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Rural Missouri Magazine

Delivering Smiles
Miles for Smiles mobile clinic often provides
the only dental care for kids

by Bob McEowen

Loretta Fishburn comforts her granddaughter, Amber, while Dr. Gerald Awadzi examines the first grader’s teeth in the tiny Miles for Smiles mobile dental clinic. Dental assistant Gail Scott waits by. The clinic provides free medical care to school children in seven southwest Missouri counties.

When 10-year-old Lynn Smith broke a front tooth her mother tried, unsuccessfully, to find a dentist near the family’s home in Macks Creek who would see her.

“I had to drive clear to Jefferson City to a dentist who would take her Medicaid and they wouldn’t do anything,” Denice Smith says. “All they did was take an X-ray and write notes.”

Smith was told it would cost $500 to fix the tooth. She couldn’t afford the work and her daughter would have gone untreated if it weren’t for an unusual program which provides free dental care to school children in seven southwest Missouri counties. Now Lynn can flash a toothy smile, her broken tooth repaired in a tiny 8-foot by 18-foot dental clinic that pulled up to her school recently.

Each week the Miles for Smiles mobile dental clinic sets up shop at one of 28 schools located within a band of small towns that stretches from Lamar and Nevada, to the west, to Buffalo to the east. From Monday through Thursday a parade of school kids pass through the trailer’s two dental chairs, receiving all manner of treatment — everything from cleanings and sealants to fillings, extractions and even root canal therapy.

The program is a response to a severe lack of dental care in rural areas. The situation is particularly serious for those who rely on Medicaid, the federal program that funds health care for low-income families.

Many of the patients Miles for Smiles treats have never been to a dentist prior to the clinic's visit to their school. Each child wears sunglasses to reduce the glare of the dentist’s light and to protect their eyes.

“In our seven county area there’s 29 dentists and none of them are taking new Medicaid patients,” says Tina Munroe, project coordinator for Miles for Smiles. “Quite a few of them aren’t taking new patients at all, even if they have insurance.”

The shortage is not limited to southwest Missouri. “Only about 15 percent of private dentists accept Medicaid,” says Chris Stewart, director of the Oral Health Initiative of the Missouri Primary Care Association. Stewart’s organization represents 15 Federally Qualified Community Health Centers in the state, 11 of which offer free dental care to anyone who walks through their doors.

Citing low Medicaid reimbursement rates — about 55 percent of normal fees according to the Missouri Dental Association — dentists say they simply can’t afford to treat low-income patients. “It costs them money every time they see anyone (on Medicaid),” says Dr. Jake Lippert, executive director of the association.

The effect is that many children never see a dentist.

“When the money’s tight, if the kid’s coughing or throwing up (parents) know they’ve got to go to the doctor. If their tooth aches, well, ‘Eat on the other side.’ It’s something you can put off,” Munroe says, explaining the thinking of some parents who can’t afford dental care.

El Dorado Springs R-II School nurse Loree Schweizer greets a young patient at the door of the Miles for Smiles trailer following his appointment. School nurses screen patients for financial need and bring students to and from their appointments.

The Miles for Smiles program began when Barceda Families, a child abuse and neglect prevention program, set out to address the poor dental health it found in children. Working with Citizen’s Memorial Hospital of Bolivar, Barceda Families (named for Barton, Cedar and Dade counties) applied for a grant from the U.S. Department of Health and Human Services’ Office of Rural Health Policy.

The $200,000 annual grant, awarded in May 2000, allowed the organization to purchase and repair a 1960’s-era travel trailer that had previously been used as a dental clinic but was sitting unused on flat tires with its interior in dire need of attention. Over the next few months the program’s first dental assistant was hired, the trailer was restored and new dental equipment purchased.

Miles for Smiles started treating children in February 2001. It relied on volunteer dentists until Dr. Gerald Awadzi, the clinic’s first full-time dentist, began work in July.

Today, the clinic treats low-income and uninsured students in kindergarten through 8th grade at schools in Barton, Cedar, Dade, Dallas, Hickory, Polk and Vernon counties. In addition, it keeps a full summer schedule, visiting health department offices and summer schools.

Working with school nurses who screen the children for financial need, the Miles for Smiles clinic has no shortage of takers. During a recent visit to El Dorado Springs R-II School parents requested service for more than 160 students. With two dental chairs and two dental assistants, the clinic only saw about 15 patients a day — leaving nearly 100 children to wait for the clinic’s next visit.

Dr. Gerald Awadzi talks with Jonathon Michlich, a student at Eldorado Springs R-II School who received dental care during a recent visit of the Miles for Smiles clinic.

“We only have so many hours in a day. We try to get in all we can but we can’t see them all in four days,” explains Gail Scott, a dental assistant who has worked for Miles for Smiles almost since its inception.

As great as the demand is, the condition of the patient’s teeth is an even more dramatic indication of the need.

“People don’t realize that right here in Missouri there are kids with just bombed out mouths and serious decay and problems,” says Munroe, a social worker who occasionally fills in as a dental assistant. “We had a child one time with 16 cavities and you only have 20 baby teeth.”

For Awadzi, who practiced dentistry in his native Ghana before attending the University of Pennsylvania, the condition of children’s teeth in southwest Missouri was hard to imagine.

“If I didn’t come here I wouldn’t have believed it,” he says. “This is America!”

Awadzi says children’s teeth are no better here than they are in rural Africa where people brush their teeth with twigs. A sugar-rich diet is responsible for much of U.S. children’s tooth decay but lack of even basic dental care is also to blame.

“You see 12, 13-year olds who tell you they’ve never brushed their teeth or they don’t have a toothbrush,” he says of his American patients.

While every Miles for Smiles patient leaves the clinic with a toothbrush, Munroe says the problem is not that families can’t afford basic necessities. Many children aren’t being taught to care for their teeth, she says.

“You can just see a lot of the parents that come (with their children). You can tell that they were not taught to brush their teeth,” Munroe says.

To counter the generational spread of poor dental hygiene the program also tries to teach children the importance of brushing and flossing.

Gail Scott, Miles for Smiles first dental assistant, shows David Green the results of her efforts cleaning his teeth. Often the Miles for Smiles staff must educate children about the importance of brushing.

“Maybe it’s the first time anyone has ever explained to them why they need to brush their teeth,” Munroe says. “If we can get the kids to realize how important it is then we’ll be able to make a big impact.”

But no matter how well a child brushes they still need to see the dentist on a regular basis. The Miles for Smiles project barely begins to address the staggering need for dental care, especially for low-income families.

“When you’ve got 850,000 people, or one in seven bodies, in the state of Missouri on Medicaid, there’s a lot of patients out there that want to be seen,” says Lippert.

Despite criticisms to the contrary, Lippert says Missouri’s dentists are doing their part to serve low-income families. Besides dental clinics funded by hospitals, federal programs and county governments, dentists themselves often volunteer their time, he says.

Still, in seven Missouri counties at least, there remains more than enough work to keep Dr. Awadzi and his staff hopping. How long that will continue remains to be seen. The clinic’s grant expires in 2003 and, like regular dentists, it’s unlikely Miles for Smiles can survive on Medicaid reimbursements alone.

One thing’s for sure. The steady stream of kids with poor dental health that passes through the Miles for Smiles trailer doors is not likely to subside any time soon.

“I have school nurses who call me all the time saying, ‘I’ve got a kid in pain here. We’ve called 15 dentists and nobody will take them. Is there anything you can do?’” Munroe says. “If we weren’t here they wouldn’t be going to a dentist anywhere else.”

For more information about Miles for Smiles call (417) 328-6334. To find a Federally Qualified Community Health Center offering dental care near you, call (573) 636-4222.

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