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It's like pulling teeth: Finding pediatric, rural dentists poses huge challenge

Niswi Linn brushes his teeth with a big smile on his face at Mahube-Otwa. Head Start students brush their teeth while stomping along to the beat of silly songs. (Meagan Pittelko/Tribune)1 / 4
Selah Carter focuses on brushing a puppet's teeth at Mahube-Otwa. When they aren't brushing their own teeth, the children in Head Start use over-sized toothbrushes to practice on puppets. (Meagan Pittelko/Tribune)2 / 4
Kaden Brausen focuses on brushing a dragon's teeth at Mahube-Otwa. Kaden said that he brushes his teeth, "So they don't fall out!" (Meagan Pittelko/Tribune)3 / 4
(Left to right) Jemma Danielson and Kiauna Basswood practice brushing over-sized teeth at Mahube-Otwa. The Head Start program also teaches children the types of food and beverages impact their teeth.4 / 4

Minnesota may be first in our hearts but, unfortunately, our teeth are a very different story.

According to the Minnesota Dental Association's webpage, "Minnesota currently ranks dead last--50th of the 50 states--when it comes to Medicaid funding rates for pediatric dental services."

That ranking is all too obvious to those working with children in Becker County.

An overwhelming need

"It's almost reached a crisis point for the children in our area," said Mary Frank, Health Specialist at Mahube-Otwa Community Action Partnership. "A lot of dentists are not taking any new clients with Medical Assistance. No one will see the children."

The one area dental care provider that does go out of its way to assist underserved populations--Apple Tree Dental in Hawley, MN--is overwhelmed, according to Frank.

"They have so many clients to see, and there are over 1,000 people on their waiting list," she explained. "And that's not counting the people who call in every single day."

Apple Tree Dental Center Director Suzanne Peterson explained that there are, in fact, currently 1,200 people on the Hawley waiting list and an additional 600 on the Fergus Falls waiting list. To make matter worse, the facility recently lost four dentists to private practices and other facilities.

"Because we're non-profit, the reimbursement rates that we get from the health plans are very low," she said. "It's very hard to compete with private practices or some of the state-funded programs that are able to pay a higher salary to dentists. There is a shortage of dentists in this area that take the state-funded Medical Assistance programs and, with the rural population that we're seeing, a lot of the population is on those state-funded plans or they have no insurance at all."

Mahube-Otwa Executive Director Liz Kuoppala agreed, saying that the low reimbursement rates and an overall dental shortage contribute to the lack of coverage for children in the area.

"We're concerned about all of these young children who need dental care," she said, "because these children have nowhere to go. Because there's a shortage of dentists, they prefer people who can pay so, just because someone has MA (Medical Assistance) doesn't mean they're being seen. "

In fact, according to the Minnesota Dental Association, "Well over half of Minnesota children enrolled in Medicaid have not received dental services in the past year--with the situation made worse by Minnesota's lowest-in-the-nation ranking for reimbursement of government dental program fees."

Facing difficult barriers

Stephanie Hogenson, Research and Policy Director for Children's Defense Fund-Minnesota, explained that, even if families on Medical Assistance do manage to make an appointment, they can find themselves face-to-face with other hurdles.

"Families on MA often have other barriers, such as transportation or jobs," she said. "Actually getting to an appointment is difficult and can be costly--if they have to take time off of work, for example."

Hogenson said that families can be asked to travel hours for a simple dental appointment. With rural dental care in such high demand, many dentists who accept Medical Assistance only accept a certain number of patients--a number that is dangerously low in comparison to the number of individuals in need of dental care.

One other concern, she said, is that the public is unaware of the problems that can be caused by untreated dental issues.

"People think that dental care isn't as important as, say, health care," she said, "but dental problems can have long-term health impacts. Some of those things can be easily prevented."

Frank agreed, explaining that the need for pediatric dental care has been a consistent one in the community but saying that it hasn't gotten the attention it deserves.

"Just in visiting with friends and neighbors," she said, "I don't think that the community is aware of the huge need. We try to serve as many children as we can with the funds that we have, but we just don't have these kinds of funds."

While adults in the community may notice the need for dental care more than children, Debbie Skjonsberg, Health Services Director at Mahube-Otwa, found that children do pick up on the importance of visiting the dentist.

"I sat down next to this little girl one day, and she had never seen me before," she said. "But she opened her mouth and showed me that she had five or six caps on her teeth. She was so proud that she got to go to the dentist."

Forward motion

The verdict is in: rural areas need dentists. From pushing legislature to encouraging collaboration, a number of possible solutions exist; however, according to Frank, there are no quick fixes.

"There are so many issues that are connected that it's a slow process," she said. "But, if a child has a bad tooth in their mouth, we can't let it go much longer than that." Occasional pop-up clinics and days like "Give Kids a Smile" do exist, but offer short-term treatment for long-term problems. One such clinic, a two-day Mission of Mercy event held at Concordia in 2016, only solidified the need in Kuoppala's mind.

"They saw almost 1,500 people that day," she said. "That's just one example of how much this is needed."

Moving forward, Hogenson feels that one of the most important steps is to address the lack of dentists who want to work in rural areas. She explained that some programs, such as one offered by the University of Minnesota, encourage future dentists to return to rural areas. "Recruitment back to rural areas is key," Peterson agreed.

Unfortunately, there are many other facets of the problem that still need to be addressed.

"We need dentists to understand the needs of the programs and why the reimbursement is the way it is," Hogenson said. "We also need to eliminate barriers by providing transportation to appointments and by providing appointments outside of work hours."

Apple Tree Dental, according to Peterson, is working to push legislation that will increase reimbursement rates, which she says will help other local dentists to serve rural populations.

"When we're fully staffed--that's with four full-time dentists and three-full time hygienists--we see between 70 and 85 patients," she said. "Right now, we're seeing around 55 patients a day, and the majority of our patients are on state-funded programs."

The other important aspect, she explained, is prevention.

"We're trying to encourage young families to seek dental care early," she said. "One thing that we've been working on with the Early Childhood Network--through the Fergus Falls office--is to get the medical side of things to stress oral care with their new moms and to stress the prevention part of it, as well. Prevention is a really big thing."

From the dental side of things to the childcare side of things, one thing remains the same across the board.

"There's still a large, unmet need," Peterson said. "I feel like we're only hitting the tip of the iceberg."

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