The quality of Paul Bunyan’s smile in his downtown Bangor statue suggest that Bunyan was never a Medicaid dental patient, because judging by the quality of his teeth he got regular dental care. Maine pays so poorly for the dental care of its Medicaid patients that most dentists lose money seeing them, and many Medicaid patients therefore go without dental care.

Emergency physicians are really the dentists for Maine’s Medicaid patients, despite the fact that they know relative beans about teeth. Its emergency departments are its principal Medicaid dental clinics, despite being staffed by people who think pulp is the stuff used to make paper. An ED doc in Maine about to see a patient with an infected tooth can predict the patient’s insurance by the condition of his or her mouth – the worse the teeth the more likely Medicaid is the dental (lack of) insurance.

These are the usual steps to dental care in many Maine towns for Medicaid patients:

1. Develop an infected tooth;

2. Call every dentist in your area – so sorry, none take Medicaid or are already taking their limit of Medicaid patients;

3. Tooth gets worse, so go to the ED (which Medicaid pays for), get antibiotics and pain medicine (which Medicaid pays for), get told by ED doc to see dentist in follow-up (which Medicaid avoids paying for by paying too little to get a dentist to see the patient);

4. Call dentists for follow-up. See no. 2;

5. Tooth gets worse, now needs to be pulled. Go to ED because many oral surgeons in the state will not see a Medicaid patient unless referred from an ED, get antibiotics and pain pills again, get referred to the dentist to have tooth pulled;

6. Dentist who cannot afford to see patient for dental care that would have saved tooth pulls tooth – who needs those pearly white accessories, anyway?

There are many solutions to this problem, but first and foremost the state needs to puts its Medicaid money where its Medicaid mouth is, by funding LD 477, This bill before the Maine Legislature would require Maine Medicaid to increase the rates it pays dentists to the 50th percentile of what is being paid across New England. The current lack of adequate reimbursement to dentists suggests the official state motto is really “Maine – where permanent teeth are for wimps,” and that permanent teeth are regarded here as an accessory, similar to painted nails or tongue jewelry.

The $3.8 million price tag is competing in a barroom brawl for funding, one in which Medicaid patients are going to get more of their teeth knocked out if the bill does not get support before the Legislature’s Appropriations Committee. While $3.8 million is a lot of monetary amalgam, poor dental health is linked to poor nutrition status, increased risk of other infections, may be linked to heart disease, and is certainly linked to expensive ED visits for inadequate dental care. The state’s failure to pay dentists reasonably is adding cost elsewhere.

The money provided by LD 477 will not only increase the number of dentists seeing Medicaid patients, but will help ensure the survival of its non-profit dental centers.

The $5 million for LD 477, however, is really just a filling for Maine’s Medicaid dental problem, and is really a first step. There are several other steps that need to be taken. Maine’s dentists need to scrape the plaque off their act and all commit to providing some Medicaid dental care. If every dentist took an equal share of Medicaid patients and the state paid reasonably for that care, a lot less dental care would have to be done in the state’s emergency departments and no one dentist would be financially buried in Medicaid cases.

Maine law needs to allow licensed, qualified dental hygienists to practice a greater degree of independent preventive dental care for which they can be reimbursed. They are currently limited to practice in nonprofit institutions. Maine will never be able to afford all of the dentists it needs, and must support lower cost preventive dental practice outside the traditional dentist’s office. To dentists who object we should simply say, “Don’t worry Doc, this won’t hurt a bit.”

Third, Maine Medicaid officials need to develop a statewide, online, computerized registry of dentists who take Medicaid patients, so patients can call an 800 number to get that information instead of going through the embarrassment and inconvenience of calling every dentist in town to see which take Medicaid patients.

Finally, funding of dental care for Maine’s Medicaid patients will never be completely adequate, and Maine’s Medicaid patients must therefore ultimately be responsible for care of their own teeth. Basic dental care must be provided to Maine’s children and good dental habits must be taught to all, so that no one grows up in this state thinking real teeth are just a transition to dentures. $5 million for LD 477 and the other steps suggested above will go a long way to improving dental care in Maine but not one of those steps will brush a single tooth or teach one child that real teeth are not meant to be lost.

Just say “Ahhhhh,” indeed.

Dr. Erik Steele is the administrator for emergency services at Eastern Maine Medical Center and is on the staff for emergency department coverage at six hospitals in the Bangor Daily News coverage area.