>> Tonight, two reports on this special edition of Frontline.

The dental carecrisis in America.

>> No dentists want to see children on Medicaid.

>> For children... >> Her teeth are infected.

She has a lot of pain with them.

>> ...and adults.

>> I've been to the E.R.

three times within the last six months.

I can't take the pain.

It's too excruciating.

>> Are corporate chains fillingthe gap?

>> Smile now and pay later... >> Let me take a look at them real quick.

>> The typical patient is probably 45 to 65... >> And, buddy, they are loose.

>> ...and struggling just to make ends meet.

>> Or taking advantage of people in pain?

>> She came home after one day and she owed $8,000.

$8,000 is close to 50 percent of her annual income.

>> Tonight, Frontline correspondent Miles O'Brien, in collaboration with the Center for Public Integrity... >> Are profits and patient care always at odds?

>> ...investigates this unreported health crisis.

>> We had whistleblowers that gave us information of what they thought was not only bad dentistr but also a waste of taxpayers' dollars.

>> This is a crisis and we need to fix it.

>> "Dollars and Dentists," on this special edition of Frontline.

>> Good afternoon, folks.

We're going to start in about two or three minutes' time.

Very glad to have you.

>> MILES O'BRIEN: Almost all of the men and women in this line are in pain.

But like millions of other Americans, regular doctors can't help them, and even a visit to the emergency room would be useless.

>> I've got a couple of cavities and a couple of molars that's got to come out.

>> I tried going to the dentist.

They just... too much out of pocket.

>> Those of you that are here to see the dentist, please raise your hand.

>> O'BRIEN: A few of the 100 million Americans without dental insurance have come here, to Grundy, Virginia.

A charity called Remote Area Medical is staging a health fair where volunteer dentists are offering free care.

>> We just want to know where does it hurt and we'll try and do the best we can for you.

>> O'BRIEN: Even though many people here have jobs, they can't afford healthy teeth.

>> I can't eat on the whole right side of my mouth.

It's like chewing on gravel.

It hurts so much I can't even eat ice cream on that side, I can't eat chips on that side.

I can't eat a hamburger on that side.

I can't eat anything on the right side of my mouth.

>> O'BRIEN: Many retirees simply live with the pain and infection because traditional Medicare does not cover dentistry.

>> Well, I'm just hoping they'll extract the teeth and I can get me a set of dentures.

>> O'BRIEN: Dr. Terry Dickinson started the dental program after realizing how many people needed help.

>> They don't have any benefits.

So it's, "What you do with the dollars that you get?"

I mean, you're going to put it in gas?

Are you going to pay the rent?

Are you going to put food on the table?

What are you going to do with those dollars?

Dentistry is not on the top ten.

>> I've been trying for, like, over ten something years to try to get help.

>> O'BRIEN: Vanessa Nations traveled eight hours from her home near Washington, D.C. to get here.

>> I have a lot of teeth that are broken off at the gum line, and they hurt tremendously.

I can't eat-- I've lost so much weight, I cannot eat-- and I keep getting infections.

I just can't live like this anymore, I really can't.

I feel like I've got little bits of poison inside of me, and it's killing me.

>> O'BRIEN: Vanessa's situation, like that of many others here, is desperate.

But this makeshift clinic has limited solutions to offer.

It cannot do crowns or bridge work.

The only option for Vanessa is to have all of her remaining teeth extracted.

>> It's to that stage at age 31 that there's nothing we can do except take out the rest of her teeth.

>> I'm just excited just to have the teeth that are hurting taken out because I can't take the pain.

It's too excruciating.

>> Here we go, one, two, three.

>> O'BRIEN: But Terry Dickinson is also promising Vanessa that once all of her teeth are pulled, his charity will see to it that she gets dentures.

>> She'll look better obviously, so it's going to help her self-image, she's going to be able to eat better, she'll be able to talk better.

So it's going to, you know, essentially give her a change in her life.

>> Look, that's  Finding Nemo.

>> That does look like Nemo, don't it?

>> O'BRIEN: For many Americans, like five-year-old Trinity Way, trouble getting dental care starts early in childhood.

We met Trinity and her grandmother, Pamela Way, in the waiting room at the hospital at the University of Florida in Gainesville.

>> I have brightened up a flower and a swordfish.

Her teeth has gotten bad.

They are infected.

She has a lot of pain with them and the side of her cheek will get real warm, you know.

And I'm sure that's from being infected.

>> When's the last time she ate or drank?

>> About 9:00 last night.

For the last two years I have been trying to get her in because she had some... it started out just discoloration on her teeth.

I've called around ten dentists in the area to see if they could see her, but she's on Medicaid and I couldn't get her in.

Is Trini getting sleepy?

>> Yes.

>> I love you, girl.

She has been on a waiting list here to get this done.

It's been probably about two months.

But you're going to be fine.

It's okay, don't cry, don't cry.

Nanny ain't going nowhere, she's going to be right here.

>> One of the ways we provide care to a child who has lots of cavities and some infected teeth is we will actually do the dental procedures under general anesthesia in a hospital setting.

>> O'BRIEN: Pediatric dentist Frank Catalanotto is a faculty member here.

>> 1,200 children a year in Florida get their dental care under general anesthesia in a hospital.

That's an enormous number.

>> We are going to do two crowns, four extractions and five fillings.

>> O'BRIEN: Dr. Catalanotto says kids wind up here because Florida's Medicaid system is broken, thanks to one of the lowest reimbursement rates for dentists in the nation.

So there aren't many dentists who see these.... >> Only ten percent of Florida dentists participate in the Medicaid program.

>> O'BRIEN: Wow.

>> That's awful.

>> O'BRIEN: That's a lot of underserved people.

>> So the result is that only 25% of Medicaid-eligible children get any kind of dental care.

And by any kind of dental care, I mean one visit a year.

>> Dentistry is, in fact, a business and in order for a dentist to survive, they need to be able to make money.

>> O'BRIEN: Dr. Cesar Sabates is a practicing dentist and president of the Florida Dental Association.

>> I looked into becoming a Medicaid provider because I do believe in giving back.

And I noticed that the reimbursement schedule was dismal, to be quite honest with you.

It was maybe 20% of what we would normally charge.

So I thought to myself, "This doesn't make any sense.

It's not the dentists' fault."

>> O'BRIEN: But whoever's fault it is, Trinity Way's dental care will now cost $18,000.

>> For pennies on the dollar, preventive services on Medicaid rates would cost between $50 and $60 a visit.

>> O'BRIEN: Pay me now or pay me later.

>> That's exactly right.

And then in addition, you don't have the pain and suffering.

You don't have the missed school days.

You don't have the missed work days.

You don't have the potential deaths.

>> O'BRIEN: The stakes are high.

Half of all children in this countr rely on Medicaid or state insurance, and many are suffering from untreated tooth decay.

>> It is occurring in the poor.

We don't know all the reasons why.

We just simply don't know.

But the numbers are huge.

>> O'BRIEN: Is it accurate to say dentists are seeing more cavities than ever?

>> I think it is accurate to say that, yes.

This is a crisis, and we need to fix it.

We need to fix this by education, by money, and by organizing a new system of care.

>> O'BRIEN: With neither government nor private dentists able to solve the problem, a new system of care has emerged in recent years: corporate dental chains like this one.

>> Can you point to what's hurting you?

Right there?

Okay... thank you.

>> O'BRIEN: If Trinity Way lived in Maryland, she could have come here, to Kool Smiles, a dental chain started just to treat kids on Medicaid.

>> Some of the children that we see, sometimes they're five, six, seven, eight, nine, ten, even 12 years old, and they've never been to a dentist before.

>> All right, big guy, you're doing so well.

>> O'BRIEN: We met one of their executives, Dr. Polly Buckey, at a clinic in Baltimore.

So this is all hygiene, right?

>> This is what we would consider our hygiene bay.

We're in an open bay concept.

>> O'BRIEN: Each Kool Smiles office sees thousands of patients a year.

These are individual treatment rooms.

What's this young lady doing here?

>> An additional area of getting films taken.

>> O'BRIEN: It's okay, sweetheart, it's going to be okay, really.

Does she have a toothache?

Dr. Buckey says its size... Is that just the day?

Wow.

>> So this is our electronic health record.

>> O'BRIEN: ...and its sophisticated computer system allow Kool Smiles to be successful, even on what Medicaid pays.

>> We started in 2002 in two offices in the Atlanta area and today we're up to about 129 offices.

>> This is my Kool Smiles, the coolest place to go for your teeth on the whole planet.

>> O'BRIEN: Kool Smiles markets to kids who don't usually go to the dentist.

Backed by a private equity firm, the company is flourishing in states that have raised Medicaid rates in hopes of getting care to more kids-- states like Virginia, where Kool Smiles opened 12 offices.

>> It was exciting.

I mean, this area didn't have a whole lot of dentists that accepted Medicaid.

They were trying to reach out to the population that wasn't necessarily having an easy access to dental care, and so that's what appealed to me.

>> O'BRIEN: Christina Bowne was an experienced dental assistant who in 2006 became office manager of a Kool Smiles.

At first, she enjoyed her work, but after a couple of years she began to feel things change.

>> It became more about numbers.

Not so much as what we were doing to help the communit but more about numbers.

It became where we had a goal that we had to meet each day.

So they would tell us if we had to make $15,000, that's what we had to make, regardless of how we got there.

>> O'BRIEN: Christina says that the company computer system tracks production in minute detail.

>> It would tell you if you're seeing enough patients and doing enough procedures.

>> O'BRIEN: We asked Dr. Buckey if any pressures were coming from the private equity investors trying to increase profits.

Presumably if private equity owns NCDR, which operates these operations, there is a lot of profit in Medicaid patients, right?

>> The focus for us again is to provide a quality dental care, to provide a quality dental home.

The fact that we have a group that wants to see us be successful, part of what they can value is the fact that we are continuing to expand access to care, we're continuing to grow our business.

>> O'BRIEN: Marissa Mares was three years old when she and her mom, Kari Reyes, first visited Kool Smiles in Norfolk, Virginia.

>> I was shocked how comfortable Marissa was getting the first treatment done.

She didn't cry, she wasn't scared, she was smiling.

She got two crowns in the back and I believe she did a filling on a bottom tooth down here.

And we were supposed to go back the next time to get Marissa's four front teeth taken care of, just fillings.

>> O'BRIEN: But the next visit was not as good an experience.

First she was assigned to a different dentist, who wanted to change the treatment plan.

>> Dr. Collins just felt like she should do the crowns instead, she didn't feel comfortable doing fillings because she felt like the fillings would fall out.

>> O'BRIEN: Dr. Collins wanted to fit white-fronted NuSmile stainless-steel crowns on Marissa.

According to former employees, this was not unusual at Kool Smiles.

They say the chain encouraged its dentists to use crowns.

>> The reimbursement for a stainless-steel crown is much more than a filling.

>> O'BRIEN: How much more?

>> About 50% more.

>> They do a lot more... >> O'BRIEN: A lot of procedures.

Frontline and the Center for Public Integrit have spent the past year investigating the business of Medicaid dentistr and the new corporate model for treating America's poor kids.

>> This is all billings from Medicaid.

>> O'BRIEN: We were able to obtain and analyze Medicaid data from two states: Virginia and Texas.

We found that on average, Kool Smiles used crowns more frequentl than other providers on children eight and under.

In Texas, half of all the restorative care on kids eight and under, stainless-steel crowns, 50% more than the state average.

Virginia, 50% more crowns than average.

That's a big difference than other Medicaid providers.

Why?

>> Our focus is looking at each and every child and looking at where their decay is, what their risk for getting cavities.

>> O'BRIEN: It's not because the crown pays more?

>> The focus on each and every child we see is to restore that child to a state of good oral health.

>> O'BRIEN: Then how do you explain that discrepancy, that difference?

>> All I can tell you is what we do.

I can't tell you what someone else does.

>> O'BRIEN: Kool Smiles later gave us data comparing itself favorably to other providers.

But the company did not address whether kids who visit Kool Smiles are more likely to leave with a crown.

Kari Reyes was not happy with what happened when Marissa went to get her crowns.

>> The doctor was shoving the crown into Marissa's gums and her gums were bleeding just everywhere.

She started screaming, like, painful, like a shrieking, painful, scary scream for a mother to hear come out of her child.

>> O'BRIEN: Kari says she thought Marissa's local anesthetic had worn off.

>> I asked Dr. Collins, I said, you know, "Could you stop and numb her mouth?"

She ignored me.

So I, you know, just kind of sat there and I was rubbing Marissa's legs and she's crying and screaming this whole time.

>> O'BRIEN: Kari asked the doctor to stop working on Marissa.

A new dentist came in, gave Marissa another shot, and after three more attempts got the crown to stay on.

>> We went home, and about 30 minutes later the crown falls out again.

This tooth right here, this front tooth.

>> O'BRIEN: A Kool Smiles dentist eventually did get the crown to stay put.

With one tooth left to treat, Kool Smiles referred Marissa to another dentist.

>> This is the tooth that they didn't get done and he just scraped the spot that was thought to be a cavity with his tool and just scraped it off.

It was like a stain.

He couldn't tell me for sure if she did need the work that was done, but just seeing that one spot on her tooth just really made me and him question the entire thing.

>> O'BRIEN: In a phone interview, Dr. Collins defended her care.

Kool Smiles called the treatment "appropriate" and "in compliance with professional guidelines" and said it was a "rare case."

In addition, the company said Kari Reyes overreacted, exhibiting threatening behavior toward Dr. Collins, which Kari denies.

>> Hold your chin up.

I'm going to do one tooth, okay?

And then you tell me.

Here, open up for me.

>> O'BRIEN: Critics say problems arise from Kool Smiles' business model.

>> Close for me.

>> I got a bonus.

So if I met my goals for the month, I got a bonus.

It was based on production, it was based on patients.

>> O'BRIEN: Is that the same for everybody who works there?

>> For certain employees.

For certain employees.

So you're looking at the office managers, you're looking at your doctors and then their supervisors that I was aware of.

>> Our dentists come in and they're salaried, and so they are focused on how many... >> O'BRIEN: There's no bonus?

>> They're coming in, they're focused on a salary, and we do have a bonus that's a quality qualifier.

>> O'BRIEN: But doctors and office managers don't get bonuses based on quality.

It's more on quantity, isn't it?

>> Actually, that's incorrect.

>> O'BRIEN: But there is a daily revenue target, right?

>> Our focus each and every day with our dentists is to provide quality care to the children that walk in that door.

>> O'BRIEN: I'm trying to figure out... there are revenue targets, right?

>> For our dentists, there are not.

>> O'BRIEN: This is the Kool Smiles associate dentist.

This is the bonus plan for Texas, and this is from 2008.

Our investigation showed that Kool Smiles bases dentists' bonuses on the revenue they bring in once a certain threshold is reached.

And so if you can double the mandatory minimum, busy day, you get a $6,300 bonus.

Now, at $5,500 a day, how busy is that dentist?

>> She's booking.

She's on roller-skates.

>> O'BRIEN: Since our interview, the company acknowledged that their dentists can get production-based bonuses after meeting quality standards.

Kool Smiles would not grant any on-camera interviews besides Dr. Buckey, but they provided this lengthy document.

Kool Smiles said it delivers millions of dollars of free care each year, and improves oral health in the communities it serves.

The company's internal surveys show three out of four patients are satisfied enough to return.

In 2008, the state of Connecticut dramatically raised Medicaid rates.

New providers, including Kool Smiles, came into the state to treat poor children.

But officials noticed a change in the kind of care kids got.

What did you see?

What happened?

>> We saw spikes in the types of services that historically can be a red flag.

>> O'BRIEN: Dr. Donna Balaski is the director of Connecticut's dental Medicaid program.

>> We saw a higher than normal number of stainless-steel crowns being performed, a huge increase, disproportionate to the number of treatments that children were getting.

>> O'BRIEN: So people were being overtreated here?

>> We felt that.

>> O'BRIEN: Connecticut then began requiring dentists to get prior approval to use crowns.

The approval process revealed other problems.

>> We had volumes of requests for stainless-steel crowns and pulpotomies, which is where we noticed Kool Smiles was not, you know, functioning up to the standards of care.

This is an example of another very poorly done pulpotomy.

>> O'BRIEN: She showed us an x-ray of a child's root canal.

>> ... it's not filled properly.

What you're seeing are some poorly done crowns.

>> O'BRIEN: They look like they don't fit properly.

>> That's correct.

There's... the margins are open on this one and food can get up and stuck underneath.

>> O'BRIEN: Something like this, if you claim to have internal quality control... >> Right.

>> O'BRIEN: ... is this obvious?

>> Yeah, yes.

>> O'BRIEN: It's screaming at you.

>> To me it does.

>> O'BRIEN: You talk about quality, I'm curious, how do you measure quality here?

>> We're going in and doing self-audits.

On top of that, we have external auditors to look and see that we're providing quality care, that we're doing the right thing.

>> O'BRIEN: To do quality audits, Kool Smiles says it relies on its electronic health record.

>> So we're able to keep the records of each child and keep it all together in one spot, and it will help us as we go through... >> O'BRIEN: You can look at the records and really decide, "Oh, that's a good dentist or a bad dentist," just by looking at the records?

>> I can go in and look at a chart and look and see based on x-rays if the treatment plan was appropriate for that child.

>> O'BRIEN: Did you see much evidence that there was quality control?

>> Initially, no.

We absolutely did not see any quality at all.

In fact, when we called them into the room and started showing them examples of their work, you know, they acknowledged that it was sub-standard work.

So if they were checking on it, why were we seeing that kind of substandard work?

>> O'BRIEN: Connecticut regulators sa that they have seen significant improvement by Kool Smiles over the past year and a half, ever since the state sent the company this letter, referring to some of its care as "malpractice."

The words "failed to achieve expected standards of care," "malpractice," of course, "poor quality of dental care," "practice without regard to medical necessity."

This is a very strong letter, isn't it?

>> It is.

We take our clients seriously.

We're here to protect them.

>> O'BRIEN: They took advantage of you?

>> They took advantage of the system.

I mean, a lot of people do it.

It's not unique to just Kool Smiles.

>> It's a Medicaid goldmine, and they're drilling for your tax dollars.

>> O'BRIEN: Another private equity backed kids dental chain, Small Smiles, was the subject of this 2010 report that led to a 24 million dollar settlement with the federal government.

Now, corporate dental chains have become the subject of a Senate investigation.

>> When private equity firms get involved, you've got to understand that their motivation is to make money.

>> O'BRIEN: Senator Charles Grassley says it's tough for the government to encourage providers on the one hand and protect patients on the other.

>> We had whistleblowers that came to us and gave us information of what they thought was not only bad dentistry delivery and bad health care, but also a waste of taxpayers' dollars.

>> O'BRIEN: Are profits and patient care always at odds, you think?

>> Well, to some extent, yes.

There ought to be complete, good relationships between the patient and their dentist.

They ought to know that the only person that that dentist is concerned about is the patient.

And that's not what I'm finding in this investigation.

I'm finding in this investigation that there's people that know nothing about dentistr who are saying you got to see so many people, you got to do so much work for each one, and in a sense, gaming the system.

>> O'BRIEN: Do you think a private equity firm and the people who own that private equity firm and its shareholders care about quality of the dentistry?

>> I genuinely believe they care about the quality of dentistry.

You know, if people are going to invest, they are going to invest in something that's sound, and the only way for us to continue to stay here and be here is to be high quality.

>> O'BRIEN: Kool Smiles later wrote us to sa its dentists make treatment decisions without interference from corporate management.

Christina Bowne says that after she reported a dentist for mistreating kids, she was fired.

She is now in a wrongful termination suit with Kool Smiles.

>> It should never be about mone when we're treating children.

Ever.

>> O'BRIEN: There is a completely different approach in Alabama to providing dental care to kids.

It looks a lot like a corporate chain, but it isn't.

>> I was calling to see if you were interested in setting up an appointment with us.

We are a clinic for Medicaid... >> O'BRIEN: It's a non-profit called Sarrell Dental run by retired corporate CEO Jeff Parker.

>> The need that I saw when I got here was tremendous.

There wasn't a dental home for these children.

They had nowhere to go.

There were more children needing care than there were dentists able to see them.

>> O'BRIEN: That's what happened to Donna Butner's grandchildren.

>> My grandchildren came to live with me when Will was two and Julie was six months old.

>> O'BRIEN: She first asked her own dentist to treat them.

>> They said they did not accept Medicaid.

They didn't want to charge me less than their normal fees, you know, and there was no rebates or no discounts or no nothing just because I've been going to him for 30 years, you know.

It was unreal.

This blew my mind.

>> Give it just a minute, okay?

>> O'BRIEN: Now they are just two of the 300,000 children who come every year to one of Sarrell's 15 clinics.

>> These people here, honey, have been a blessing untold to my family.

>> O'BRIEN: Sarrell doesn't have to make a profit, and most of its dentists get paid a straight salary.

>> Our dentists receive no bonuses.

They are paid the same whether they see no one that da or if they see 20 patients that day.

I pay them exactly the same.

>> Oh, this is Miss Cameron.

I'm gonna take a look at these pictures that you took for me last time.

>> O'BRIEN: Dentist Tara Wheeler connects with the families who come into Sarrell because her own child was once on Medicaid.

>> Just because you have Medicaid insurance doesn't mean you don't have that love and concern for your child.

I treat everybody the same, whether they're from, you know, zip code 90210 or here at Sarrell.

>> O'BRIEN: Jeff Parker says Sarrell actually saves the state money.

>> Be really, really still, okay?

>> Having run big companies and being a capitalist, it almost sends chills down my spine to think that I would say I'm proud that we have reduced the cost of our patient visits to now where it's down to only $126 per patient visit.

>> What we believe that results from is the fact that these children have been getting preventive care.

So the dentists are now switching from filling teeth to only providing preventive care.

>> Cut out the Dr. Pepper, drink more water, brush better, floss.

>> O'BRIEN: Frank Catalanotto is a supporter of Sarrell and hopes to bring its model to Florida.

But Alabama's traditional dentists are deeply suspicious of Sarrell's success.

>> I accept Medicaid on a very limited basis.

In Alabama, as a dentist, unless I saw a lot of patients and did a lot of unnecessary work, if I had a Medicaid practice, I could not survive on what Medicaid will reimburse me for.

The second thing with Medicaid patients is they have no value in the appointment-- it doesn't cost them whether they come or go-- and so you have a very high degree of failures and no-shows.

>> There is no problem with Medicaid patients showing.

I would put our show rate up against any private practice-- not a Medicaid practice, any private practice-- in this country.

Alabama Medicaid is a good partner and Alabama Medicaid pays enough.

I wish the reimbursements were higher, but they're fair.

>> O'BRIEN: Sarrell's rapid growth was enough of a threat that Alabama dentists discussed it at a meeting in January 2010 at this Birmingham hotel.

>> O'BRIEN: Frontline and the Center for Public Integrit obtained an audio tape made by one of the meeting's participants.

>> I think the dental establishment in Alabama was shocked at our success.

I don't know if it scared them, I don't know if it is because it was new-- maybe they didn't think of it.

Whatever the reason, I think we took them off guard by our success.

>> O'BRIEN: In 2011, the state's board of dental examiners, led by its president, Dr. Thomas Willis, pushed legislation that would allow it to control Sarrell and, Jeff Parker says, even shut it down.

Their big objection: it was run by Parker, who isn't a dentist.

>> We're talking about running and operating the clinic and setting standard operating procedures as, "This is how you will do the work and this is what work you could do."

>> O'BRIEN: Some would suggest that that's about protecting turf.

>> Well it is, but you know, who best owns a dental practice?

You want to go to a dental clinic owned by a used car salesman?

I wouldn't.

>> The dental profession and organized dentistry's typical mantra is that the dentist is the captain of the health care team.

Mr. Parker is a non-dentist, and I think dentists feel threatened by this, and therefore they push back against these kinds of innovations in solving, in some way, the access problem.

>> O'BRIEN: But in the end, the Alabama legislature protected Sarrell, and the company continues to grow.

>> Who can be against a model that is eliminating decay?

People need to come see it, they need to adopt it.

It works.

>> O'BRIEN: There's another innovative approach that's upsetting the dental establishment, this time in Minnesota.

>> Alrighty, so why don't you come on back?

>> O'BRIEN: Christy Jo Fogart is one of the first dental therapists in the United States.

She treats children and pregnant women at child and family services in Minneapolis.

>> We are trained to the level of a dentist.

How I'm taught to do a filling, how I'm taught to do a root canal on a baby tooth, how I'm taught to extract a baby tooth is identical to the type of education that dentists receive.

I am trained to that level.

I'm just trained in fewer things than a dentist is trained to do.

Go ahead, open real big.

Although it's brand new, patients don't seem to be having any kind of reservations about it.

As soon as you explain that it's much like a nurse practitioner in medicine, they're like, "Sure."

You're good to go.

>> O'BRIEN: Because Christy Jo can do simple procedures for less money than a dentist, this non-profit will be able to treat more patients both on and off Medicaid.

At least ten other states are considering creating similar programs.

But the American Dental Association is fiercely opposed.

>> That model is not an answer.

What we feel is that, especially when you are dealing with underserved populations, you have to step back and think that these people are not only underserved probabl from a dental perspective, but also from a medical perspective.

So we don't understand why anyone would want a lesser-trained individual dealing with that population.

>> O'BRIEN: Really, are they undertrained?

I mean, it seems like they go through a fair amount of training and a couple thousand hours of direct supervision by a dentist.

>> They go through training, but to compare that training to the training of a dentist?

In my eyes, you just cannot do that.

>> O'BRIEN: To some degree, if I'm poor and I have a toothache, you know, half a dentist or 70% of a dentist is better than zero.

>> There are already models that exist that are used within the system that we have in this country.

We have trained auxiliaries that assist dentists in performing a lot of those duties.

Our concern is the idea of a lesser trained individual doing surgical procedures.

>> I don't know why anyone would want to oppose a very well-trained professional treating someone who otherwise would not get treatment.

And I've not heard a lot of good ideas or suggestions come from the Dental Association on how we address this access issue other than pay dentists more to do it.

>> O'BRIEN: Lobbying by dental associations has to date helped block any other state except Alaska from establishing a dental therapist program.

So dentists are spending a lot of mone to maintain the status quo.

>> They are.

>> O'BRIEN: Why?

>> Because the status quo is good for dentists.

They see the patients that come to their practice and they think everything is fine because those patients are getting care in their office.

>> O'BRIEN: Should we fault them for that?

>> In one sense, you can't really fault them for that, and in another sense, they know the problem.

They have been told about the problem for years.

You have to see that data and recognize that there is a problem.

>> Coming up next, Miles O'Brien continues this report with the dental care crisis for adults in America.

>> So I had to go to the emergency room because I didn't want to die from an infection.

>> Checking in on VanessaNations from earlier in the program.

>> It is the big day.

>> Part two of "Dollars and Dentists" begins right now.

>> O'BRIEN: In 2010, Vanessa Nations lost her job, and having no teeth has made finding another almost impossible.

Now she's moved in with her mom while she waits for the dentures she was promised in Grundy to be ready.

>> O'BRIEN: You've got a few pictures here.

Tell me about these pictures.

First of all, where was that taken?

>> This is at my school, when I was in high school.

>> O'BRIEN: You've got a nice smile there.

>> Yeah, I was happy.

>> O'BRIEN: Yeah.

>> I love this picture.

>> O'BRIEN: But Vanessa admits that her dental problems are largely due to habits she developed when she was young.

>> After you brush your teeth at night and you go to bed, you drink Coke and you go to sleep.

Very, very bad.

Don't do that.

>> O'BRIEN: Right, is that what you did?

>> I did.

I mean, and it's stupid, yeah.

That is neglecting, I guess, your teeth, you know?

>> O'BRIEN: But once Vanessa's problems began, the only way to get help was to go deep into debt-- first, from charging visits to the dentist on her credit card.

And after she lost her job, the only place to turn was even more expensive.

>> I had no money and no insurance, no job, so I had to go to the emergency room.

So I had to... and I knew I had to go get a $3,000 bill, which I'm sure it is-- I haven't opened any of the envelopes because I can't pay it-- just to get a prescription for an antibiotic, because I didn't want to die from an infection, you know?

>> O'BRIEN: Well, it still doesn't treat the root cause of the infection.

>> It does not.

And then they tell you to go see a dentist.

Okay, well, the reason I'm here is because I can't go see a dentist.

>> O'BRIEN: Vanessa is just one of the nearly one million Americans who visit the emergency room each year because of dental pain, at a cost that runs into the hundreds of millions.

>> The really tragic part of that expense is, all they can do in a hospital emergency room is control the infection and control the pain.

Most of those hospital emergency rooms are not equipped to provide dental care.

So the patient gets a dose of antibiotics, they get some pain medication, they go home, they take that, the swelling goes down, the temperature goes down, the pain goes away.

A couple of weeks, that same tooth flares up again.

>> O'BRIEN: But where else are adults who can't afford dental care to go?

Neither the government nor traditional dentistr have come up with an answer.

And so, just as with children, the biggest changes to the adult dental landscape are being made by for-profit dental chains.

Backed by private equity firms, they're setting up shop in communities where there are large numbers of adults who haven't been going to traditional dentists.

One of the largest chains is Aspen Dental, with 350 offices in 22 states.

>> You know, the best thing about being part of racing histor is bringing smiles to folks everywhere.

And Aspen Dental does that, too.

>> O'BRIEN: Aspen sponsors a NASCAR team and last year had three-quarters of a million customers.

>> Our vision is to have the most trusted dental brand in the country.

The typical patient is probably 45 to 65 and struggling kind of just to make ends meet.

They're taking this week's paycheck to pay last month's mortgage, making a car payment.

They will push things off and push things off until they can't put them off any longer, and hopefully, if we're doing our jobs, we've located in the right markets, we're creating awareness in those markets, and those people are choosing to come into our offices.

>> O'BRIEN: Bob Fontana invited us to come to one of Aspen's showcase offices in Warsaw, Indiana.

Here we met dentist Kurt Losier, who owns the practice at this Aspen-run office.

>> So, Ted, you're saying you're having a pretty significant toothache on the bottom left.

When's the last time you saw a dentist?

>> About ten years ago.

>> Okay.

>> O'BRIEN: Ted Collins is a typical patient-- a truck driver with no dental insurance.

He came in because of intense pain in two teeth.

But Dr. Losier tells Ted that he has problems with almost all of his teeth.

>> Let me take a look at them real quickly now, okay?

And, Buddy, they are loose.

I would advise that what we would do is, we'll do an upper denture.

There's just not much of a way around it at this point.

>> O'BRIEN: Aspen specializes in dentures and makes them right in the office.

>> Here we go.

Here we actually make a number of different types of dentures, which is really complicated.

We organize them based on a warranty that we give them.

And my manager will run you through the details on them.

From my perspective, my goal would be get the longest warranty you possibly can.

>> O'BRIEN: So basically, almost all dentures is what he's saying you have to do.

>> Yeah.

>> O'BRIEN: Can you afford that?

>> No.

>> O'BRIEN: At this point, you'd probably pay anything to get those teeth out, huh?

>> Pretty much, yeah.

>> Is there one denture specificall that you'd like to start with when we're talking about putting your package together for you?

>> I don't know enough about them.

>> Okay.

>> I'm just going with what the doctor recommends.

>> Okay, and so did he talk to you about recommending one of these specifically, possibly like the Comfis?

>> I think he might have.

>> Okay.

>> O'BRIEN: It's the office managers who work directly for Aspen that sell the patient the package.

>> So what we want to do is we'll put your package together in the computer.

We'll see what prices we have and what payment options we're looking for for you.

Okay?

>> O'BRIEN: The price for Ted's package turns out to be $6,784.20.

Ted doesn't have that in cash.

And that's where health care credit cards come in.

>> And you're clear on how the payment plans work and what you're going to be talking about as far as payment options for a co-signer?

>> Right.

>> Okay.

So you have everything you need.

>> O'BRIEN: According to a former Aspen office manager, Heather Haynes, what we saw at Aspen was a typical attempt to encourage a customer to finance expensive treatment.

>> O'BRIEN: Was there pressure to get them signed this first day?

>> Yes, yes, it was.

>> That first day.

>> Yes.

>> Why?

>> If you... because it's just like anything else.

You walk out that door, you probably won't see him again.

>> O'BRIEN: It seems like there's a lot of effort here to put people on the hook, so to speak.

>> Yes.

I felt, though, that if they couldn't afford it, why should I sell them that product?

I have grandparents who are on a monthly budget.

I would think about that all the time.

I'd just think, "Wow, those are my grandparents sitting in front of me, "and I'm telling them to pa for something that they can't afford."

>> O'BRIEN: The credit cards Aspen offers are backed by major corporations like G.E.

and are used widely by dentists.

According to Moody's Investors Service, one key to Aspen's business model is that it gets paid by the credit card companies in advance for the patient's entire treatment plan the moment Aspen signs the patient up for the card.

>> O'BRIEN: So this is an important part of your business.

The third-party financing is key.

>> I would agree with that.

It's absolutely key to providing the solution for these patients.

There's no doubt about it.

Because, again, they're struggling to get through life, and so it does become an important part of the solution for them.

>> Oh, what a nightmare.

>> O'BRIEN: Theresa Ferritto, who's hearing-impaired, signed up for a credit card after going to Aspen to get two teeth removed.

>> Mom's 87 years old, and she's in pretty good shape for her age.

She's pretty sharp.

And she comes rolling into Aspen Dental prepared to have these two teeth removed.

But, much to her chagrin, she found out that they wanted to do a whole makeover of her mouth-- removal of many more teeth than the dentist had initially recommended, and then the creation of dentures, all at the tune to about $8,000.

$8,000 is close to 50% of her annual income.

>> When they presented that big... eight, seven thousand dollars, I says, "I can't afford that.

I don't have that kind of income."

Well, they didn't care.

They figure, well, I could put it on a credit.

>> O'BRIEN: Mrs. Ferritto wound up with the G.E.

credit card called CareCredit.

>> They never mentioned or explained about a lot of interest, high interest-- never.

Look at this-- look, look, look.

>> O'BRIEN: CareCredit began charging Mrs. Ferritto interest as soon as the credit card was issued, even before much of the work had begun.

>> So as soon as she got approved for that credit, those charges and that interest started to accrue at that second, before she even left the dental office.

And so we feel like she was really taken advantage of, just in that regard alone.

The potential payment over five years would have been close to $12,000, and she initially came in for the excision of two teeth.

>> O'BRIEN: Allan Ferritto called the Aspen Dental office to try and get his mother off the hook.

>> The girl at the office says, "Well, you know, your mother came in here and she was very happy with our treatment plan, and she told us that she wanted a Hollywood smile."

>> I was confused, I was really confused.

And then I realized, until I got home I realized, oh, what I put myself into.

This, this!

I feel like...

I wish I could hit them on the head with it.

>> O'BRIEN: In the case of an 87-year-old woman who can't hear very well, to get her to sign on the dotted line without perhaps somebody there advising her seems like it might be a little bit predatory, potentially.

>> Well, I don't think so and I certainly hope not.

I hope that the team was clear about what she needed and that she completely understood what she was getting into, and hopefully, you know, she made the choices that she thought was right for her.

>> O'BRIEN: Aspen patients have complained to regulators about being billed before their work was done and being charged credit card interest as high as 29.9% retroactively if they miss payments.

>> So this is the consent decree between Pennsylvania and Aspen from 2010.

>> O'BRIEN: In response to such complaints, the Pennsylvania attorney general investigated Aspen, and the company agreed to pay a $175,000 settlement.

>> It's a conflict of interest.

>> O'BRIEN: And in New York, Andrew Cuomo, then attorney general, launched an ongoing investigation into the growing use of high-interest health care credit cards.

>> And it is where health care providers become agents for financing, and the financing company is providing the money to the doctor all up front.

>> O'BRIEN: According to Heather Haynes, there's another controversial aspect to how Aspen does business.

The more work employees convince customers to do, the more money they make.

>> They want us to sell the Cadillac of all dentures, and that's how we would try and sell.

We would sell the biggest, best product, and if that didn't work, then we'd downsell.

>> O'BRIEN: If you succeeded and did well, could you make a lot of money?

>> You could.

>> O'BRIEN: Bonuses?

>> Yes.

Bonuses were given on a monthly basis.

>> O'BRIEN: So how do you incentivize your people and the dentists along the way here in order to keep the money flowing?

>> Well, the incentive for everybody is, let's do the right things for the patients.

>> O'BRIEN: But they have to meet certain goals in order to derive income.

There's a bonus system, right?

>> When you say "they," who's "they"?

>> O'BRIEN: Well, office managers, for example.

>> So the office managers are rewarded based on controlling expenses and making sure that they reach a certain patient satisfaction score.

The doctors don't have any budget to reach.

They're not rewarded based on hitting any level of production or any level of budget.

>> O'BRIEN: So doctors don't get bonuses, or their income is not linked to their production?

>> I wouldn't describe them as bonuses.

They get a percentage.

You know, so in traditional practice, they get a hundred percent of the profits.

In our practices, typically, they get a smaller percentage of those profits from that practice.

>> With Aspen, you'll share financial rewards and benefits... >> O'BRIEN: This video that Aspen uses to recruit dentists tells another story.

>> Compensation for associate dentists includes an annual salary plus bonus opportunit that increases as key target levels are met.

>> O'BRIEN: Lili Reitz, executive director of the Ohio Dental Board, which regulates dentists, worries about bonus opportunities at corporate dental chains.

>> In some of these kinds of practices, there are quotas and goals that the dentists are expected to meet that work there.

And when you're offering bonuses for services, there's going to... there's incentive for that person to want to do more of that, obviously, to set themselves up better financially.

But that jeopardizes the standard of care.

That puts the standard of care at risk.

>> O'BRIEN: But Ms. Reitz, who prides herself on being a no-nonsense regulator, is virtually powerless to do anything about it, because she doesn't have the authorit to discipline corporations.

>> The Dental Practice Act just gives the board the authorit to issue a license, regulate that license and take action against the license when necessary.

>> O'BRIEN: When you say a licensee, you are regulating dentists.

>> Dentists, dental hygienists and other auxiliary.

>> O'BRIEN: Who regulates the corporations in this case?

>> I don't know that anyone regulates a corporate dental practice per se.

>> O'BRIEN: So, in a way, you can only attack the problem indirectly.

>> Correct.

I'm not going to argue with you that that's not frustrating, but that's... that is what we're responsible for addressing.

>> O'BRIEN: With little oversight of its corporate practices and intense demand from Americans in need of dental care, Aspen is expanding rapidly across the country.

>> O'BRIEN: Tell me what the plans are.

You're right now at 350 offices.

Where are you headed?

Global domination, right?

>> No, I wouldn't say global domination, but we have... we do believe that there are communities across the countr that are still, like Warsaw, we know there are people, good, hardworking people trying to make ends meet in those markets that need our care and need our services.

We're in 22 states, and we have half a country to go.

>> O'BRIEN: Of course, if there were other options for Americans without dental insurance, maybe people like Vanessa Nations wouldn't find themselves charging dental work they can't afford on credit cards they can't pay off.

>> Hey.

>> O'BRIEN: But as Vanessa knows, the only other place for most to turn is to charity.

>> Hello, Vanessa.

>> Hey.

>> How are you doing?

>> O'BRIEN: Today, Dr. Joshua Swanson, one of the volunteers at Grundy, is going to give Vanessa her new teeth.

>> It is the big day.

>> Yes.

>> Let's try this top one in.

Put it in, you're going to give it a good push.

Up there nice and tight.

Bite together for me.

Let me give you a mirror here, okay?

Have a smile.

See what you look like with some teeth in.

Big smile.

>> I feel so blessed.

I can't express how blessed I feel.

I mean, it's a miracle, is what I feel.

>> O'BRIEN: As for the millions of other adults in our countr that charities can't treat, there is to date no solution for them.

>> Frontline continues online.

Learn more about our broken dental system.

>> You've got to have good dental health.

>> Read stories from our partner, the Center for Public Integrity.

>> It's just not a simple matter.

>> More about why it's so difficult to get qualitydental care.

>> About 30 minutes later, the crown falls out again.

>> Removal of many more teeth than the dentist had initially recommended.

>> Plus, watch the full program again online andfollow Frontline on Facebook and Twitter, or share your reaction at pbs.org/frontline.

Captioned by Media Access Group at WGBH access.wgbh.org >> For more on this and other Frontline programs, visit our website at pbs.org/frontline.

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