Owen Greene, 14, has had braces for two and a half years.

Every sixth Thursday over these years, his grandmother, Devon Bergeron, drives him to Community Dental in Portland from where they live in York. It takes an hour both ways, and Owen often misses a full day of school. Open only on Thursdays and operated by Dr. Meghann Dombroski, it is one of the only offices in the area that accepts MaineCare – Maine’s Medicaid program – for orthodontics.

“Unfortunately, with MaineCare, where we live in York – and they consider it such a high-class area – there’s not dentists down there that take MaineCare,” said Bergeron, who is also Greene’s guardian.

Greene and Bergeron’s experience is not unusual in Maine. Orthodontic clinics that accept MaineCare are few and far between in Maine, with Community Dental the only one in an hour radius of Portland. The clinics that do accept MaineCare often have long waitlists or are not accepting new patients.

Community Dental is a nonprofit oral health care program with locations also in Biddeford, Lewiston and Farmington. While all the locations accept MaineCare and offer other payment options for low-income patients, Portland has the only orthodontic unit, which exclusively accepts MaineCare patients.

Greene first was connected to Community Dental through its Biddeford office for general dentistry. When it was time for him to potentially receive braces, he was referred to the Portland location. It is not unusual for patients and their families to travel for hours to Portland’s Community Dental for orthodontics. The costs of travel and missed work are also burdens that can hinder care.

The Community Dental orthodontic team provides medically necessary orthodontic care to adolescents 10-21 years old. The orthodontic care is not cosmetic, but for oral function and health as deemed by MaineCare. For children who do not get the care they need, the effects can go beyond oral health. The resulting chronic pain, speech impediments and social stigmas can linger well into adulthood, affecting both their personal and professional lives.

“There’s a need and it matters, and these kids deserve it,” said Dombroski.

“I genuinely love the idea of helping people, but also doing it in the type of public health system that we are here because I want to. I want those barriers to be gone,” said Dombroski.

On Thursdays, Dombroski leaves her private orthodontic practice in Falmouth and treats about 50 patients at Community Dental with her staff of three. While now they just take over four general dentistry chairs for the day, in the next month, construction is scheduled to convert an office space in the building into a new orthodontic suite, allowing them to treat more children and hopefully hire a full-time orthodontist and expand their capacity to meet demand. Currently, the wait alone for a new patient to receive a consultation is seven months.

“I hope also that (the new office) has the ability to be able to sort of be a like crown jewel of this place,” said Dombroski, who founded the program in 2018 and hopes to see it grow and sustain itself.

With a master’s in public heath in addition to her doctorate of dental medicine, Dombroski saw the need to expand access to orthodontics in the greater Portland area and took matters into her own hands.

“(The new clinic) will really show off good public health programming, but also good public health integration … how it all works together in a system.”

Community Dental found their solution to providing orthodontics for children on MaineCare, a puzzle that still remains for providers and patients in Maine at large.

Straightening out the finances

At Community Dental’s orthodontic clinic, 13-year-old Abdirazaq Ahmed got fitted with an expander, a metal device on the roof of his mouth that will make room for his teeth to later line up straight with braces. His three older siblings all got braces through Community Dental, a medical necessity that would have been cost prohibited if it were not covered by MaineCare, said his father, Abdi Ahmed.

“Without this, it would be really damaging,” said Ahmed, who lives with his family in Westbrook.

In 2022, MaineCare coverage of orthodontics for adolescents was expanded based on evidence that orthodontic treatment is an effective approach to mitigating severe oral health issues later in life. The same year, MaineCare was also expanded dental coverage for adults.

However, MaineCare’s reimbursements for orthodontic procedures limit which clinics can accept MaineCare, as the reimbursement rate is two-thirds or less than the cost of braces at a traditional orthodontic office. At Dombroski’s practice in Falmouth, Mbrace Orthodontics, braces cost between $5,000 and $7,000 for the equipment, staff and overhead. For braces at Community Dental, MaineCare reimburses $3,172. This difference means that many orthodontic practices cannot accept MaineCare patients and be sustainable, and those that do have to be creative.

Some clinics make it financially feasible to accept MaineCare through grants or through charities, or add-ons to existing dental clinics. Other orthodontic practices take a limited number of MaineCare patients and make ends meet with enough pay-for-service patients. At Community Dental, the unique integration into an already-functioning, low-income dental office keeps them afloat.

“Part of the reason it happens to work here in this clinic is because we were able to embed this orthodontic clinic inside a fully-functioning, already existing clinic,” said Dombroski.

“It would be exceptionally challenging, and I almost want to say impossible, for an orthodontic practice to solely see MaineCare (patients) without either grant funding or utilizing other resources that this clinic already has,” she said.

A strain on wider health care

The limited number of orthodontists accepting MaineCare puts a strain on other aspects of health care as well. MaineHealth’s cleft lip and palate clinic at the Barbara Bush Children’s Hospital in Portland treats children born with the tissue of their upper lip and roof of the mouth underdeveloped, of which about 20 are born in Maine each year. Many children with the condition must receive a bone graft between ages 8 and 10 to complete their gumline; for this to be possible, they have to get orthodontic work between ages 6 and 8.

With no orthodontist in the MaineHealth system, the cleft lip and palate clinic must refer patients to external providers. Amanda Payne, nurse practitioner and coordinator of the clinic, said that over half of their patients are on MaineCare.

“So, there’s just a small handful of orthodontists that we can refer these patients to, many are not geographically accessible to families, and that makes things really difficult for a lot of families,” said Payne.

Finding an orthodontist accepting MaineCare patients is a point of stress not just for parents, but the providers as well.

“Whenever it’s time for us to refer to a kid to an orthodontist, I immediately feel the stress on myself to find an orthodontist who has availability to see kids and that’s accessible enough to the families to be able to make it work,” said Payne.

More generally, pediatric oral health care at large in Maine is facing challenges. When a child does not receive regular dental care, not only can this cause untreated cavities and decay, but they are unable to be referred to orthodontics at the right time. This can cause dental issues later on that are more painful, intensive and costly.

In Cumberland County, in 2022, there were 94 clinics or offices for restorative and preventive dental care, and only six of those practices reported accepting new pediatric patients with MaineCare insurance. As of June 2024, 16,593 children in Cumberland County who had MaineCare did not receive the minimal standard of two exams and/or cleanings in the past 12 month, according to MaineCare dental metrics. 

“It’s not like we can meet the need with a few spots here and a few spots there. Like, if everybody just takes two more … we’re just so far from being able to meet the scale of the number of kids who need service,” said Becca Matusovich, executive director of Children’s Oral Health Network of Maine.

Comparing states, Maine ranked 20th for children who had one or more preventive dental care visits during the past 12 months, with an estimate of 81% over two years, according to America’s Health Rankings. This is around the national average but the lowest in New England.

Matusovich and other dental care leaders in the state are thinking systematically about how to provide more dental and orthodontic care to children in Maine. This includes integrating into school clinics, combating the shortage of dentists and orthodontists coming and working in the state, and working to expand MaineCare coverage and integration into the system of providers.

“We have to really think about how to create solutions at the scale that we need,” said Matusovich.

Making a lasting impact

At Community Dental’s orthodontic clinic, their work is changing oral health outcomes, smiles and lifetime well-being. For some patients, orthodontic treatment is not only health care but an affirmation from a larger system that they matter, said Dombroski. The entire orthodontic staff had stories of watching the confidence of children improve over the course of their care.

“Imagine you get your braces off, and someone has been this cheerleader for you for two years is like ‘This is such a big day!’ You will never forget that for the rest of your life. That changes … the trajectory of your life,” said Dombroski.

As for Greene, he is looking forward to revealing his new smile in his sophomore year of high school, as his braces are scheduled to come off this summer. Around the same time, his grandmother will start taking his younger sister to begin orthodontic treatment at Community Dental.

“My road trips will continue,” said Bergeron.

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