Left Behind: New Jersey’s Dental-Care Gap

When Dr. Nicole McGrath first met Karen Hankerson at the Montclair Child Development Center, a federally funded HeadStart program, the 4-year-old had an abscess under one of her baby teeth. An abscess is the final stage of dental caries, the infection that causes cavities. It’s extremely painful; the infection spreads through the tooth, cracking holes in the enamel until pus pools in the gums. The rotten tooth had to be pulled.

Karen hated “anybody with a white coat,” says her mother, Kyisha Branch. But a gentle kindness in Dr. Nicole, as her patients call her, eased Karen’s fear. Karen’s mother had a different anxiety, which McGrath eased by offering to treat Karen’s abscess for free at her office in Montclair. “I automatically switched my family to her practice,” says Branch, who has four children. “The first visit was amazing. Karen clinged to Dr. Nicole so much.”

Karen’s oldest sister Khalia, 21, now works at a dental office in Montana training to become a hygienist, inspired by the family’s close relationship with McGrath.

“Dr. Nicole is like their dentist-mother,” says a teary-eyed Branch. “She has a special place in all of our hearts.” Karen, now 13, shows off a pearly white smile and lights up when it’s time to visit the dentist.

According to the American Academy of Pediatric Dentistry, tooth decay, though preventable, is the most common chronic childhood disease, well ahead of better publicized ailments like asthma, early childhood obesity and diabetes. Low-income children suffer disproportionately. For families on a budget, caring for teeth often takes a backseat to putting food on the table. What’s more, they often forgo fresh and nutritious food in favor of cheaper alternatives that tend to be lower in nutritional value and higher in processed sugar, which hastens dental caries.

“If they’re making ends meet, the thing they cut from their budget for their family, unfortunately, is dental,” says Dr. Elisa Velazquez, vice president of the New Jersey Academy of Pediatric Dentistry.

Ignoring cavities in adult and baby teeth can have devastating effects. The decay-related infections can spread to the bloodstream, requiring heavy doses of antibiotics. If left untreated, they can lead to chronic ear and eye infections, and in rare cases, fatal brain infections. The pain can be  debilitating, and the stigma of toothless smiles and speech impediments can degrade self-confidence and lead to misdiagnosed learning disabilities and diminished job prospects.

According to a report from the Surgeon General, dental problems and pain cause children to miss 50 million hours of school per year, with low-income children losing 12 times as many school days to dental illness as higher-income kids. (Adults lose 164 million work hours per year due to dental issues, according to the report.) Not brushing and flossing and missing fluoride treatments at an early age lead to poor dental hygiene in adulthood, further stacking the deck against the disadvantaged.

Despite the obvious need, only a fraction of New Jersey’s 8,897 licensed dentists accept patients covered by NJ FamilyCare, the state’s publicly funded health insurance program, which includes Medicaid and its associated managed-care organizations (MCOs—the providers who deliver Medicaid benefits). Of that fraction, many don’t accept all MCO plans. New Jersey’s MCOs include commercial insurers like Aetna Better Health, AmeriGroup, UnitedHealthCare and Wellcare, as well as the non-profit Horizon NJ plan.
“It’s very complicated for people to figure out,” says Velazquez. “And then just imagine adding another barrier—a language barrier—and it’s really difficult.” Roughly 20 percent of New Jersey’s population uses NJ FamilyCare, with 1.75 million enrollments as of March, including more than 800,000 minors, or one-third of all children in New Jersey.

Luckily, a number of organizations have made it possible for dentists to provide pro bono care for those unable to access care through the public program. Organizations in New Jersey include Donated Dental Services, the annual Give Kids a Smile day and McGrath’s KinderSmile Foundation.

Most dentists volunteer only a small amount of time to charity care. McGrath has made it close to a full-time commitment. Born in Jamaica and raised in Brooklyn, she completed her dental residency at UMDNJ and opened a part-time private practice in Montclair. She founded the KinderSmile Foundation in 2007 to help provide oral health care and education to low-income families; expectant and new mothers; uninsured  children; and the special-needs population.

READ MORE: “For Special Needs Population, Dental Care is a Struggle”

Dentists, hygienists and oral health educators volunteer with KinderSmile in northern New Jersey locations where demand for dental care is high. Recently, they’ve visited locations such as the East Orange Child Development Center; the Arc Kohler School in Mountainside, a school for kids ages 3 to 14 with developmental and physical disabilities; and the Community Food Bank of Newark.

KinderSmile volunteers also travel to the East Caribbean and Central and South America to provide free oral care to needy communities. McGrath says the oral health problems seen in New Jersey are “no different clinically” than those seen in developing nations. However, she notes, “socially, there is a huge difference.”

In America, free care carries a stigma that deters many patients from seeking help, while those in developing nations eagerly line up to receive pro-bono care. “Here in New Jersey,” says McGrath, “they finally do get it and it clicks, but it’s not an easy click like you get in Guatemala or Haiti or Nicaragua or Trinidad or Jamaica.”

Dr. McGrath shows Karen and mother Kyisha Branch the proper brushing technique using Prince, a purple dragon. Photo by Andy Foster.

Give Kids a Smile, another program that encourages parents to seek oral care for their children, operates under a nationwide initiative organized by the American Dental Association. Participating dentists give free dental care to children on the first Friday in February. This past February 5, 115 locations in New Jersey participated.

“We see about 100 kids that day for free,” says Velazquez, who owns Ocean Pediatric Dental Associates in Toms River and Manahawkin. She closes her offices for the Friday to regular patients, and her entire staff treats children pro bono. “It’s very satisfying to help these kids, and it’s about $15,000 of dentistry that we do that day.”

KinderSmile runs an oral health fair each year with live entertainment and free, nutritious lunches. Representatives from Medicaid and its MCOs sign up uninsured families. Parents are encouraged to watch their children receive free cleanings and learn about dental hygiene in a nonjudgmental environment.

Kindersmile, which depends on grants from foundations and individual donors, is opening a brick-and-mortar headquarters in Bloomfield in August, just in time for back-to-school checkups. Located at 10 Broad Street, the KinderSmile Community Oral Health Center will be “accessible from every single bus line you can think of,” says McGrath, who has had to defend the location of the center. Some question whether Bloomfield is a community in need. “People are like, ‘Why Bloomfield?’” says McGrath. “Well, there’s a pocket of families who are very poor, and where we are going to be is in the Third Ward, where 53 percent of the residents are at or below poverty level.”

Statistics confirm the existence of a hidden dental desert: In a 5- to 7-mile radius of Bloomfield’s Third Ward, there are 80 practicing dentists, but only two accept Medicaid and its associated MCOs. Neither of the two accepts kids under six. Until KinderSmile opens its clinic in August, Medicaid families in the area will have to get their dental care from Rutgers dental students or a Federally Qualified Health Center. Most FQHCs—government-funded public clinics— have months-long waiting lists, including the ones closest to Bloomfield (in Newark and East Orange). Public clinics are listed in the New Jersey Dental Clinic Directory, known as “Dial a Smile”; a search turned up only one FQHC in each of Sussex, Somerset, Salem, Cape May and Warren counties.*

Perhaps more New Jersey dentists would accept Medicaid patients if the state offered the incentives other states do. New Jersey has one of the lowest fee reimbursement rates in the country: starting at 17.8 percent of the cost of the service, compared to the national average of 40.7 percent. For example, a dentist might bill $225 for a typical exam, including x-rays, cleaning and fluoride treatment, but be reimbursed as little as $40 if the patient is on Medicaid. “The reason I cannot take managed care plans is because I wouldn’t be able to run the business that I have,” says Velazquez. “I have 30 [employees who support] families because of my office…. They can’t live on half salary.” Under the current fee-reimbursement rates, dentists carry the brunt of the cost. Most Medicaid plans only cover routine cleanings and emergencies, forcing last-resort hospital visits funded by taxpayers.

New Jersey’s public policy on dental care scores poorly in other ways. The state meets only two of the eight oral health benchmarks outlined by Pew Charitable Trusts, a nonprofit that analyzes public policy. Failings include not having sealant programs (to protect children’s teeth) in high-risk schools and not tracking data on children’s dental health. Only 14 percent of residents receive fluoridated water, compared to the 75 percent national average. New Jersey also receives an F each year in Pew’s children’s dental health report. In 2015, the only other states with failing grades were Hawaii and Wyoming.

Advocates for reform, including the New Jersey Dental Association (NJDA), say we need a statewide dental director who is experienced in clinical dentistry and empowered to oversee all aspects of oral health care access, outreach and education. Beverly Kupiec-Sce, a registered nurse, is the closest point person for a dental director, and only oversees the Department of Health’s Children’s Oral Health Program—which, according to a DOH spokesperson, conducts “age-appropriate interactive oral health education.”

“Her position does not even remotely resemble what you would expect from a dental director,” says Arthur Meisel, executive director of the NJDA.

The NJDA supports a bill that would have established an Office of the State Dental Director and a New Jersey Oral Health Commission. Despite unanimous Senate passage and a 66-2 vote in the Assembly, Governor Chris Christie pocket vetoed the bill in January. He vetoed an earlier version in 2011.
“Why were the bills vetoed?” asks McGrath. “You have children who are literally dying, and can be dying, and [bills] are just sitting on your desk?…It’s not a priority. It’s disgusting. We are failing this population.”

Assemblyman Gordon Johnson (D-Teaneck), the Assembly bill’s main sponsor, explained by e-mail that New Jersey “does have an acting dental director in title, but the office does not perform the duties that one would assume.” The proposed bill would create a position with the requirements and powers sought by reformers. The dental director would collect and report data on the effectiveness of oral health programs, develop oral health awareness campaigns and, as stated in the bill, “serve as an advocate for the adoption of effective measures to improve the oral health of state residents and eliminate disparities among the various racial and ethnic populations” and “ensure their maximum participation in publicly funded oral health programs.”

Questioned about the pocket veto, Christie’s office issued this statement: “Having the Legislature pass more than 100 bills in such a hasty and scrambled way, praying for them to be rubberstamped, is never a good formula for effectively doing public business.”

“Basically,” says Velazquez, who is an NJDA trustee and supports the bill, “we were told to wait for the next administration. We won’t give up, trust me.”

Since no government agency connects needy patients with willing dentists, the responsibility is left to nonprofits like KinderSmile and Donated Dental Services (DDS). The latter—part of a national foundation called Dental Lifeline Network—refers eligible patients (who must be low income and either over 65 or considered medically fragile) to one of 668 dentists volunteering across the state. Only a limited number of free patients can be treated each year. According to the group’s 2014-2015 annual report, only 418 patients were treated in New Jersey through DDS. In Essex County, the waiting lists are so long that DDS is closed to new applicants.

A similar program, New Jersey Donated Orthodontic Services (DOS), sponsored by the American Association of Orthodontists, provides pro bono orthodontic care for low-income children between ages 7 and 18 who are “in obvious need” and can prove they maintain good oral hygiene. Another organization, Smiles Change Lives, a national nonprofit, offers discounted braces for children ages 10 to 18, with a non-refundable $30 application fee and a flat $600 investment (braces can cost $2,500 to $6,000 out of pocket). Nineteen orthodontic practices in the state participate.

Some patients find their way to dentists through broad-based charitable organizations such as Project Ezra, founded in 2001 in Englewood to help financially challenged families. Among other services, Project Ezra identifies doctors and dentists who will treat clients pro bono.

“In terms of dentists who provide free dental care, we all do that every day, honestly,” says Velazquez. “We’re always helping out our communities.” But she says it requires an empowered dental director to resolve issues such as getting the word out about services.  Gaudio Cosmetic Dentistry, a private practice on Main Street in Chester, for example, provides free initial exams and x-rays for new patients who lack insurance. It then offers them a discount Smile Club membership for $399 a year. Sadly, it takes word of mouth to discover such unique private-practice options.

It isn’t just poor children and families who are in need. So are people with special needs, the unemployed, the elderly and cancer patients without dental insurance whose teeth have rotted from chemotherapy.

“It’s a human-race problem,” says McGrath.

*This story has been updated from the print version to include new clinics from the 2016 Dial a Smile directory. There are now two clinics in Burlington and Hunterdon counties instead of one.