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In pain, mom-to-be found only dentist wait list

When Michelle Hamberlin learned she was pregnant in April, it gave her one more reason to seek treatment
for a broken, abscessed tooth and swollen gum.

Dental infections during pregnancy can pose a risk to both mother and baby, experts say.

But for Hamberlin, 21, deciding to see a dentist was one thing.

Finding one was another.

"I called everyone listed in the book," said Hamberlin, one of more than 4,700 pregnant women in Milwaukee
County in July eligible for dental coverage through BadgerCare Plus, the state's Medicaid program
for pregnant women and families.

"They had a three-month waiting list, or their numbers were disconnected, or they said they weren't
taking my insurance."

The Journal Sentinel found a similar result: Calls to all 55 dental clinics in the city listed on the state
BadgerCare Plus website found only eight that were accepting new adult BadgerCare patients enrolled in the
managed care organizations that administer the program. And most were booking new patients two to three
months out.

Dentists say the low participation is due to the state's Medicaid reimbursement - which, at about 40% of
the billed amount, ranks fifth-lowest in the country and often does not cover a dentist's costs. The amount
is less for those in a managed care organization, as are more than 90% of BadgerCare Plus patients in
Milwaukee County.

Hormonal changes during pregnancy make the gums more susceptible to swelling and infection, and some
studies point to a link between gum infections and premature birth. For that reason, the state Department
of Health Services recommends pregnant women see a dentist.

Yet just 35% of all BadgerCare Plus patients in Milwaukee County did so during the year that ended June 30,
2010, said department spokeswoman Stephanie Smiley. A breakdown of dental visits by pregnant patients was
not available.

The lack of dental access points to a flaw in the BadgerCare Plus program at a time when state and local
officials are striving to improve the health of low-income pregnant women in Milwaukee.

More than two months after she began looking, Hamberlin still hadn't found a dentist. By then, she was
14 weeks pregnant and in constant pain. Pieces of her tooth were breaking off in her mouth.

Link to preterm birth?

Dentists emphasize the need for good oral hygiene and dental care before and during pregnancy.

In addition, a number of studies have found that pregnant women with periodontal disease - a more serious
form of the gum infection gingivitis - are more likely to have a preterm or low birth-weight baby.

Preterm birth caused 53% of infant deaths in Milwaukee during 2005-'08, according to the Milwaukee Health
Department's 2010 infant mortality report.

But because periodontal disease is more common in people with other risk factors for preterm birth - such
as smoking or diabetes - not all researchers agree gum infections themselves are a cause.

In addition, while treating periodontal disease during pregnancy has been shown to be safe, not all studies
have found doing so lowers preterm birthrates.

Bryan Michalowicz, a dentist with the University of Minnesota, authored a study of 823 pregnant women with
periodontal disease who lived in Minnesota, Kentucky and New York City's Harlem.

About half the women were randomly selected to receive periodontal treatment during pregnancy. The rest
were treated after giving birth.

The study, published in 2006 in the New England Journal of Medicine, found no significant difference between
the rate of preterm birth or low birth weight between the groups.

"I think it's fairly well settled that treatment of periodontal disease doesn't affect these birth outcomes,"
said Michalowicz.

Although several other large clinical trials showed similar results, researcher Marjorie Jeffcoat of the
University of Pennsylvania strongly believes there is a link.

She did a study of 322 pregnant women with periodontal disease that found those whose disease was successfully
treated during pregnancy had significantly lower preterm birthrates.

She attributes her findings to the study's methods. Jeffcoat and colleagues selected only patients who had
moderate to severe periodontal disease in the first place, and then measured preterm birthrates in women
whose disease was effectively treated.

This year, Jeffcoat published another study of low-income, mainly African-American women with periodontal
disease who refused dental care. The study found that those who rinsed twice daily with an alcohol-free
antibacterial mouthwash had preterm birthrates that were about one-quarter those of women who rinsed with
just water.

Jeffcoat is now planning a larger study of the mouthwash that will enroll women in several cities.
She stressed that no matter the results, using mouthwash shouldn't take the place of going to a dentist.

"We know we need to study (the link between periodontal disease and preterm birth) more," said Monica Hebl,
a former president of the Wisconsin Dental Association. "But studies continue to strengthen the idea that
women should consider a periodontal evaluation as part of their prenatal care."

Dental access problems

The state's dental access problems are well-known. As the Journal Sentinel reported two years ago, statewide,
more than 300,000 children in the BadgerCare Plus program didn't see a dentist in 2007.

Of the dentists in Milwaukee County certified to bill the state's Medicaid programs, including BadgerCare Plus,
42% submitted claims totaling less than $10,000 in the year that ended June 30, 2010, Smiley said. That suggests
many dentists have few patients covered by BadgerCare Plus or Medicaid.

In 2008, a report by the state Legislative Audit Bureau found that the managed care organizations that
administered Medicaid dental benefits in four southeastern Wisconsin counties had not fulfilled their contractual
requirement to maintain an adequate number of providers or timely access to care.

Despite a recommendation to pursue alternatives, the department expanded the model to include two more counties
in southeast Wisconsin, a move the Wisconsin Dental Association opposed.

Health services deputy secretary Kitty Rhoades said she didn't know why the department didn't act on the
bureau's recommendation.

But with a $1.8 billion deficit in the Medicaid program, she said, it was unlikely the state would increase
the reimbursement for dentists.

Instead, the department is trying "creative solutions" to improve dental access in southeastern Wisconsin,
Rhoades said.

Under its current contract, beginning in 2012, if managed care organizations fail to meet certain benchmarks,
the department can withhold up to 0.25% of what it pays them to provide services.

For example, 34.8% of adults continuously enrolled in BadgerCare Plus must use dental services in the year
that ended June 30, 2011. That percentage increases to 38.3% this year and 42.1% the year after.

"It's kind of the beginning of pay for performance," Rhoades said. "Here's what I hired you to do, and if
you don't get it done, you don't get all your money."

Prevention important

Preventing oral disease is key to overall health, dentists say. And that not only includes improving access
to dental care, but making changes at home.

"We can't drill and fill our way out of the problem," said Hebl, a dentist at Burleigh Dental in Milwaukee,
which treats Medicaid patients on Thursdays. "We have to educate people on the front end."

Jorelle Alexander, dental director of Milwaukee Health Services, agreed.

"We need a paradigm shift," she said. "Most of the resources have been focused on fixing the problem, when
we need to work with (people) to prevent it."

Milwaukee Health Services offers six support groups a year to provide health information to low-income
pregnant teens and young women who aren't already receiving prenatal care. Alexander teaches each group
about oral hygiene during pregnancy and caring for babies' teeth, said program director Jill Denson.

After birth, many young mothers and fathers graduate to parenting groups, where they get more hands-on teaching.

Women in the groups are screened for urgent dental problems and receive priority for treatment at Milwaukee
Health Services. They're typically seen within a week, Alexander said, while normal wait times for dental
care there run four to six weeks.....Read more
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