In the Driver's seat

Maryland public health hygienist remains saddened by dental tragedy, but delighted that change did occur

By Judith E. Sulik, RDH, MBA

Long before Deamonte Driver of Prince George County in Maryland died in 2007 from an untreated tooth infection that spread to his brain, dental hygienist Jane Casper knew Maryland's poor children desperately needed access to dental treatment.

Casper, a 1974 graduate of Howard University's dental hygiene program, completed her bachelor of science degree at the University of Maryland and continued on to earn a master's degree in applied sociology from the University of Maryland, Baltimore County.

She said, "Public health really interested me and was a reason to get my bachelor's degree. While studying, I applied for a job with Head Start and began working in Montgomery County. We did screenings and provided oral health instruction, and we eventually began a fluoride varnish program. I worked there for about four years and simultaneously interviewed with Howard County for a sealant program that hadn't started. They told me I had to screen the kids first to identify a need. I asked, ‘What are we going to do about the dental decay when we find it?' I told them we needed something in place. At that time, the health officer was a big proponent of oral health and agreed to open a dental clinic as part of the Howard County Health Department. I couldn't believe that we were in a wealthy county, yet so many children were in need of dental care." She said that exacerbating the situation was that not enough dentists accepted Medicaid.

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Casper is not easily daunted, nor does she take a passive position when she sees a problem in dire need of a solution. But solutions do not often come quickly when public policy is involved.

She worked in different settings, including Prudential Insurance and in a prosthodontist's office, and when her husband opened his pediatric dental practice, she worked part-time for him while raising their three children.

She continued to notice a significant number of children with dental decay in their practice, just as she had while working with Head Start, and she wondered why. She said, "I noticed children from families of all socioeconomic levels in our practice, which was in an affluent area."

While working with the Howard County Health Department, Jane called all of the dentists who were participating in the children's dental Medicaid program, Health Choice, and learned there were seven different HMOs whose plans were confusing to parents, as well as to the dentists who participated in Medicaid. To make matters worse, the lists of participating dentists was rarely updated.

"I began looking for dentists who would accept the Medicaid patients," she said. "I called all 60-plus of the dentists on the list and learned that only six were still seeing these patients. Some of the dentists no longer participating were listed two or three times. One dentist on the list had been dead for three years!"

"The whole system was a myth," she continued. "Reimbursement was so low and the money so lousy that some dentists preferred treating patients for free rather than deal with the administrative issues."

In 2004, still three years before Deamonte Driver's death became a lightning rod for major change, Jane joined a state Oral Health Advisory Committee as a public health advocate. The committee was able to approve an increase in some reimbursement rates, hoping that action would lead to more dentists joining the Medicaid program. Some did, but Jane notes, it was still hard to navigate the system, and it was a slow process getting kids treated.

But then Deamonte Driver died. "He lived in the backyard of the federal government in one of the richest states in the country," Jane said. How did this terrible tragedy happen? Insurance companies, nurses, physicians, dentists, hygienists, Driver's mother's attorney, child advocates, and the Department of Mental Hygiene all took action and came together to form the Dental Action Committee. This committee was appointed by then Secretary of the Maryland Department of Health and Mental Hygiene, John Colmers. "I was honored when I was asked to join," Jane said. "I had one question before I agreed to participate -- would this committee really take action? I was told it would, so I accepted."

Driver died in February, and the first meeting was held the beginning of June. Twenty-five people were on the committee, with Jane serving as co-chair. She said, "We met twice a week during the summer, with subcommittees meeting separately. Secretary John Colmers set Sept. 11, 2007, as the deadline for our report. We made seven recommendations we felt would prevent something like what happened to Deamonte from happening ever again."

She explained that the recommendations were presented to the Secretary, saying, "Some laws had to be changed. We brought the changes to the legislature to get support. Dentists and dental hygienists came together and agreed. Before this process, there were more turf battles among the professions. This time hygienists, both in private practice and public health, and dentists united with no agenda. Everyone only cared about getting children treated."

Jane Casper and other advocates of public health in Maryland discovered more cooperation between dental groups after the tragic death of Deamonte Driver.

Twelve of the 27 counties in Maryland had health departments with dental clinics. The committee wanted a safety net dental clinic available throughout Maryland, in either a local health department or a federally qualified health center (FQHC).

"The state health department needed more money, and we got it," Jane said. "We focused on areas that needed serving the most. Worcester County, for example, applied for one of the grants and was able to open in 2011."

Today, all Maryland residents have access to a safety net clinic in their county or an adjoining county. Many of the small counties on the Eastern Shore share a regional FQHC.

Interestingly, Maryland has never had school dental hygienists, and as a result, one recommendation was to have public health hygienists go into schools without a dentist and perform screenings and preventive services. This suggestion became the Public Health Hygiene Act, and its passage and implementation resulted in an expansion of sealant programs that can now be done without a dentist's supervision.

Casper is elated that Maryland has been in the spotlight as a national model because of its changes to increase and improve access to dental care. Maryland is now a single-payer state with increased reimbursement rates, and a lot more dentists are participating in Maryland Healthy Smiles.

It is recommended that all children visit a clinic either after the eruption of the first tooth or by age one. Toddlers receive screenings and parents receive education. Pediatricians and nurse practitioners are Medicaid providers, and have taken part in the Maryland Mouths Matter training on oral health risk assessment and fluoride varnish applications to help spread the word to patients. Maryland's oral health literacy campaign, Healthy Teeth, Healthy Kids, which was also one of the Dental Action Committee recommendations, educates parents and caregivers of very young children on the importance of oral health.

While the Dental Action Committee was supposed to exist only through the summer of 2007, it transitioned into the Maryland Dental Action Coalition.

Thanks to Jane's commitment to improving access to dental treatment for all children, she has seen a reduction in caries cases become a reality. Her experience and success shows that when many determined, dedicated individuals join together, they can become a galvanizing force for epic and positive change.

Jane said, "I'm so happy these kids are getting treated. They have no problem finding a dentist today. This was a medical/dental collaboration that succeeded. I felt honored and blessed to be a part of this. It was amazing and fulfilling. From my years of doing screenings, especially at Head Start, I knew the reality of these kids' needs. All of my dreams have come true, but I know there is still more work to be done. When we got off topic back in 2007, we asked ourselves, 'Why are we doing this?' The answer was always the same -- 'For the kids.'"

JUDITH E. SULIK, RDH, MBA, is president of Finally Finished Press of Middleton, Wis. She recently published a cookbook based on Madison, Wisconsin-area restaurants. For details, contact her by e-mail at Judy.sulik@gmail.com.

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