It was a sunny Tuesday morning and 9-year-old Ariante had just finished his 10th visit to the Ronald McDonald Mobile Dental Center parked in a sprawling Target parking lot in Richmond.

A student with a love of science and baseball, Ariante was here to have a decayed tooth pulled. His mother, Crystal, had spent months looking for a dental center that would treat him before she came across the mobile clinic. She was especially grateful that after a season of worry, his teeth were nearly all fixed.

“You’ll have to monitor this cavity closely,” Dr. Vanessa Franks, the resident dentist, said through a Spanish interpreter as she bustles between two rooms checking on young patients in the large RV-style van. The clinic targets low-income populations in Contra Costa County and, Franks said, seeks to fill a gap caused by MediCal’s low reimbursement rates, which makes it difficult for many dentists to take on lower-income patients – not to mention the “daunting bureaucratic and administrative hoops” required to receive compensation.

“No one is turned away here,” Chris Grazzini of the Community Health Alliance said. She oversees funding for the mobile dental care clinic, which is supported by a patchwork of grants and donations.

The lack of adequate dental care for California children is an enormous problem. Although 71 percent of all California children develop tooth decay by the third grade, almost one in four of these children under age 12 have never seen a dentist, according to a June 2011 report by The Children’s Partnership. Recent studies have shown that children in California  – especially low-income children - lose millions of hours of school due to dental issues, which can result in poorer academic performance and grades

Small wonder that healthy teeth are often a sign of socio-economic status, as Franks points out. According to the U.S. Centers for Disease Control and Prevention, tooth decay, or “caries,” is the number one disease for children in the country and occur five times more often than asthma, the next most widespread childhood disease.

Besides causing extreme pain, tooth decay can turn into an abscess whose infection spreads through the rest of the body, leaving a child vulnerable to ear or sinus infections. In rare cases, an abscess, untreated, can cause dangerous neck and jaw swelling and even death.

Children whose poor teeth are visible to the world also suffer psychologically. Franks explained that visible tooth decay often causes children and teens to withdraw socially and even to suffer from depression. Franks mentioned one teenager that had arrived the week earlier with visibly decaying front teeth. The young girl smiled as little as possible. By the time the patient had completed her series of treatments, Franks said, she was “a different person” who smiled radiantly as she left.

Yet even though a child who loses an appendix would be fully covered by MediCal, infections such as cavities and abscesses in children find very little support, according to Professor Pamela Den Besten of University of California San Francisco Dental Clinic - a school-subsidized clinic that sees a disproportionate number of MediCal patients from Oakland and Richmond.

Medical reimbursement for dental care is low compared to those of other healthcare treatments, dentists say, adding that many of them simply cannot afford to perform the procedures for the fees paid. This issue was highlighted by California Dental Association this June, which reported that only 25 percent of dentists in California now accept MediCal, compared to 40 percent in 2003. The association - CDA - attributes that shift mainly to the “low reimbursements and high administrative overhead.”

Finding another way

On Nov. 16, Dr. Jared Fine, the dental director for Alameda County announced “Healthy Smiles for Healthy Futures,” a five-year oral health care plan for the county. This plan - and another research plan funded by the California Dental Association, which has not yet been made public - contain new proposals to improve access to dental care in California, partly through leveraging untapped resources in the current health system. Fine showed special interest in expanding the coverage to the Women, Infants and Children program, or WIC, a program. In addition, the five-year plan included expanding access to private dental contractors.

Although the report to the California Dental Association has not been made public, Fine said it contains a “progressive agenda,” beginning by insisting that the state hire a dental director - something, he said, most states already have. The federal government has significant funds available for preventive care programs, but California cannot access them without a state advocate to actively seek out the support, Fine said. Additionally, many of the proposed ideas in the report would be covered by accessible funds that apparently only a state-level advocate can seek out.

Fine also suggested that research shows as much as 50 percent to 60 percent of all children in California are eligible for the WIC program. This “phenomenal finding,” he said, led the CDA to propose integrating dental care into WIC program clinics statewide – which a few scattered WIC centers have already done.

Fine also said he believes this is one way to circumvent the failing MediCal program and “go to where mothers and children already are,” not only to fix teeth, but provide preventive dental care for toddlers and invaluable education to pregnant mothers.

“People assume dental decay is inevitable,” Fine said. However, it is not.

Cavities and decay often occur due to a lack of information and education. Teaching parents and children about preventive dental care, Fine said, could, over time, reduce the pressure on the “overstretched California dental care system.” This includes not having enough dentists.

Fines said what was surprising to him was to learn that even with public and private dental practices combined, the state of California does not have enough dentists to care for state residents. He added he finds this "especially troubling" as the Affordable Care Act looms closer.

Taking on Medical’s “administrative nightmare”

President Barack Obama’s health care reform bill, the Affordable Care Act, has in fact touched on child dental care.

In 2014, more children will be eligible for coverage - in California alone, 1.2 million children are expected to receive eligibility. However, the bill does not mention any increase in reimbursements for dental procedures – meaning that poor families will still be hard put to find dentists who accept them.

In five counties in California with more than 17,000 children on MediCal, there is not one dentist who will accept MediCal, according to The Children’s Partnership report earlier this year.

In one district of Alameda County, Fine said, a single dentist has 989 MediCal patients, even though most dental offices generally have 2,000 active patients. Having half of your patients on MediCal is “simply not sustainable from a business perspective,” he said. While it is only a start, Oakland recently received a grant of $200,000 to increase dental care access and preventive care education for under-served children at their schools.

Furthermore, Fine is ready to take on MediCal’s “administrative nightmare” and win. His proposal, for example, recommends that dentists be allowed to work through dental clinics for administrative purposes, but be able to practice “outside the four walls of the clinic.”

In this way, places like La Clinica de la Raza in Fruitvale, which are already set up to deal with MediCal, could hire dentists as private contractors and refer patients to them. Fine said that this is not a new phenomenon, explaining that New York and Massachusetts already successfully integrated such practices. He said a federal law allowing community dental clinics to contract dentists has already been approved, but California has not yet accepted it at a state level.

Nonetheless, the dental care shortage is expected to grow as the current national debate increasingly shifts to making cuts in Medicare.

Recently, the Obama administration cleared the way for Gov. Jerry Brown to cut funding to MediCal by 10 percent, including dental services. As a result, even if 1.2 million children join the MediCal system in 2014, actual coverage is expected to shrink unless aggressive changes are made.

Meanwhile, a growing number of young school children like young Ariante continue to endure severe pain due to untreated tooth decay even as they struggle to focus on their studies. As Grazzini of the Community Health Alliance said in reference to the Affordable Care Act, “It’s one thing to have well-meaning policy, but it’s another to actually implement it.”