For decades, Paula Sibley would refuse to say "cheese" whenever a camera was pointed in her direction. "I was too embarrassed to smile because of my teeth," says the 47-year-old Old North Ender. Ultimately, though, the aches from her decaying teeth forced Sibley to seek treatment.
She had received no adult dental care until 2004, partly because she's a Medicaid recipient, and many dentists don't accept such patients. About 70 percent of the state's 372 dentists do treat at least some federally insured, low-income patients, notes Steve Arthur, head of the Vermont Health Department's oral health unit. But, he adds, most of these practitioners are unwilling to increase their Medicaid caseload because the cost of treatment significantly exceeds the reimbursements they get from the program. "Someone with Medicaid coverage who's moving into the state or seeking dental care for the first time will find it tough to get treatment," Arthur says.
Two local facilities -- the Community Health Center (CHC) in Burlington and Vermont Dental Care in Winooski -- thus play the role of tooth fairy for Chittenden County residents who might be unable to get dental care anywhere else. Sibley, for example, underwent several extractions and had bridges and dentures installed over the course of multiple visits to CHC, which opened a dental clinic two and a half years ago.
"Now I smile all the time," Sibley says. "And people are always telling me I look so much younger. I feel a lot better about myself, too."
Like thousands of other Vermonters, Sibley was psychologically debilitated and economically impaired by her poor oral health. Maladies of the mouth can be as big an impediment to self-sufficiency -- and self-esteem -- as chronic diseases affecting other parts of the body can be. In addition, studies have shown that oral infections can limit longevity and impair overall health, says Dr. Kevin Risko, head of CHC's dentist residency program.
Smoking cessation is most often initiated in a dentist's office, adds Dr. Chuck Seleen, director of Vermont Dental Care. Each initial visit to his clinic includes a blood-pressure test, he notes. Inadequate nutrition is another common problem afflicting those with extensive tooth decay. "It's hard to eat many foods if you don't have teeth," he says. "And even people with dentures chew at only 15 percent of capacity."
Rotten or missing teeth are emblematic of poverty, observes Alison Calderara, director of development and community relations for the Burlington health center. Cosmetic defects resulting from tooth loss sap self-confidence and also eliminate many job possibilities that involve interaction with the public, Calderara points out.
Children account for a sizable share of the impoverished Vermonters who suffer the effects of foregoing regular dental care. Toothaches are prevalent among kids who never see a dentist, and they often have trouble concentrating in school as a result.
That's why CHC opened a satellite dental clinic that serves Medicaid-covered or uninsured K-8 students attending Burlington public schools. Dental professionals working at the clinic, located in the H.O. Wheeler school in the Old North End, have filled 823 cavities and extracted 94 unsalvageable baby teeth from 279 students during the past two academic years.
"We're used to long timelines in seeing the outcome from preventive medicine," says Calderara. "It's rare to have a project that instantly comes back to us as, 'Wow, this is really making a difference.'"
Recent immigrants make up another significant segment of the dental caseload at both the Community Health Center and Vermont Dental Care. Dr. Risko says he treats many Somali Bantus, often with the assistance of an interpreter of Mai Mai -- one of the 10 languages spoken by staff members or translators whom CHC can call upon.
"The Somalis are very appreciative and also very stoic," Risko says. "We're all babies by comparison. Dentistry is nothing compared to what they've been through."
Interestingly, the Somalis generally require less remedial care than do native-born Americans, Risko adds. "They don't have diets high in sugar, so their decay rate isn't as high as a typical American's."
Homeless people in the Burlington area are also now able to access dental services tailored to their needs. CHC has operated the Safe Harbor medical clinic on South Winooski Ave. since 1988; an oral-health component was added a few years ago. The full facility treats 1200 homeless people a year, says Safe Harbor Director Paul Dragon. He defines homelessness as including those staying temporarily with friends or sleeping in shelters, cars or encampments in the Intervale and other open-air hideaways.
Being homeless is a condition that feeds upon itself, Dragon says. He cites the case of a Russian immigrant who has been living in the Burlington area for 10 years. The psychologically disabled veteran of the wars in Afghanistan and Chechnya has told outreach workers that at some point a homeless person becomes so marginalized that it is nearly impossible to reconnect with society, according to Dragon. But this man was recently persuaded to get medical treatment, including dental care, at Safe Harbor. "Maybe he's on his way back to the world," Dragon suggests.
Not all the patients at VDC and CHC rely on Medicaid. Many of the centers' clientele are financially comfortable. At CHC, reports Alison Calderara, 22 percent have private dental insurance. That type of coverage is uncommon, even among those with medical insurance. And a dental policy pays much less for complex procedures than does medical insurance, Seleen notes. Someone with dental coverage may have to meet half the cost of a $1000 bill, he says.
And bills of that magnitude are not unusual. "Dentistry is expensive," Calderara acknowledges. "It's actually a kind of mini-surgery." The costs put dental treatment beyond the reach of millions of middle-income Americans.
The Community Health Center was able to establish its three dental sites through federal funds obtained with help from Vermont's congressional delegation. Private donations were also crucial. A plaque in the center's waiting room on Riverside Ave. pays tribute to the "Oral Health Angels" as well as the "Crowns," "Bridges" and "Tooth Fairies" who contributed to its 2001-04 Open Wide Campaign.
The center as a whole has been serving Chittenden County residents of diverse economic backgrounds for the past 34 years. As one of 950 federally supported local health centers in the United States -- including six in Vermont -- the Burlington facility has a primary mission of providing care to "under-served" communities. That includes neighborhoods with a high proportion of low-income residents without health insurance or with no history of having access to a medical provider. In Burlington, the area designated as under-served encompasses all of the Old North End, downtown and parts of the South End.
The centers use a sliding-fee scale in billing uninsured patients with incomes up to double the official poverty level. Federally qualified clinics are also fully reimbursed for the cost of services provided to Medicaid recipients. That makes a huge difference in doctors' and dentists' willingness or ability to accept low-income patients. Vermont Dental Care's Seleen notes that his clinic, which specializes in treating children in the state's Dr. Dynasaur program, receives 50 percent less than does the Community Health Center when it fills cavities for one of these Medicaid-covered kids.
Vermont Dental Care represents the private sector's response to the dearth of treatment options for low-income Vermonters in need of dental care, Seleen says. The initiative was launched in 1971 as a mobile clinic that visited schools around Vermont. It later operated seven stationary sites throughout the state, but only two -- in Winooski and Barre -- have survived reductions in outside aid.
Vermonters of all income levels who live in rural parts of the state may have trouble finding a local dentist, says Seleen, a University of Vermont graduate who earned a DDS degree from Tufts in 1975. Seleen attributes the shrinking number of dentists in the state to the lack of a dental school in Vermont, as well as to the view of many dentists elsewhere that "this is the boondocks where you can't earn the same sort of money as in other states." It's estimated that half of the dentists who do practice in Vermont are 55 or older.
Nationally, too, the ranks of dentists are beginning to thin. One-third of the 152,000 active practitioners in the United States has passed the age-55 signpost, according to the American Dental Association. As his gray hair suggests, Seleen himself has reached that marker.
Given the high demand for dentists, it's not easy to recruit professionals to work with low-income patients. "There's not much of a financial incentive" to become a staff dentist at the health center, says Risko. Staff dentists at CHC are paid a percentage of what they bill. Calderara says earnings are "competitive" with those of a private practitioner, but she concedes that a dentist at the health center may have to work twice as hard to make the same money as one who works at, say, the Timberlane Dental Group in South Burlington.
Fortunately, money isn't the only motivator. One thing that drew Risko away from four years of private practice in Connecticut and Brattleboro was the opportunity to work with a diverse group of patients. At CHC's dental clinic, he treats patients ranging in age from 2 to 96. Some other dentists who had practiced privately are likewise attracted to work at the community clinic because they are able to apply their skills to special-needs patients and to carry out advanced procedures, Risko explains. "We treat people in wheelchairs, adults on the autism spectrum, others with mental illnesses and the homeless."
Those dental trainees who elect to join the CHC staff after completing their residency are often driven by goals similar to Risko's, he suggests: The practice appeals to someone committed to social justice. It can also involve types of treatment not often provided in suburban settings. Because the Burlington health center houses the only dental residency program in all of Vermont, Maine and northern New Hampshire, it attracts many aspiring dentists who want to live in northern New England -- at least for a year.
Seleen and the two other full-time dentists at the Winooski facility are salaried employees of a nonprofit organization. The highest annual salary is $123,000; the lowest, $88,000, Seleen reports. By contrast, an experienced dentist in private practice in the Burlington area could expect to make $200,000 a year, he estimates.
Seleen says his own earnings are sufficient to meet his material needs. "I long ago got wed to the mission of helping low-income kids. I can't see myself doing anything else."
The practice's focus on service rather than revenue is evident in his chair-side manner, suggests Kelly Merchant, who calls Seleen "a good all-around and gentle guy." She comes to VDC with her three young daughters. Her mother is a patient there as well, and so was her grandmother, until her death two years ago. Merchant notes that when her grandmother was living at an assisted-care facility in Burlington, a Vermont Dental Care hygienist regularly cleaned her teeth without charging.
Other professionals at Vermont Dental Care share the social ethic articulated by Seleen and Risko. Seleen notes that a periodontist volunteers one day each week to treat children who visit the Winooski practice.
In Risko's view, the dentistry establishment does not do nearly enough to help those unable to pay the full cost of treatment. "I think every dentist should treat Medicaid patients. They're the ones with the greatest needs," He declares.
But Seleen is sympathetic to dentists in private practice who turn away Medicaid recipients because of the program's low rate of reimbursement. "They're not discriminating against the patient but against the fee schedule," he says. "An office accepting an unlimited number of Medicaid patients will become less and less competitive. They won't be able to pay well enough to retain a highly skilled staff."
Many of the private dentists who do treat a large number of low-income people are reluctant to let that commitment become widely known, Seleen says. He says they worry that middle-income individuals will stop coming to a practice that is perceived as geared to the poor.
His clinic, situated on the top floor of the Champlain Mill, looks like any other large private practice. Modular gray dividers surround the nine treatment chairs serviced by three dentists and a half-dozen other clinicians. One recent afternoon, the waiting room is filled mainly with children, but there is no indication that 60 percent of the facility's patients receive Medicaid assistance.
The site where the practice was previously housed had "an austere, almost semi-professional look," recalls Seleen, who has worked at Vermont Dental Care for 30 years. "We decided we needed a more upscale image to attract middle-income patients. We don't want to be seen as a low-income clinic, and most of our patients don't know that we are."
If Vermont Dental Care did not appear inviting to those able to pay the full cost of services, it wouldn't be able to achieve its mission of helping large numbers of poor children, Seleen explains. The facility engages in the practice of cost shifting, which is standard throughout the health-care industry. Under this approach, better-off medical consumers indirectly subsidize the treatment of Medicaid-covered or uninsured patients who qualify for the sliding-fee scale.
A few financially secure individuals choose to be treated at Vermont Dental Care precisely because it's responsive to their poorer neighbors, Seleen notes. Among these socially conscious patients is Meg Pond, a housing development specialist who has been coming to the clinic since the late 1970s. "For me, it's a philosophical choice," Pond says. "I think it's important that health care gets delivered not only to people with insurance and with money."
The quality of care at Seleen's clinic is "excellent," she adds. Pond took her two daughters there when they were children, and one of them still goes, along with her own young daughter.
Even so, Vermont Dental Care struggles to remain solvent, Seleen notes. The practice recently concluded a $350,000 fundraising drive to finance a planned move from the Champlain Mill to a new family health center on Malletts Bay Avenue. in Winooski. The campaign raised $125,000, with the balance made up in the form of a low-interest loan, Seleen says.
The move was prompted by the redevelopment of downtown Winooski. Months of construction made the office virtually inaccessible to many patients, and some still find it inconvenient now that they must pay to park in an underground garage 100 yards from the mill.
Paula Sibley faces no such difficulties when she visits CHC's clinic just down the road in Burlington. "I live practically next door," she points out. And she's a proud and grateful neighbor. "There's nothing I wouldn't do for the people there after all they've done for me. I don't have much money, but if I were ever to come into some, I'd give it all to the Community Health Center. I owe them a lot."