance, according to state officials. That is a rate nearly four times the 11 percent of people who lack regular health insurance.
“It's the No. 1 unmet health-care need that Ohioans have,” said Dr. Mark Siegal, chief of the state's Bureau of Oral Health Services.
State research also shows 31 percent of 6- to 8-year-olds in low-income families in Ohio could not afford to get the dental care parents wanted.
“Food and housing are their No. 1 priorities,” said Sandra Bernard, outreach coordinator at the McMicken clinic.
Families with Medicaid also have problems finding a dentist to accept their coverage. This leaves America's uninsured children 2.5 times less likely than insured children to get the care they need, according to the surgeon general's report.
“These are the people most likely to have disease, and they're the least likely to get the treatment,” Dr. Hill said. “We wouldn't let that continue if that were earaches, but somehow it's OK if it's a toothache.”
Cases that bring tears.
Tristate medical experts are increasingly alarmed that some of the worst dental problems they see are found in the region's youngest patients.
Nationally, research shows nearly 80 percent of the childhood dental decay is found in just 20 percent of the children. Dental damage starts early in life. Some early childhood decay - or caries - is caused by extended bottle or breast-feeding. As they grow older, many poverty-stricken children and teens also do not see a dentist regularly.
Many do not own a toothbrush, Dr. Hill said.
The lack of preventative care leads to pain and discomfort. But it also can affect a student's grades and overall learning. Cincinnati teachers and dentists say kids suffering with painful toothaches fail to concentrate and struggle in the classroom.
“We know these problems create self-esteem issues and hinder their academic progress,” Dr. Hill said. “It's tough for our schools to increase test scores when kids are sitting there in pain.”
Across the country, more than 51 million school hours are lost because of dental-related illness, according to the surgeon general.
While Cincinnati has not calculated the same statistics, city school administrators say many of the 500 referrals nurses make are repeats from the previous years.
“They're really sad cases that just make you cry,” said Kim Toole, a nursing supervisor with Cincinnati Health Department. “It's no wonder they do poorly in school.”
The pain of a long-standing toothache was too much for 11-year-old Kenyada Davis of Avondale last week. She had to leave Cincinnati College Preparatory Academy early Wednesday.
“It hurt so bad,” she said.
The next morning, the sixth-grader was sitting outside the city's Elm Street dental clinic an hour before it was open. Her mom, Angela, had to call off work so she could wait with her.
“It's frustrating, but I have to do what I have to do,” said the 36-year-old mom.
The severity of the dental decay among Cincinnati's children can be seen in many of the medical files squeezed onto shelves at the city's five health clinics.
Dr. Allen has stacks of snapshots from her worst cases sitting in her office. Kids with abscesses that have eaten away the roof of their mouths. Green stumps where teeth should be. Swollen cheeks caused by untreated toothaches.
They have left the 30-year veteran of dentistry heartbroken.
“I don't see how they can live in this pain,” she said. “But there are people in Cincinnati who can't afford anything else.”
One of her worst cases involved a 15-year-old girl who needed 12 of her permanent teeth extracted.
“She wouldn't even smile,” Dr. Allen said. “She wouldn't talk to me. She either wouldn't smile because it hurt so much or because she was so embarrassed."
City officials are certain there are more kids who should see a dentist - but parents are unable to bring them.
“I don't know if parents don't know their kids are in pain or they don't know where to take them,” Dr. Hill said. “Either way, we're in no position to go out and ring a bell and get them in - not with thousands of people on the waiting list.”
City dental clinics are not the only place being overwhelmed. Many uninsured families, unable to get in Cincinnati's clinics, are taking their children to hospital emergency rooms. Children's Hospital, for instance, sees about 2,000 after-hour emergency dental patients a year.
“They see more tooth abscesses and dental caries than anything,” said Tracy Deck, a registered nurse at Children's for more than 13 years. “Their teeth are just rotting out.”
Dental pain is the No. 1 reason people go to the emergency room at University Hospital, according to a United Way study. Last year, patients at area hospitals were charged $17 million for oral care procedures - much of which could have been prevented with routine care.
“It's frustrating because they're supposed to be treating cardiac arrests and other emergencies, but instead, they're seeing people with toothaches,” Dr. Hill said. “That just shouldn't be happening.”
Money for programs
The surgeon general's 2000 report said dental health costs are exceeding $60 billion, but warned the figure underestimated the country's problem. Local officials say tooth decay-related problems are expensive - and can be prevented.
“Every kid that we take to an operating room because they have a disease that is very preventable is costing $5,000 to $6,000,” said Dr. Jim Cecil, administrator of Kentucky's oral health program. “For maybe a couple hundred dollars per kid, you could have prevented that $5,000 or $6,000 (by filling a cavity or extracting a tooth.) We're wasting a whole lot of money by waiting. We're also wasting a whole lot of valuable human resources.”
As costs escalate, the funding for some local agencies battling the tooth decay problem is running short.
One of the region's largest groups providing access to dentists to those who are low-income, lack insurance, handicapped or elderly is the Greater Cincinnati Oral Health Council. It has operated since 1909.
Roughly 25 percent of the council's $1.4 million budget comes from the Ohio Department of Health. With the state facing budget cuts, the Oral Health Council could be given fewer public dollars.
And that could mean a cut in programs for an already worsening oral health epidemic. At risk, for example, is a program that put preventative plastic coatings on the grooves of the back teeth of 8,253 school children in seven Ohio counties last year.
Some businesses and foundations have tried to help. Procter and Gamble's Healthy Smiles 2010 program aims to provide toothbrushes, toothpaste and more access to dental professionals to 50 million children and their families across the country by decade's end.
Also, the United Way of Greater Cincinnati and the Health Foundation of Greater Cincinnati are working on the Oral Health Regional Assessment and Planning Project for nine counties in Ohio, Kentucky and Indiana. When complete in January, the plan should offer way to improve access to dental care.
But private dollars are not enough.
“They can help, but the problem is too big for the foundations to solve,” Dr. Hill said. “We're just so far behind the needs.”
For Cincinnati and the thousands of patients in pain and waiting to see a dentist, it means continued lines outside the dental clinics. But for people like Tina Jennings, a June Ohio University graduate who has no dental insurance though her loan-processing job at Fifth Third Bank, there is no other place to go.
“It's excruciating pain,” Ms. Jennings said last week outside the Elm Street clinic. The 25-year-old Bond Hill woman held her mouth, hoping to ease the intense ache caused by an infected wisdom tooth.
“I'll be here as long as they need me to stay.”