A dentist provides dental care to a little girl, France on June 28, 2023. llustration of the profession of dental surgeon who is a health professional specializing in the management of pathologies of the teeth and gums. Photo by Thibaut Durand / Abaca/Sipa USA(Sipa via AP Images)

Two hospitals in south Mississippi have limited local pediatric dentists’ access to their facilities, potentially preventing hundreds of kids from receiving necessary dental care, according to one dentist.

Though the hospitals — Merit Health Wesley and Forrest General Hospital — are located in Hattiesburg, experts say this is an issue happening throughout the state and around the country. 

In Mississippi, where over half of the adult population has had one or more permanent teeth removed because of gum disease or tooth decay, the effects of limiting pediatric dentists’ access to hospitals where they can safely put children to sleep for procedures could be devastating. 

And one solution recently adopted by the Centers for Medicare and Medicaid Services hasn’t yet been implemented in Mississippi. 

In order for young children or children with special needs to tolerate dental procedures, most dentists agree that at least moderately sedating them is necessary, said Dr. Huel Harris, who’s been practicing pediatric dentistry in Hattiesburg for nearly four decades. However, it’s not easy — or always safe — to do in an office setting. 

But after Merit Wesley and Forrest General decided to limit access to their operating rooms, a decision Harris suspects can be traced back to low reimbursement rates the hospitals receive from Medicaid, he and other pediatric dentists in the area have no safe way to put patients to sleep.  

Harris was previously seeing about 40 kids a month for procedures that necessitated the use of an operating room and even had a standing weekly block at Forrest General for decades, where an anesthesiologist or nurse anesthetist sedated his patients.

Now, he’s not allowed to see any patients at Merit Wesley, and only about three patients every few months at Forrest General. 

“If you look at myself and my other fellow pediatric dentists in the Hattiesburg area, we probably treated between 1,500 to 2,000 kids last year,” he said. “They now will not have a way to get the stuff done.”

He’s concerned that hospitals closing their doors to dentists could result in riskier situations for pediatric patients — or no care at all. 

Current regulations say with enough training, dentists can sedate patients to a certain degree. But they cannot put patients to sleep. 

Harris was told that Forrest General needed the space for “more necessary things,” he said. 

In a statement provided to Mississippi Today, a Forrest General spokesperson said the hospital would be providing one day a month for pediatric dental cases. She refused to answer further questions. 

Spokespeople from Merit Wesley said the hospital was prioritizing its resources on cardiac, orthopedic and bariatric surgery as well as breast and gastrointestinal cancer removal, citing limited availability of surgical suites and staffing.

But according to Harris, the hospitals’ reasoning is rooted in money. 

Harris’ patients are predominantly insured by Medicaid. When a dental procedure is performed in a hospital setting, hospitals submit a facility charge for use of their operating room, and anesthesiologists submit a separate charge for their service. 

Medicaid on average reimburses dental procedures at low rates compared to other medical procedures. Generally, Medicaid’s reimbursement to dentists for procedures they perform only covers about 30% of the procedure cost.

Matt Westerfield, spokesperson for the state Medicaid agency, said the department will explore whether it should adopt a new dental billing and payment system that would pay more for hospital dental operating room cases requiring general anesthesia with the hopes of increasing payments to facilities. 

Though private insurers and state Medicaid divisions across the country are not required to recognize this new system, the American Academy of Pediatric Dentistry encourages it.

“The optimal oral health of all children needs to be a priority in all states,” the statement from the organization reads. “Operating room access for dental care is a pervasive issue across the country, in part due to costs to facilities and lack of reimbursement. This restricted access impacts both the oral and overall health of vulnerable children, as well as limits potential treatment options.”

Denny Hydrick, the executive director of the Mississippi State Board of Dental Examiners, declined to “speculate” regarding whether pediatric dentists need hospital space to perform operations and said he had not heard of this issue affecting other parts of the state. 

Members of the Mississippi Academy of Pediatric Dentistry executive board either could not be reached or declined to be interviewed. Other Hattiesburg-area pediatric dentists followed suit — one mentioned hopes that the issue would be worked out among the involved entities.

No matter how potent, pediatric dental anesthesia and sedation largely requires special permitting. 

In Mississippi, there are three levels of permits. A Class 3 permit allows dentists to lightly sedate patients. They’re completely awake but slightly subdued through laughing gas, or nitrous oxide, combined with anti-anxiety drugs like Valium. The Class 2 permit allows dentists to put patients in a moderately sedated state. In this state, a patient might drift off to sleep, but they’re breathing on their own and can respond to pain. 

According to Dr. David Curtis, a longtime dentist who’s previously served on the Mississippi Academy of Pediatric Dentistry board and currently serves on the state dental examiners board, the sedation permitted in a Class 2 permit requires a great amount of skill. 

But no dentist can acquire a Class 1 permit, which gives license to fully put patients to sleep in an unresponsive state. Only an oral surgeon or anesthesiologist can do that. 

And in a hospital setting, trained anesthesia personnel can sedate patients and intervene during complications. That’s not the case in a dental office, Curtis said. 

“If you get in over your head, which has happened around the country, you can get into serious trouble very, very fast,” he said. “If you’re in a hospital operating room, you have nurses and an anesthesiologist, and if you get into trouble they can get you out.”

A 2013 study found that 44 people under 21 have died nationwide from causes related to dental anesthesia between 1980 and 2011. A year after the study was published, a young girl died in Hawaii after undergoing sedation in a dental office.

And while anesthesiologists can be brought into dental offices to perform the sedation, that’s not always an option, Harris said — there’s a shortage of health care professionals nationwide, and it can be expensive.

Even oral surgeons can be hesitant to put people to sleep in their offices, Harris said, and when they do, they prefer to have a nurse anesthetist present.

He said the biggest difference between sedating adults and children is size. The larger someone is, the easier it is to find the right dose, he said. 

“When someone is very small, the dose difference can be critical,” Harris said. 

Curtis said while some dentists are comfortable moderately sedating patients in their offices, he’s not. 

“There’s never been any question about whether dentists can do what they’re trained to do,” he said. “What comes into question is … if you get in over your head, you’re in trouble. Fortunately it doesn’t happen often, but when it does, it’s tragic.”

Research shows that low-income people are more likely to have poor oral health. That’s why in Mississippi, one of the poorest states in the nation, the consequences of limiting pediatric dentists’ access to operating rooms could be especially dire, Harris said.

During his 35-year career, Curtis said operating rooms have been readily available up until a few months ago. Since then, nearly every week he hears of another Mississippi hospital cutting access, he said. 

“I’ve been doing this a long time, and it’s a problem everywhere,” Curtis said. “Not just in Mississippi, but across the nation.”

Harris said many of his young patients need extensive work — including crowns, fillings and extractions — to mitigate severe dental disease. 

Left untreated, severe dental issues in kids can turn into abscesses and create long-lasting issues. The next best solution is sending kids to oral surgeons, which Harris said he’s already started doing. However, that’ll likely result in kids getting their teeth pulled instead of getting restorative treatments like crowns. 

“That’s going to snowball, and they may get overwhelmed,” Harris said. “We’ll just be kicking the can down the road.”

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Devna Bose, a Neshoba County native, covers community health. She is a 2019 graduate of the University of Mississippi, where she studied print journalism and was a member of the Sally McDonnell Barksdale Honors College. Before joining Mississippi Today, Devna reported on education at Chalkbeat Newark and at the Post and Courier’s Education Lab, and on race and social justice at the Charlotte Observer. Her work has appeared in the Hechinger Report, the Star-Ledger and the Associated Press, and she has appeared on WNYC to discuss her reporting. Devna has been awarded for her coverage of K-12 education in the Carolinas.