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Dental care for disabled may grow even scarcer
Dr. Diana Zschaschel leaned over Boogie's wheelchair to check his teeth with a mirror and probe.
"It's OK, Boogie," said his father, Vergery Grubbs Sr. He reached over to take his son's curled hand. "Keep your mouth open. You're doing a good job."
For the elder Grubbs, this was the easy part. The challenge had been finding a dentist willing to treat his namesake, who is 13 but looks half that age. Dubbed "Boogie" because music makes him laugh, Vergery Grubbs Jr. was born with cerebral palsy and hydrocephalus, or water on the brain. He is mentally and physically disabled.
Once father and son waited for three hours to see a dentist, only to be told to go to a county hospital.
"I was hopping mad that day," Grubbs said. The dentist "wanted to put him to sleep just to clean his teeth."
Zschaschel hears such stories all the time.
"I'm kind of the last-resort dentist," she said. "There are very few private dentists who will take on this kind of work."
With cuts to the state's Denti-Cal program scheduled to go into effect in July and another round of cutbacks already on the table, there could soon be even fewer.
Finding dentists to care for patients with disabilities is a challenge under the best of circumstances, said Dr. Paul Glassman, co-director of the Pacific Center for Special Care at the University of the Pacific School of Dentistry in San Francisco.
For starters, he said, few dental schools teach students how to care for patients with disabilities. Over the last 12 years, the USC School of Dentistry has required every student to spend a week working in its Special Patients Clinic, one of the few clinics dedicated to patients with disabilities. But most dentists in private practice haven't had that kind of experience.
Another barrier is the state's low Denti-Cal payments. Disabilities can interfere with finding work and take a toll on family resources, so many people with disabilities depend on this state-federal insurance program for the poor.
But dwindling numbers of dentists accept Denti-Cal patients because reimbursements are among the lowest in the country. They will fall even lower under a 10% rate cut scheduled to go into effect July 1 as part of the Legislature's efforts to reduce the state budget deficit. And Denti-Cal doesn't pay extra for the additional time that goes into treating a patient with disabilities.
"You're asking dentists to do something they're not well-trained to do, that's going to take a lot of time, and they're going to be paid a third of their normal rate," Glassman said. "It's no surprise that a lot of people aren't lining up to do this kind of work."
Hospitals aren't lining up either.
Depending on the degree of disability, some patients require general anesthesia at a hospital to have a tooth pulled, a cavity filled or even just a cleaning.
But across the state, hospitals that once extended staffing privileges to dentists like Zschaschel are cutting back on dental services or discontinuing them altogether, Glassman said.
"It's pretty clearly because of money," he said. "Hospitals have to pay attention to their bottom line. They have to stay in business."
Zschaschel used to treat about eight patients a week under general anesthesia at St. Vincent Medical Center near downtown Los Angeles. She is now down to about four a month, which the hospital evaluates on a case-by-case basis.
Dr. Jay Rindenau, an anesthesiologist and consultant who advised St. Vincent to cut back its dental services, agreed that California's low reimbursements strain hospitals. But that was not what drove his recommendation, he said. Children with disabilities have a higher risk of complications, he said, and unlike county, teaching and specialized children's hospitals, St. Vincent does not have a pediatric unit.
"It's absolutely a quality-of-care issue," he said. "You need to be doing procedures at places that are well-suited to handle any complications that occur."
But the parents and caretakers of Zschaschel's patients say they face long waits at backlogged county and teaching hospitals. Like Grubbs, many search for months to find a dentist willing to treat a child who is paralyzed or autistic or whose diabetes is out of control, which makes anesthesia riskier.
Zschaschel continues to see as many of these patients as she can in her Fairfax district office.
She is inspired to do so because of the example set by her late mother, a Cuban immigrant with a strong religious faith. By age 3, Zschaschel was accompanying her mother to feed the homeless.
After majoring in psychology as a UCLA undergraduate, Zschaschel worked with autistic children. She remained drawn to patients with special needs after starting dental school, also at UCLA. Now 39 and in solo private practice, she sets aside Mondays to care for patients with disabilities.
She has endured slaps and punches, thrown out her back leaning over wheelchairs, chased patients down sidewalks and done exams in cars.
But her days are not short of hugs or gratitude. And they're never boring.
"I enjoy the challenge," she said. "I like doing what nobody else can do."
Paul Perez has been driving his grandson, Paul Reyes, from Victorville over the last year to have a tooth pulled, a cavity filled, a cleaning. Reyes, 21, survived leukemia at 15, but a reaction to the chemotherapy robbed him of motor and mental skills.
"She's great with this guy," Perez said as he gently lifted his grandson from the wheelchair to Zschaschel's dental chair.
Diane Collins also drove from Victorville after her son, Victor Hill, was turned down by five other dentists. He is autistic and had an abscessed tooth he tried to remove with pliers.
"It's like these children are just in the shadows," Collins said. "They'd prefer you put them in homes."
Hill is 29, and like Reyes, he is not -- technically -- a child, which presents another dilemma: On top of the payment cuts scheduled to go into effect July 1, Gov. Arnold Schwarzenegger's revised budget calls for eliminating Denti-Cal benefits for adults. With clinics and county hospitals backlogged, that would make it even harder than it is now for poor adults to find dentists, much less poor adults with disabilities.
"It's going to come to the point that there's not going to be anywhere people can go," Zschaschel said. "We're going to be like in the 1800s, when people actually died of dental infections."