Bootleg Teeth

From the Times:

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 and a swig of peroxide.

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. . .

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