Dentist Nicole Thompson-Marvel, right, talks to patient Natalie Prystay… (Al Seib, Los Angeles Times )
Little surprises Nagaraj Murthy, a dentist in Compton for the past 32 years.
He has seen patients who have suffered toothaches for years. Others who haven't been to the dentist in a decade. Some who can't chew hard food.
But in the two years since California sharply reduced dental benefits for roughly 3 million Medi-Cal recipients, he and other dentists say the situation has become dire for patients who are waiting until their infections land them in an emergency room or their rotted teeth have to be immediately pulled.
"They aren't coming until the mouth is completely swelled up or the pain cannot be tolerated," Murthy said.
Dental care is the oft-ignored cousin of medical care, experts say. Because dental coverage is an optional benefit under the federal Medicaid program for the nation's poor, several states don't offer it. Others, like California, have slashed the benefit in recent years, meaning millions nationwide are going without treatment and facing heightened risks of serious and costly health problems like respiratory infections and heart disease.
One-third of Americans reported skipping dental checkups and care because of the cost, according to a Kaiser Family Foundation poll released in April. And a report by the national Institute of Medicine in July said "persistent, systemic" barriers, including lack of insurance and a shortage of dentists, are increasingly limiting people's access to dental care and exacerbating socioeconomic disparities in public health. The report urged states to include dental coverage for adults with Medicaid and recommended better training so primary care doctors can spot oral diseases.
"Oral health isn't just the responsibility of dentists," said Frederick P. Rivara, a Seattle pediatrician who chaired the committee that wrote the report. "There is a real need to have other healthcare providers involved."
Pending reforms of the healthcare system aren't expected to help. Some provisions are designed to increase public education, dental training and dental care by providers such as hygienists and dental health aides. But many of the those improvements aren't funded. And despite the push to provide health coverage to the uninsured, experts say adults who cannot afford private dental plans will still be on their own.
Since California cut back dental coverage, Murthy said he has lost about half of his adult patients because they don't have money to pay for services. He doesn't charge them for preliminary exams but said he can't afford to provide free treatment.
Medi-Cal, California's version of Medicaid, still pays for necessary extractions for adults but no longer covers cleaning, X-rays, fillings, root canals or dentures, dentists said. As a result, dentists and researchers said patients are having teeth pulled but not repaired or replaced. That affects their appearance, chances of finding work and odds of contracting gum disease.
Since children are still covered under Medi-Cal, dentists often compete for pediatric patients. But many families don't know their children are eligible or can't find dentists in their neighborhoods.
Free clinics are trying to pick up the slack and see more dental patients.
"We've definitely had an increase of those people looking for free care because they don't have anywhere else to go," said Van Anh Dastur, dental director at the Saban Free Clinic in Los Angeles.
The clinic does root canals, fillings and cleanings but doesn't have the funding to do crowns. Dastur said she and her dental staff also do a lot of education — both for parents and children.
"If we can focus on them early, we can save a lot of money," she said.
To meet the growing need, the Venice Family Clinic opened a new dental service, primarily funded by private donors. The dental service, under director Nicole Thompson-Marvel, has gone from two portable chairs to six examination rooms where she and another staff dentist see patients. The clinic also trained its pediatricians to do some initial dental screening and care.
One of her patients, Jason Archuleta, 46, recently sat in a dental chair under a poster that read, "Healthy eating habits = healthy teeth." A recovering alcoholic, he came to the clinic because a tooth broke and was waking him up at night.
"How long has it been broken?" the dental assistant asked him.
"About a year, but it's just getting worse and worse," said Archuleta, who doesn't have dental insurance.
Thompson-Marvel put on a purple mask, leaned Archuleta back in the chair and examined his teeth one by one. She told him that the broken tooth needed to be pulled. He also had lost some bone on two other teeth. "You might end up losing both of these," she said.
Archuleta nodded and told her that he hadn't been to the dentist in a "very, very long time" — 20 years as it turned out.
Thompson-Marvel nodded and smiled. "It's all right. You're here now."