A dedicated dentist: one lawmaker's passion for dentistry brought nationwide attention to kids' oral health woes.

When Ray Rawson first ran for the Senate in the mid-1980s, his opponent called him "Root Canal" Rawson, poking fun at him and his profession. But he won the race (by a mere 680 votes) and became the first dentist to serve in the Nevada Legislature.

Though he held off on pushing major dental initiatives for nearly 10 years--"I didn't want to be accused of conflict of interest,"--he discovered that his strength as a legislator came from the knowledge his profession brought him. Today, this quiet and unassuming man is described as authoritative and "committed to the cause" by peers and colleagues across the country. He's been lauded for his work on dental health by Nevada's public health and social workers' associations. Last year he helped establish the state's first dental school at the University of Nevada-Las Vegas and secured $20 million in funding for the facility.

Rawson says one issue that brought him into politics was the plight of poor people who had serious oral health problems, but no way to get services. "I would see patients every day who had no ability to pay. Nobody else would see them. I could never turn those people away," he says. "We had to deal with the basic human essential of getting them out of pain and infection. It seemed to me that I could never solve that problem from just my office. It took a bigger effort, and we needed more programs."

HELPING KIDS

One of his first major projects was helping to create a hospital-based dental residency program to take care of all the kids showing up at emergency rooms with teeth problems. "We found there were 2,400 hospital admissions a year of kids with dental complaints, bad infections and pain. They didn't have a dentist in the emergency room, so they would admit these kids and put them on antibiotics. It's very expensive to do that and it didn't solve their problem," he explains.

Building the residency program sparked a change in the way Rawson saw his role in the Legislature. He'd held off for a long time, but then he decided he needed to take more action. "From that point on, I realized we've got a citizen Legislature with firemen, school teachers, accountants and lawyers, and nobody is going to deal with the dental problems," Rawson says. "If I don't speak up, nobody will. So I jumped in with both feet. It's from the residency program that we decided to fund a dental school. And it's off and going. They're accepting their first class right now.

Rawson also decided in 1997 to tackle the thorny issue of fluoride treatment in drinking water. It was one oral health-related area where he met with relatively strong opposition.

Fluoridation is cited by the U.S. Centers for Disease Control and Prevention (CDC) as one of the 10 greatest public health achievements in the 20th century for the role it has played in dramatically reducing tooth decay.

Approximately 162 million people across the country have fluoridated water, the CDC reports. State percentages range from a high of 98.2 percent of the population in Minnesota to a low of 2 percent in Utah.

THE FLORIDE DEBATE

Some groups oppose increasing water fluroidation for what they see as health reasons. Organizations like the Fluoride Action Network and California-based Citizens for Safe Drinking Water say fluoride is akin to harmful pesticides, causing long-term health risks such as bone fractures and arthritis.

Robert Hall, head of the Nevada Environmental Coalition, who challenged the fluoride regulation, told the Las Vegas Review-Journal the water additive is a scheme by government and industrial interests to poison millions of Americans. "It's ethically and morally outrageous," he says.

Rawson says arguments like Hall's are based on "junk science" and are phony. "Fluoride really works, and it really is safe," he says.

Rawson won out over the arguments against fluoride in the 1999 session, and Las Vegas--which holds 71 percent of the state's population--finally got fluoridated water.

During the quest to bring fluoride to Nevadans, the senator started looking at statewide data on dental health. He looked at what's known in the business as the "decayed, missing and filled rate." What he saw wasn't anything to smile about.

Nevada had the highest percentage of dental disease in the country, and the worst ratio of dentists to people. Only 16 percent of kids in the state had dental insurance coverage, and 25 percent had no access to dentistry.

"That translated to more than 100,000 kids with no care," Rawson says. "And pursuing that a little bit, I thought, 'Well Medicaid ought to cover the lowest economic group here, let's see what's going on in Medicaid.'"

What lawmakers found out shocked even Rawson, who regularly saw poor kids come in to his practice, with families who couldn't afford to pay. Only eight dentists Out of 700 in the state said they would see a Medicaid child.

"It was a serious, serious problem. We figured that there were 2,000 kids going to bed in pain every night with no way to see a dentist. You can't get that out of your mind," Rawson says.

At the time, he was part of the Milbank Memorial Fund's Reforming States Group, whose members-including lawmakers and state health officials-produced analyses of state children's health programs, managed care oversight and health care expenditures. During one of the meetings, Rawson suggested that the group undertake a dental project because he was pretty certain that what he saw in his state was happening elsewhere. "We did an assessment and found that less than 25 percent of the kids across the country who are on Medicaid are actually seen by a dentist," he says.

GROUNDBREAKING REPORT

Out of that meeting and after subsequent research, the group produced in 1999 a groundbreaking report on pediatric dental care. It serves as a guidebook of sorts for lawmakers crafting dental health services for state Medicaid and children's health insurance programs.

Kansas Senator Sandy Praeger, who now chairs her state's insurance committee, was at that initial Reforming States Group meeting, and she remembers the light-bulb effect Rawson's idea had on everyone involved. "People just jumped on it. We all went back to our states, started checking the numbers, and sure enough he was right," she says.

Rawson, she says, was very forward thinking and not only laid out the problem, but he also provided some concrete ways states could address the issue. Among the solutions: raise reimbursement rates for dentists so they're getting paid enough for what they provide and encourage more dentists to take part in Medicaid.

Praeger says Rawson is responsible for spearheading real nationwide reform. "Ray did a great job of waking us all up. He made it easy for us to address it and hard for us to ignore it," she says.

And ignoring the problem means you'll have more on your hands than kids with a few cavities or crooked teeth. Fifteen million school days are lost every year across the country because of dental pain, Rawson says. "That's a loss of productivity in the worst way. I don't know that anybody's ever studied how many of these kids are dropouts or have those kinds of problems. But I think a significant number of them have had things that have interfered with their learning to read, and it's everything from drug-abusing parents to dysfunctional homes to other problems," he notes.

Rawson remains humble about what he's accomplished. But when he hears all the states that have grasped the dental health reform ideas he helped craft--Alabama, Delaware, Georgia, Indiana, Michigan and South Carolina are at the top of the heap--you can see the pride in his face.

"That's one of the satisfying things about being involved in this," he says.

"There's so much grief that comes with holding office, and I don't mean to overplay that, but there aren't many thank yous. This makes it worthwhile," Rawson says.

What's next for a lawmaker who's accomplished so much? According to Rawson, there's a lot still to do. "Gosh," he exclaims. "We still have 100,000 kids who don't have dental care. As soon as the dental school has all of its classes, we think we'll set a model in the country as far as being able to treat the sick who haven't had access," he notes.

Five clinics that are already up and running in Nevada will serve as outreach for the dental school, and Rawson is helping design a children's specialty program within dentistry. He also has plans for a dental anesthesiology program, so some specialists can give the general anesthesia in a hospital setting. He's helping encourage oral cancer detection in younger adults, and he's overseeing curriculum development for a public health dental hygienist who will work in schools and nursing homes. In his spare time, he helps out with Miles for Smiles, a grant-funded program that brings mobile clinics to schools. In one school district alone, Rawson says the mobile clinic stayed put for nearly a year and treated 800 kids with serious dental problems.

Despite all he's done, Rawson is not quite ready to hang up his hat, or his dentist's drill. "What I want to see before I retire is not just all these programs in place, but actually see the numbers change, so kids have a place to go for dental care, and we're bringing the disease rate down. I expect to see that before I retire. I'm 61 this year, so we don't have long to go," Rawson says.

RELATED ARTICLE: CUTTING-EDGE STATES

Six states in recent years have elected to "truly commit" to increasing payment levels for dentists in the Medicaid program, says Columbia University's Burt Edelstein. This is the "fresh story" in all too frequent tales of Medicaid-related failures, he says.

Alabama, Delaware, Georgia, Indiana, Michigan and South Carolina all make this "A" list, according to Edelstein and colleague Jim Crall.

Specific results seen by the states include: Indiana dentist participation in Medicaid jumped from 64 percent in 1998 to 83 percent in 2000. More than 1.6 million claims were processed in 2000, compared with 800,000 in 1998.

Michigan is getting more kids in to see the dentist since its May 2000 launch of the Healthy Kids Dental Program, a public-private partnership between the state's Department of Community Health and Delta Dental Plan of Michigan. Researchers say the number of kids on Medicaid who now see a dentist has jumped 27 percent in the first 12 months of the program. So far, Healthy Kids Dental is up and running in 37 of the state's 83 counties.

Georgia saw dentist enrollment rise from 8 percent to 26 percent by mid-2001.

Kids visiting the dentist in South Carolina increased from 115,394 to 156,725 in the last two years. Expenditures during the same time frame spiked from $31.5 million to $62.6 million.

Delaware's dentist participation increased from one to 96 dentists. Only 17 percent of kids on Medicaid were visiting the dentist in FY 1999. in FY 2000, 22 percent were.

Alabama's provider participation jumped 22.5 percent; patients per dentist are up 10 percent; and 24 percent more people are getting dental care.

Source: Columbia university's Dr. Jim Crall, with support from the W.K. Kellogg Foundation and the Milbank Memorial Fund, 2002.

DENTAL HYGIENIST LEGISLATOR HELPS KIDS IN CONNECTICUT

When Connecticut Representative Vickie Nardello was first deciding what career path to take, she almost went into teaching. But in the waning days of her high school senior year, Nardello's dentist asked her if she'd ever thought about dental hygiene as a career. The seed was planted, she says, and that's the route she took.

She's worked as a dental hygienist for the last 30 years, first in private practice and then in the public sector in Hartford, Conn., where 65 percent of the city's population qualifies for Medicaid. Nardello says the reality of those stats really hit her hard. "It was quite an eye-opening experience. I noticed immediately the needs of the children. My heart broke, and I thought, 'We need to do something about this,"' she says.

Nardello wrote regularly to the state's Department of Social Services to discuss an expanded role for dental hygienists, so that more kids could be served in schools, for instance. "All my letters received a polite response, 'thank you very much,' but nothing was ever done," she says.

That all changed when she took office. Elected to the General Assembly in 1994, Nardello was appointed one year later to the state's Medicaid Managed Care Council, a group formed to advise social services on the move to managed care for some of the state's neediest people.

Through her work on the council, Nardello says she got up to speed on Medicaid and how the system worked. Combined with her background in dentistry, "it was the perfect combination for addressing oral health and lack of access to it," she explains.

She's not only helped raise awareness about the importance of good oral health for kids but she's also secured funding and established more school- and community-based dental clinics, including the use of mobile vans.

Nardello says additional projects are on hold right now, as officials await a ruling on a class action lawsuit that says the state has failed to provide adequate oral health services for kids as required under federal law.

A ruling against the state means Connecticut will need to increase the fees it pays to dentists who serve the Medicaid population. That's not such a bad thing, Nardello says. Raising the fees means more dentists will sign up to help needy kids, taking some of the burden off public clinics. That means public clinics can use time and resources for other needs.

Aside from the ruling, Nardello takes pride in being part of a team that brought oral health access to the front burner. "It's very rewarding to see you've been able to affect a child's life in that way," she says.

Mary Guiden is a former NCSL health writer who now covers health policy for Stateline.org