In Kentuckyâ's Teeth, Toll of Poverty and Neglect

BARBOURVILLE, Ky. — In the 18 years he has been visiting nursing homes, seeing patients in his private practice and, more recently, driving his mobile dental clinic through Appalachian hills and hollows, Dr. Edwin E. Smith has seen the extremes of neglect.
 He has seen the shame of a 14-year-old girl who would not lift her head because she had lost most of her teeth from malnutrition, and the do-it-yourself pride of an elderly mountain man who, unable to afford a dentist, pulled his own infected teeth with a pair of pliers.

He has seen the brutal result of angry husbands hitting their wives and the end game of pill-poppers who crack healthy teeth, one by one, to get dentists to prescribe pain medications.

But mostly he has seen everyday people who are too busy putting food on the table to worry about oral hygiene. Many of them savor their sweets, drink well water without fluoride and long ago started ruining their teeth by chewing tobacco and smoking.

Dr. Smith has a rare window on a state with the highest proportion of adults under 65 without teeth, where about half the population does not have dental insurance. He struggles to counter the effects of the drastic shortage of dentists in rural areas and oral hygiene habits that have been slow to change.

“The level of need is hard to believe until you see it up close,” said Dr. Smith, who runs a free dental clinic at a high school in one of Kentucky’s poorest counties. He also provides free care to about half of the patients who visit his private practice in Barbourville.

Kentucky is among the worst states nationally in the proportion of low-income residents served by free or subsidized dental clinics, and less than a fourth of the state’s dentists regularly take Medicaid, according to 2005 federal data.

Until August 2006, when the system was revamped, the state’s Medicaid reimbursement rate was also one of the lowest in the country. Experts say this contributed to the shortage of dentists in poorer and more rural areas.

The state dental director, Dr. Julie Watts McKee, said that last year, Medicaid reimbursement for children’s dental services was raised by about 30 percent.

But even with this increase, which was paid for by cutting orthodontic benefits, reimbursement fees remain about 50 percent below market rate, said Dr. Ken Rich, the state’s dental director for Medicaid. And for adults, Dr. Rich said, they are about 65 percent below market rate.

“Not much has changed over the years here, really,” said Glen D. Anderson, who for two decades has made dentures in Corbin, Ky. He sells a pair of dentures for $400 that many dentists sell for more than $1,200. Like his brother, father and grandfather, he makes them without a license.

“Bootleggers exist here for a reason,” Mr. Anderson said. “People need teeth, but they can’t afford to go to dentists for dentures.”

While Kentucky may have some of the worse oral health problems in the nation, it is by no means alone. Residents in neighboring states across the region suffer similar dental problems for many of the same reasons — inadequate access to dental care or the inability to pay for a dentist, widespread use of chewing tobacco and a pervasive assumption that losing teeth is simply part of growing old. West Virginia, for example, which has the highest proportion of people over 65 without teeth, also has one of the lowest percentages of adults who visit the dentist at least once a year.

Dr. Smith is trying to catch these problems before they progress. Each week, he drives his mobile clinic, Kids First Dental Care, up the windy Appalachian roads to visit schools and to provide free check-ups to children in the poorest counties of Kentucky.

Dr. Smith paid about $150,000 of his own money to build the mobile clinic inside an 18-wheel truck. The clinic has a staff of seven and operates with private and Medicaid financing.

Pain caused by dental problems is a leading cause of missed school days in Kentucky, according to state health officials, and almost half of the state’s children ages 2 to 4 have untreated cavities. About 1 in 10 state residents are missing all their teeth, according to 2004 federal data.

At his private practice, Dr. Smith said that at least once a month he sees a patient who has used Krazy Glue to reattach a broken tooth to the root or to an adjacent tooth. Just as often, he sees patients who have tried to avoid the cost of a dentist by swishing with rubbing alcohol to deal with a tooth infection or by rubbing crushed aspirin pills on gums to numb pain. Both tactics worsen the situation by burning the gums and creating ulcers, he said.
“Under Medicaid,” Dr. Smith said, “the only choice a person with a severe infection has is to have the tooth pulled, even if she’s 25 years old and the tooth is right in the middle of her face.” He added that the program does not pay for root canals or dentures, though it does help pay for a liquid diet for those without teeth.

Medicare, the federal government’s health insurance program for seniors, does not pay for dental services.

Dr. Smith said some people assumed that if their parents and grandparents lost their teeth before they were 40, they would too. They figure no teeth, no costly toothaches, so they pre-emptively pull them.

“Try finding work when you’re in your 30s or 40s and you’re missing front teeth,” said Jane Stephenson, founder of the New Opportunity School in Berea, Ky., which provides job training to low-income Appalachian women.

Ms. Stephenson said the program started helping women buy dentures 10 years ago. She said about half of the women who go through the program, most in their 40s, were missing teeth or had ones that were infected. As a result, she said, they are shunned by employers, ashamed to go back to school and to be around younger peers and often miss work because of pain or complications of the infections.

His teeth crooked and blackened, Justin Baker is the face of another reason for Kentucky’s oral hygiene problems: methamphetamine use.

“They just rotted,” Mr. Baker, 16, said about the damage done in less than a year of drug use.

In 2006, Kentucky law enforcement seized 342 meth labs and made more than 32,000 arrests related to methamphetamine. The previous year, the Office of National Drug Control Policy designated Kentucky’s largest city, Louisville, among 23 nationwide that were hot spots of methamphetamine use.

Kentucky also has the highest rate of cigarette smoking in the country and one of the highest proportions of chewing tobacco use. Smoking and chewing tobacco, which account for more than half of all cases of periodontal disease in the United States, often lead to oral cancer and can encourage the growth of the bacteria that erode teeth and eat away at the gums.

As Mr. Baker sat up to rinse and spit at a free dental clinic at his school, Knox Central High School in Barbourville, Dr. Smith shook his head.

“Even though he is turning his life around, the damage is done,” Dr. Smith said about the likelihood that Mr. Baker would soon lose all his teeth.

The consequences of oral hygiene problems are far reaching, Dr. Smith said. When teeth fall out, he explained, the mouth loses some of its structural support and turns in on itself; that can lead to distorted speech and, in the absence of dentures, force a person to eat only soft foods, which can lead to poor nutrition.

Back in the southeast Kentucky city of Corbin, Mr. Anderson, the maker of dentures, said, “People shouldn’t be ashamed to smile.”

Growing up, Mr. Anderson said he and his brother moved around — from Massachusetts to Florida to Oklahoma and, finally, to Corbin — whenever local dentists complained to the police about their father’s denture-making practice. In 1990, he said, their father moved to Washington State to practice legally after repeated arrests in Kentucky.

The American Dental Association objects to denturism, as the trade is called, because it says practitioners have not received proper training through dental school. They are not competent to diagnose cancers or other diseases in the mouth, the association says, or to spot broken roots of teeth, which can lead to injury if not corrected before the installation of dentures.

Denturists are allowed to practice independently in Idaho, Maine, Montana, Oregon and Washington. In Arizona and Colorado, they can practice with at least limited supervision of a licensed dentist, according to the National Denturist Association.

Pointing to the wall where his license to practice the trade in Maine is mounted, Mr. Anderson said he trained in a program at George Brown College in Toronto. He has continued to practice in Kentucky even though it is illegal because no one complains about the quality of his work, he said, and he has a licensed dentist on staff and in his office several days a week.

“The truth is that we see people dentists don’t because those people are too poor,” said Glen Anderson’s brother, Eric Anderson, 36. “And there’re a lot of these people around here.”

Seated in Glen Anderson’s office, David Caldwell, 53, smiled widely as he stared into a mirror at his first pair of dentures. Mr. Caldwell attributed his dental problems to his smoking habit. He said he quit smoking but still chews tobacco.

“You get in the habit of keeping your mouth shut if you’re in public,” Mr. Caldwell said about the embarrassment of having no teeth.

Now, with his full set of false teeth, he said he could stop talking with his hand in front of his mouth. He could stop tilting his head downward, so people would only see his lower, less damaged teeth.

“I’m a new man, I suppose,” he said with a shy laugh.¨

(referred to by Mar Patalinjug and added by Ms. Cheryl D. Tinonga)