Quality of Needy Kids’ Dental Care in Question : * Health: Children go to high-volume, high-speed clinics, experts say, because doctors won’t take subsidized patients. And the state may cut funds for malpractice probes.

SANTA ANA — Javier Villa loved fruit-flavored hard candies. So his father wasn’t surprised when the staff at Megdal Dental Care told him his 4-year-old needed eight cavities filled. The elder Villa, a gardener who earns $200 a week, handed over the boy for treatment.

“I thought they would take good care. It seemed like a friendly place, with pictures for the kids on the wall,” he said.

Instead, within hours, his son was dead.

The boy’s death this month raises questions about the type of dental care available to low-income children, and who is responsible for ensuring its quality.

This week, the Legislature will consider slashing funds for specially trained investigators of dental malpractice cases, further weakening what some say is an already overburdened, confusing system of regulation.

“Public health and safety will be at risk if this happens,” said Dr. Peter Hartmann, president of the Board of Dental Examiners, which may lose its entire staff of 15 investigators.

Many experts say needy children in California already are at risk when it comes to quality dental care.

A 1996 federal study found that only one in six low-income children in the state who are qualified for government subsidized dental care actually receives it. In Orange County, the number is slightly better, with half of all low-income families who are eligible for subsidized dental care obtaining it.

“There isn’t adequate dental care for poor kids in Southern California,” said Dr. Charles Goldstein, a faculty member at the USC School of Dentistry who supervises a public clinic at the school.

The federal report, by the Inspector General for the Department of Health and Human Services, cited a host of reasons for the lack of care, from parents under-educated about dental care to unwillingness by most dentists to accept government-subsidized patients.

The study says that if prevention and care for poor children don’t improve, “the gains observed in oral health earlier in this century could revert to the earlier normative situation of pain, suffering, and excessive costs associated with oral problems.”

Experts disagree on why many private dentists won’t treat low-income children. Dentists say government reimbursement is not high enough to meet their costs, while officials who work with Denti-Cal, the state’s dental subsidy program, note that an additional $500 million annually has been poured into payments in the last five years so that care can be available. Both sides agree that those looking for care are sometimes forced to go to clinics that make profits off high-volume, high-speed treatment.

There are several reasons why many children don’t receive the care that is available.

Goldstein said that in urban areas, low-income parents don’t take time to get care for their children and that it is difficult for children to walk long distances to clinics by themselves.

Dr. Robert Doubleday, the public dental health officer for Orange County, said the children of illegal immigrants are entitled to emergency care, but their parents are afraid to ask for help. He also said that children of migrant workers and other people who move often don’t get long-term care.

When low-income children do get care, dentists say they find serious problems because education and oral hygiene are lacking, nutrition is often a problem and tooth decay sets in at an early age.

One of the culprits cited repeatedly is baby bottle tooth syndrome, caused when a child is put to bed with a bottle of milk, apple juice, or worst of all, sugar water.

“The last gulp of milk or apple juice doesn’t get swallowed, it just sits there,” said Dr. Ray Stewart, president of the California Society of Pediatric Dentists. “We see 2-year-olds with 20 cavities.”

Community advocates and others charge that many of those who do receive care get it at clinics where profit rather than patient care is the primary motive. In Orange County, 1,000 dentists participate in Denti-Cal.

Dentists not in the program say they can’t afford to offer their services to Denti-Cal patients because their overhead is too high and the government reimbursement is too low.

Stewart said that dentists make 35 cents on the dollar when they treat children under Denti-Cal.

“Dentistry has tremendously high overhead. Everything we use we throw away after every patient--disposable cups, napkins, gloves, masks,” he said.

Denti-Cal senior manager Dave Bierman disagreed and said the state pays dentist 65 cents on the dollar of the average amount billed. He said annual reimbursements have grown from $110 million in 1989 to $700 million in 1995, aimed at providing more care for those who need it.

He said that since the increase, fraud cases have climbed, including billing for work that was never done; doing unnecessary work, and billing for higher-rate emergency care when only routine care was received. He said such fraud was one possible indicator of poor dental care.

In the wake of Javier Villa’s death, state officials from half a dozen agencies are investigating Megdal Dental Care and its owners and staff for possible criminal and civil violations of patient care, dental credentials, advertising laws and billing fraud.

Philip Megdal and his attorney, William Kent, have expressed sorrow over Javier’s death, but deny legal responsibility and any wrongdoing.

But dentists who formerly worked for Megdal long before Javier’s death said in court documents and interviews that they were expected to produce a high volume of business and were rewarded with a percentage of revenues and bonuses.

“You put enough pressures on doctors, and production quotas to meet, and you create a scenario for disaster, for serious injury or death,” said Barry Levy, a dentist who worked at the Megdal clinic in Lawndale in 1986. Levy was sued by a patient for unnecessary fillings, and for causing permanent nerve damage. The case was settled, and Levy said he accepted responsibility but felt he was forced into it.

“There were very great quality control issues because of the pressure placed on me. They were expecting me to do all possible treatment on a patient at one time, to maximize cash and minimize cost,” Levy said.

“That’s absolutely ludicrous,” said Megdal. He said he did not recall Levy nor the case, and was not responsible for the work performed by dentists at the clinics. He said he bought the buildings and set up the equipment and advertising for dentists who owned the practices.

Kent said that sharing of revenues was done, and bonuses were given for a high amount of billing.

He said Megdal was providing a service to foreign-educated and recently graduated dentists by setting up clinics they would not otherwise be able to afford on their own; purchasing expensive equipment, and providing advertising on highway billboards, in the Yellow Pages, and through fliers and doorknob notices.

Kent said the dentists hired by Megdal were “not always Ivy League graduates. You can’t always have the 100% perfect candidate in every field.”

As for the quality of care provided, he said, “These clinics are providing a Cadillac service to people in neighborhoods who are more used to driving Hyundais. . . . This type of operation serves as many people as they can, and serves the poor, and they perform a wonderful function in that regard.”

However, Santa Monica community advocate Jamie Court said there are potential dangers to children because of the emphasis on profits: “You’re creating a conflict of interest for the doctor to provide an accurate diagnosis by pitting their financial interest against appropriate medical standards.”

And when there are problems with care, it can be difficult for consumers to figure out where to seek help.

Half a dozen state agencies monitor different aspects of dentistry and billing.

The Board of Dental Examiners, the lead agency on malpractice cases, received 2,800 complaints last year, but it has only 15 trained investigators to do enforcement work.

Proposed legislation may eliminate them. The Assembly appropriations committee this week will consider scrapping funds for the investigators; the Senate committee has already approved the plan.

Hartmann, the board president, said the cuts would supposedly save $1.2 million, but in fact, the agency would have to contract out with the Department of Consumer Affairs for investigators, none of whom would be trained in dental care.

“The argument is that this is a cost-saving measure, but cutting them would save zippo,” Hartmann said.