When a 12-year-old Medicaid-insured child living in a suburb of Washington, D.C., died of a brain infection caused by an untreated abscessed tooth, it was hard for Congress to ignore the questions raised by the tragedy.

In a hearing called March 27, just a month after Deamonte Driver's death, the chairman and ranking minority members of the House Subcommittee on Health called it "shocking" that in the U.S. today, oral disease is the most prevalent chronic disease of children, and 80 percent of the decay occurs in 25 percent of children--"primarily low-income and minority children." 

The president of the American Dental Association (ADA), who said she is herself a Medicaid provider, echoed the committee's concern that dental care is not available to uninsured children or in many cases to children who are covered by Medicaid, as was the case with Deamonte. The boy's death "underscores the significant chronic deficiencies in our country's dental Medicaid program," said ADA president Kathleen Roth.

Barriers that make it difficult to supply care, Roth said, include the geographic distribution of providers, who are often located far from neighborhoods of children who are covered by Medicaid. She conceded that Medicaid payment rates are also a problem, with analyses showing that Medicaid reimbursements are lower than Medicare or private insurance. "In short, the vast majority of the dental Medicaid programs in the United States are woefully under funded and the reimbursement rates simply cannot attract enough dentists," particularly young people who are graduating from dental school with  indebtedness often exceeding $150,000, she said. "This level of debt puts a great deal of pressure on young dentists to set up private practices in relatively affluent areas to the exclusion of underserved areas."

"To truly address the oral health access problems faced by underserved populations, we need to get more private sector dentists participating in Medicaid," she said. "Over 90 percent of practitioners are in the private sector, and with over 30 million children estimated to be Medicaid-eligible, there is simply no other way to adequately serve such a large segment of our nation."

The Problems

Calling the death of 12-year-old Deamonte Driver "a result of the passive complicity of a failed system," Dr. Stephen Corbin, an official of Special Olympics International, described Deamonte's condition as "heart failure, precipitated after an infection of the brain, arising out of a blood-borne infection that moved from an infected pulp of a tooth, that had been preceded by a deep carious lesion of the dentin of the tooth, that was preceded by an extensive carious lesion of the enamel, that was preceded by a minimally invasive carious lesion of the enamel, that was preceded by a barely detectable lesion of the enamel."

"Was this some exotic new invader unknown to medical science? Was this a clinical condition for which there was no known treatment? Sadly, the answers to these questions are 'no, no, and no'!" Instead, he said, Deamonte died "from a disease that we have known how to prevent and treat for more than a hundred years."

Speaking for the American Academy of Pediatrics, Dr. David Krol of the University of Toledo College of Medicine noted the need for providing information about the importance of dental care to low-income families, whose children are most likely to have serious dental and other health problems. The board chair of the Children's Dental Health Project in Washington, D.C., Dr. Burton Edelstein, agreed, pointing out that research sponsored by the National Institutes of Health (NIH) over the past 40 years "has well established that tooth decay is an infectious disease that is typically transmitted from mothers to children during a child's first year of life."

Citing a recent upswing in tooth decay in the youngest children, the Centers for Disease Control and Prevention (CDC) reported in August 2005 that more than a quarter (28 percent) of 2-5-year-olds already have cavities in their baby teeth and half (49 percent) of children ages 6-11 have cavities in their adult teeth.

Currently, Edelstein noted, only 30 percent of children enrolled in Medicaid at any time during the year had at least one dental visit and only 25 percent had at least one preventive dental visit—less than half the rate of services obtained by commercially insured children. State-by-state performance varies greatly, ranging from as low as 13 percent in one state to as high as 47 percent in another. Those figures are for Medicaid: Edelstein said we know far less about the effectiveness of the State Children's Health Insurance Program (SCHIP) in covering dental care, because Congress has not to date required systematic dental performance reporting in SCHIP.

What To Do?

Since they were testifying before congressional committees with jurisdiction over federal health programs, including Medicaid and SCHIP, witnesses at last month's hearing stressed the need for more federal oversight of the dental care that is supposed to be provided to Medicaid-eligible children under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program, and they urged new requirements for dental coverage in Medicaid and SCHIP, along with increased federal funding of those two programs. They also cited need for federal support of community health centers, many of which provide dental services.

Said one witness, "On behalf of America's children, I urge you and your Committee to continue attending to pediatric oral health, to maximize opportunities for cost-effective cavity protection and to integrate oral health into every federal program that addresses the health and welfare of our nation's children."