Tooth decay is a disease. That is what Dr. David Krol, chair of the department of pediatrics at the University of Toledo, tries to impress upon his patients.
“It is an infection in the mouth that can be passed from caregiver to child—most often, mother to child,” he said. “This is important, and something that I'm not sure everyone understands.”
For families who have private dental insurance plans and who keep up with appointments and take care of toothaches and cavities right away, Dr. Krol's warning may not be something they need to think about.
But for families on Medicaid, getting a dental checkup isn't quite so simple. Many dentists don't accept Medicaid at all because of historically poor reimbursement rates.
Often, any dental clinics that do accept Medicaid patients are few and far between, or perform a limited range of services, and patients can expect long wait times for an appointment.
Small Smiles is a national organization of dental clinics that are run by FORBA (For Better Access), a management company based in Pueblo, Colo., that counteracts those unfortunate trends. The 52 Small Smiles clinics in 17 states accept nothing but Medicaid-qualified patients.
That makes it the largest provider of Medicaid dental services in the country, according to Dr. Aldred Williams, the lead dentist at Small Smiles of Washington.
On the inside, this Small Smiles looks like many of its private-practice counterparts in the affluent suburbs surrounding the District of Columbia. There is a spacious waiting room filled with toys and decorated with colorful professional murals, plus a television.
The examination rooms are also bright and inviting, and there are plenty of them—nine treatment rooms, plus separate consultation rooms, hygiene rooms, x-ray rooms, and doctor offices. They, too, are outfitted with high-tech, top-of-the-line equipment.
Dr. Williams—or “Dr. Al,” as his colleagues call him—is happy to give a tour. In a Medicaid-only setting, one might expect a bare-bones, cost-cutting setup.
But Dr. Williams, a retired military dentist who received a commendation for emergency service at the Pentagon on September 11, 2001, proudly shows off his clinic's themed Winnie the Pooh and sports rooms, on which no expense has been spared.
In high contrast to the inside décor, the Small Smiles of Washington building exterior is a converted nightclub that used to be called “The Black Hole.” Dollar stores and pawnshops abound up and down the stretch of Georgia Avenue where the clinic is located. A security guard, employed by the clinic, circles the block.
But this is a perfect location for Small Smiles. Its patients, after all, aren't coming from the wealthy suburbs. This is their neighborhood dentist.
And in fact, the neighborhood's high concentration of Medicaid-qualified patients enables the clinic to stay financially afloat despite Medicaid's poor reimbursement rate. The sheer volume of billing—anywhere from 60 to 90 visits per day (up to 150 appointments, as many as 40% of which are canceled or result in no-shows, for which Small Smiles charges no punitive fee)—brings in just enough revenue.
The place is busy, but not overwhelmed. Five front-office personnel, five dentists, 12 assistants, and three hygienists keep the clinic running smoothly. The average wait for an appointment at Small Smiles is just 2 weeks, and the practice accepts walk-ins and emergency cases.
Its staff—although not necessarily trained as pediatric dentists—is fully qualified to perform complicated pediatric procedures as well as routine cleanings.
Dr. Williams said in an interview that they are paid a competitive wage, and although turnover is high, advantages like regular working hours and FORBA's handling of reimbursement and human resources lure new graduates and former retirees, like himself, to the clinic.
Often, area clinics send their developmentally disabled or autistic patients to Small Smiles, which is trained and equipped to treat these special needs children.
At its opening last November, there were already 1,000 confirmed patients. Todd Cruse, vice president of development and government affairs for FORBA, said in an interview that last year there was a total of 697,000 patient visits at Small Smiles clinics around the country. (For locations, visit www.smallsmilesusa.com
In areas without a clinic like Small Smiles, “It is difficult for many low-income families to find or afford a dentist,” said Dr. Krol, who listed multiple problems that can arise following lax dental care. “Imagine trying to concentrate in school with a toothache, or trying to eat when it hurts to chew. If a child isn't eating, think of how hard it is to get the calories needed to grow.”