With a sedative flowing through his veins, John Simon rested comfortably as his teeth were examined and cleaned at the University of Pittsburgh School of Dental Medicine.

	Tony Tye, Post-Gazette At the University of Pittsburgh clinic, which offers specialized dental services to people with disabilities, dentist Lotus Su, left, and student Chad Morris work on Nancy Burdick of Carnegie. Click photo for larger image.

Without the intravenous sedation, Simon, 53, who has bipolar disorder and severe mental retardation, would scream and would not sit still for a dentist.

"There's no place near where we live that will take care of someone like him," said Darlene Cassels, a supervisor of his group home in Elk County. So the group home staff drives him three hours to the dental school in Oakland for his dental checkups.

But Simon is one of the lucky ones. Dental care is so scarce for state residents with disabilities who receive Medicaid, advocates contend, that they have filed a class action lawsuit against the state.

Lawyers recently submitted final written arguments in the case, which is being heard in U.S. District Court for the state's Middle District. Attorneys for the state deny a widespread problem exists, although state officials acknowledge they are working to improve the availability of treatment.

Similar lawsuits have been filed in more than 20 states demanding improved access to medical and dental care for people with developmental disabilities, according to the American Academy of Developmental Medicine and Dentistry.

In many states, Medicaid payment rates for dentistry are so low that providing treatment "really becomes charity care," said Dr. Matt Holder, a physician and the group's executive director.

Saying people with disabilities have "an overwhelmingly difficult time finding proper dental health care," Achieva, a local agency serving people with developmental disabilities, plans to hold a policy forum on the issue this fall in cooperation with the FISA Foundation.

Special needs clinic

The challenge of finding dental care for people with disabilities has increased the importance of the Pitt dental school's special needs clinic, where Simon receives care.

Usually, openings occur only when patients decide to no longer come in for treatment, become ill or die, said Dr. Deborah Studen-Pavlovich, who chairs the school's department of pediatric dentistry. It sponsors the clinic with the school's anesthesia department, dental hygiene program and advanced education program in general dentistry.

Advocates note that untreated oral health problems may lead not only to pain but to other health conditions, including diabetes, stroke and heart or lung disease.

Lack of access extends beyond people with disabilities, said Dr. Robert Brandjord, an oral surgeon and president-elect of the American Dental Association.

"For people on Medicaid, it's a problem across the country," he said.

Low payment rates and bureaucratic red tape make many dentists reluctant to participate in the Medicaid program, he said.

Other factors that inhibit participation include high no-show rates among patients and a shortage of dentists in some communities, particularly in rural areas, said Dr. Michael Cerveris, a Chambersburg dentist who is leading a Pennsylvania Dental Association task force examining access to dental care.

Medicaid recipients with disabilities often require extra treatment time because of their special needs, Holder said. Some need sedation even for minor procedures.

Candy Smith, of Regent Square, said dental care is so traumatic for her son Colton, 5, who has Down syndrome, that she has scheduled it when he has been in the hospital for surgery. With no additional operations scheduled, she said she has been searching for a dentist in the area who will provide Medicaid-funded care with sedation.

Waiting at the Pitt special needs clinic last week, community home supervisor Mary McCue said she has been able to find dentists for clients with disabilities who do not need IV sedation. But that is not an option, she said, for Nancy Burdick, 46, of Carnegie, a group home resident who was at the clinic for a checkup.

Without sedation, "she just can't handle it," McCue said. "She tries to leave and won't open her mouth."

In the Pennsylvania class action suit, filed in 2000, attorney Edmond Tiryak of Wayne, Delaware County, and lawyers for the Disabilities Law Project claim that Medicaid-funded dental payments are "grossly inadequate" to ensure access to care for adults and children with disabilities.

Better payment rates

To attract more dentists to the Medicaid program, the suit argues that the state Department of Public Welfare needs to raise payment rates.

In court papers, state attorneys emphasize the department has taken a number of steps to improve access to Medicaid-funded dental care, including raising some rates in 1999 and 2001.

The state also plans to increase rates this month for dental-related anesthesia and behavioral management, and no dental services are targeted for cuts in the proposed state budget, said Stefani Pashman, an assistant to Department of Public Welfare Secretary Estelle Richman.

Carol Horowitz, an attorney for the Disabilities Law Project, questioned whether those increases are sufficient to improve access to care. She noted that even after the increases several years ago, Medicaid payment rates were so low that less than 10 percent of the state's dentists were likely to accept them.

State attorneys say the plaintiffs have shown only that some people with disabilities "might have an occasional difficulty accessing dental services."

They contend many dentists donate care, but do not participate in the Medicaid program "to avoid being inundated with large numbers of additional patients."

Studen-Pavlovich believes many dentists could do more to provide care even if they are not equipped to provide anesthesia. She noted that since the late 1990s, students at the Pitt dental school have served rotations through the special needs clinic to give them more familiarity with patients with disabilities.

Some dentists cannot afford to provide much free care, she said, noting that recent Pitt dental school graduates may have school loans exceeding $160,000.

On the other hand, she noted, some dentists "are uncomfortable being around people with disabilities."

Dentists at the special needs clinic said that caring for some patients can be a challenge.

Sometimes, patients have to be sedated even before they enter the building, said Dr. C. Richard Bennett, chair of anesthesiology at the dental school.

Many patients are unable, because of their disabilities, to even brush their teeth between six-month visits, said the clinic's director, Dr. John Geary.

Officials noted that the clinic plans to expand beyond 1 1/2 days a week, though additional funds need to be identified.

The welfare department's Richman said her agency is working to find ways to improve dental care, particularly for children and people with disabilities.

Studen-Pavlovich said it is important for officials to continue to seek solutions.

Otherwise, "you're never going to improve this," she said. "It's not a simple problem and it doesn't have a simple solution."