Dr. Brian Alexander, a dentist in Franklin County, prepares a denture for a patient. Alexander is one of the only dentists in the county who offers pro bono services to the local free clinic. (Katie O'Connor/Virginia Mercury)

ROCKY MOUNT — One of the patients the Free Clinic of Franklin County sent to Dr. Brian Alexander had a hole in the roof of her mouth.

A dentist, Alexander has cared for dozens of low-income patients referred to him by the free clinic over the last several years.

But that woman’s case stands out in his memory.

She had been living that way for years. Some sort of disease, likely cancer, had eaten away at the tissue on the roof of her mouth. He could see straight up through to her nose. She used to try to cover it with a sheet of aluminum foil when she ate, until Alexander fashioned her a denture that fit over the opening.

“She had a really tough life,” Alexander said.

Virginia is currently preparing to expand its Medicaid program, insuring an estimated 400,000 of its residents and closing a massive health coverage gap.

But even after expansion, major health care needs for low-income residents will remain. Like most other states, Virginia does not have a comprehensive Medicaid dental benefit, including preventive care, for adults. The state will only cover emergency procedures — which usually boils down to tooth extractions.

“I’m thrilled Virginia is expanding Medicaid, and that’s going to close a big part of the gap,” said Patrick Finnerty, who was the director of Virginia’s Medicaid program from 2002 to 2010. “But it doesn’t close the whole gap.”

There are only five dentists in rural Franklin County, just below Roanoke, where farms yawn over rolling hills and crisscrossing streams trickle from Smith Mountain Lake, which sits to the northeast. It has a population of about 56,000.

Franklin is considered a “dental health professional shortage area” by the federal government, meaning there are too few dentists for the size of the population. The free clinic especially feels the weight of that designation: There aren’t enough dentists to provide the volunteer hours necessary to see the hundreds of patients who visit the clinic every year.

Donna Proctor, executive director of the Free Clinic of Franklin County, also known as Bernard Healthcare Center, said the patients her clinic sees often cannot afford to seek preventive care.

Rocky Mount, the county seat of Franklin County, is nestled in rolling hills just below Roanoke. (Katie O’Connor)

“They don’t have a way to pay for it,” she said. “And if the teeth aren’t hurting, then it’s not urgent. If you have a choice between having to have a couple of hundred dollars to have your teeth cleaned, or buying groceries for the week, what would you choose?”

And Franklin County is far from unique. There are 89 dental care health provider shortage areas in Virginia, and about 1.2 million people live in those areas, according to the Kaiser Family Foundation.

This creates a problem both for people of means and those with low incomes. But driving an hour away for a dentist is much easier for someone in the middle class than it is for someone who has to worry about getting food on the table, Proctor pointed out.

“I think a lot of people think what we’re looking for here is pearly whites, or orthodontically perfect teeth,” Finnerty said. “That not what this is about. This is about getting somebody free of dental disease, oral disease, and being able to speak, eat and smile normally.”

TIME FOR A BENEFIT?

For years, advocates, such as the Virginia Oral Health Coalition have pushed the state to add a dental benefit for adults. So far, Virginia has expanded dental benefits to pregnant women and children until they turn 20.

As of the start of this year, 17 states offered extensive dental benefits — including preventive and restorative procedures — to their Medicaid populations, according to the Center for Health Care Strategies, a group that advocates for improved health care delivery for low-income Americans.

A benefit, advocates argue, would make a major difference for the 1.2 million adults covered in the state’s Medicaid program.

And some think now, in the shadow of Medicaid expansion, is the right time to add a comprehensive dental benefit.

Sarah Bedard Holland, CEO of the Virginia Oral Health Coalition, said she thinks there’s momentum in Virginia.

Rather than focusing on how much it would cost to give a dental benefit to adults in Medicaid, advocates point to the money the state could potentially save — such as the $3.31 million that Medicaid spent on emergency department visits in 2016 related to dental pain.

Those who work with low-income people to access dental care note that the emergency department cannot actually treat a dental issue. Typically it will provide antibiotics for the infection or opioid painkillers for the pain and tell the patient to seek an actual dentist.

A 2016 report by the American Dental Association’s Health Policy Institute estimated that expanding the benefit in Virginia would cost anywhere from $24.4 to $60.8 million. The report modeled the cost using three different scenarios with different assumptions for the adult dental care utilization rate and the level of reimbursement to dental care providers.

And with a slew of other competing demands facing the state — such as expanded funding for substance-use disorder or mental health treatment — the challenge is making adding a dental benefit a higher priority, Finnerty said.

“I think oftentimes people don’t really understand the full set of circumstances that a lot of these folks deal with,” he said.

‘A FAILURE OF THE HEALTH CARE SYSTEM’

Since 2000, the Virginia Dental Association Foundation’s Mission of Mercy project has held clinics across the state to provide dental services to the uninsured. Often, people will wait all year for the clinics because it’s the only option they have, said Finnerty, who regularly volunteers at the clinics.

And when they do show up, usually they’re only getting a tooth — or many teeth — pulled, rather than getting treatment.

“The service we provide the most are extractions,” said Finnerty, who is also the president of the Virginia Dental Association Foundation’s board. “And you know that, to me, is a failure of the health care system. Dental disease — caries, the technical term for cavities — which often lead to abscess teeth, is almost 100 percent preventable.”

Finnerty said he sees people who have been living with serious infections for years.

So far this year, Mission of Mercy clinics have seen 953 patients and done 2,536 extractions. Some people, Finnerty said, must get every tooth removed.

Dental disease is associated with a slew of other health problems, including chronic diseases like diabetes and heart disease.

And often, those seeking care at one of Virginia’s safety net providers have complicated dental problems as well as other health ailments, said Tara Quinn, executive director of the Virginia Dental Association Foundation.

“It could be that they need treatment for cancer and they can’t be cleared for treatment until they have comprehensive dental issues dealt with, for the risk of the infection,” she said.

THE DENTIST SHORTAGE

The Free Clinic of Franklin County has a dental operatory in its building, but it hasn’t been used since 2015.

Alexander had volunteered on a regular basis in that operatory, but he had to stop in 2015 because he simply didn’t have the time to keep it up, he said. Now he offers pro bono care to free clinic patients who are especially in need in his own offices.

Not only are there not enough dentists to see its patients, the free clinic has also found that older dentists may lack the strength in their hands needed to extract teeth, noted Proctor, the clinic’s executive director.

The dental operatory in the Free Clinic of Franklin County hasn’t been used since 2015. (Katie O’Connor/Virginia Mercury)

So the clinic has started giving patients a reference sheet of where they can go to get care. Usually that means driving about an hour or more to Roanoke or one of the neighboring counties. And that can be a real hardship for low-income people, Proctor said.

There are several barriers that make rural areas an unattractive place for dentists to set up practices, but mostly it boils down to one: money.

According to the American Dental Education Association, the average graduating dental student leaves school with $287,331 in debt.

With that kind of burden, there’s little incentive to set up shop in a rural area. Alexander, the Franklin County dentist, said it cost him $1 million to purchase land, construct his building and get his practice off the ground. That was in 2005, and he’s almost done paying it off.

Advocates for adding a dental benefit to Medicaid say dentists will have more of an incentive to serve low-income patients if they can get paid for providing care.

Holland, the CEO of the Virginia Oral Health Coalition, said dentists must have a way to pay for their practices, and when the 1.2 million people covered by Medicaid don’t have comprehensive dental coverage, it’s nearly impossible to serve them.

Sixty-six Virginia localities have no dental safety net provider, according to the Virginia Health Care Foundation. And of the 81 with a community dental provider, usually it’s only offered on a part-time basis.

That’s why, in many parts of the state, relying on annual clinics like those provided by the Mission of Mercy project becomes the only option for some people.

“I go to these clinics and it’s probably one of the most meaningful things I’ve ever done in my life,” Finnerty said. “But when people come here and you see how they struggle with this, it’s heartwarming to help someone like that, but it’s heartbreaking to see that so many Virginians are in that kind of situation.”