The Dentist Is Out

The closure of a publicly funded children's dental clinic has low-income patients down in the mouth

In a small cabinet in the Pediatric Dental Clinic of the Children's Diagnostic & Treatment Center, several rolls of brightly colored stickers sit ready to bring smiles to young and hurting faces.

An elephant with a drooping trunk groans, "Watch Me! My Lips and Cheeks Are Numb!" Fred Flintstone's favorite family pet dinosaur flashes a toothy grin and shouts "Dinomite Checkup!" Two clapping seals award a grand-prize ribbon to a giant tooth "For Being Sealed!"

Despite their exuberance these stickers today seem strangely sad and out of place. For the past nine months, they have not provoked a single reluctant giggle nor coaxed a sheepish smile. During that time this dental clinic has had no clients, no treatments, no appointments, and no dentists.

What the clinic does have is three rooms' worth of perfectly functional dental equipment, including two state-of-the-art dentist's chairs complete with overhanging directional lamps, two x-ray machines, four autoclaves, and an ultrasonic instrument cleaner, not to mention a multitude of cabinets and drawers full of untouched boxes of syringes, picks, toothbrushes, crowns, and other dental supplies. Today, nine months after closing its doors, the clinic remains a carefully preserved tableau, a silent symbol of still-unmet needs of the poor and still-lingering fears of HIV infection.

This wasn't the plan at all. As the Children's Diagnostic & Treatment Center (CDTC) Community Relations Director Stormy Schevis explains, the center was originally intended to provide a single location where parents and children living in poverty could come for answers to general health questions, consultations with pediatricians and other medical experts, and basic outpatient treatments and examinations. When the dental clinic opened in 1996 (using seed money from a mix of local and national foundations), it seemed a natural extension of the bedrock CDTC principle of one-stop shopping.

And indeed the clinic was a hit from the start with clients like De'Andrea Hubbard, a 21-year-old unmarried mother of two, who loved the convenience of having a dental clinic in the same building where her children received their medical exams. She also admired Curtis Barnes, the long-time county dentist assigned to the CDTC clinic, for his patient and unpatronizing attitude.

"My kids are scaredy-cats -- they're quick to cry," Hubbard says. "That's why Dr. Barnes was so good. He was always gentle, and he always explained what he was doing. He always told you exactly what you were going to feel next."

The clinic was important to Hubbard for another, more personal reason as well. Although the CDTC was created for the purpose of meeting the needs of all the county's poor children, the nature of poverty in the '90s has decreed that many of its clients -- both mothers and children -- are HIV-positive. And this is the case for Hubbard, though not for her children.

Hubbard knows from experience that finding dental services in the private sector is not easy for someone who is HIV-positive. "You know, when you're Medicaid, a lot of dentists don't treat you well to begin with. They always let you know somehow they think you're just wasting their time," she says. "But then, as soon as you tell them that you're HIV-positive, oh man, then they really start giving you the treatment. They treat you like a public menace."

Dentist Joel Shapses knows the types of discrimination described by Hubbard from a different point of view. The former owner of a private dental practice and a current part-time contracting dentist for the county-run Northwest Health Center, Shapses maintains that some private dentists do try to avoid taking Medicaid or HIV-positive clients if they can help it, while others try to "isolate them from the rest of the patients, perhaps by scheduling all their Medicaid cases on the same day of the week."

Fear of AIDS is not a new phenomenon in the medical field, but it seems to have struck the dental profession especially hard. It's understandable, in a sense, when one remembers how the nation reeled nine years ago when confronted with the tragedy of Kimberly Bergalis, a young woman in her twenties who became infected with the AIDS virus through contact with her dentist.

Gabor Bodnar, president of the Broward County Dental Association, says the fear of being associated with HIV -- a fear he argues has diminished substantially in recent years -- was always rooted in perception and not in prejudice. The answer, he says, "is a matter of educating patients about what we do, such as using gloves and masks and goggles. I even use goggles on patients. They're universal precautions, common sense."

Still, the experiences of clients like Hubbard lead Schevis to suspect that fear has in fact played a role in limiting the pool of dentists available for such settings as the CDTC clinic. "I do know that many of our HIV clients have a difficult time finding dental services, and I do think it's related to the Bergalis tragedy."

And in fact Gary Morey, chair of the Broward County HIV Health Services Planning Council, thinks that such fear is part of the reason the health department has had a hard time filling staff slots not only at CDTC, but also at two other dental clinics devoted exclusively to HIV-positive adults.

Nevertheless, according to Ames, the reason the clinic shut down in the first place had nothing to do with HIV. It was purely a monetary decision, says Rick Ames, head of all county dental clinics. Last winter the worst budget crunch in decades forced the Broward County Health Department to strip its services to the bone. (Although the CDTC is by jurisdiction part of the North Broward Hospital District, its dental clinic has been managed by the health department, which provided its dentist and supervised its operations.)

Suddenly the department found its budget for dental services cut by more than 20 percent, from $918,000 to $722,000. As a result Ames was forced to cancel many part-time contracts and consolidate what staff still remained. Ames decided he had no choice but to transfer Barnes out of the CDTC clinic and into the health department's Northwest Health Center.

That left the CDTC clinic without a dentist and 19-year-old Jenelle James with a sore jaw. Last spring James felt a sharp pain in the side of her mouth and realized that the loose filling she'd been ignoring for some time had finally sprung out. Since she had already been treated several times by Barnes, she naturally called the CDTC clinic to set up an appointment. Instead she learned that "all of a sudden, he was just gone." James, like Hubbard, is HIV-positive and an unmarried mother of two. She doesn't have many other options, and she's not alone.

In a survey completed earlier this year, dental services were listed as the third-most-needed service among the HIV-positive population of Broward County, according to the Broward County HIV Health Services Planning Council. Recognizing this need the council has directed more than $400,000 of the state's Ryan White funds to the county health department for the explicit purpose of providing dental services, says Gary Morey, council chair.

Meanwhile Ames says he is working with the CDTC on several fronts to try to find enough extra cash to allow the dental clinic to get back in business. So far, though, no amount of number-crunching has been able to solve the basic problem: not enough money to reopen the clinic and meet the demand. "Our northwest clinic is double-booked up solid two months ahead," he says. One possible solution, says Schevis, would be to staff the clinic at least in part with instructors and graduate students from local dental colleges.

For the time being, though, the CDTC clinic remains a strange and disorienting island of emptiness in the center of such a large and sprawling health complex, one devoted to healing children of a multitude of medical problems -- except those having to do with teeth.

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