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For Kentuckians Living With HIV/AIDS, Dental Care Is Complicated

u of l dentist
Courtesy U of L

Growing up on a farm in Western Kentucky, Harold Bucy said he always knew he was different.

As a little boy, he played with Tonka trucks but he also liked to try on his grandmother's dresses. More than once, he dressed as Wonder Woman for Halloween.

Bucy, who is gay, said his family accepted him. But the messages he heard every Sunday morning coming from the pulpit of his family's church in Murray told him he was an abomination.

"I went to a strict church that said if you’re gay, you’re going to burn in hell," Bucy said. "I felt I was unlovable and I was doomed from the beginning."

Bucy left his home when he was 21, traveling first to Indiana, then California, then Chicago and many other states in between. When he returned to Bowling Green in 2011, Bucy was HIV-positive and had a mouth filled with cavities and broken teeth.

It started at a party in 1998, when Bucy said a friend gave him a powder to snort. He wasn't sure what it was, but it turned out to be crystal meth. Suddenly, he said, all of his fears and anxiety about being gay went away.

When Bucy was diagnosed HIV-positive a few months later, dental work became the last thing on his mind. The crystal meth wore the enamel off his teeth, while the HIV drugs made his bones brittle.

“I used to have beautiful teeth that I took very good care of,” Bucy said. But after 10 years of drug use and neglect, he said, "they were in such bad shape, I wouldn’t smile.”

Bucy is finally getting back the smile he left Kentucky with 30 years ago. He couldn’t afford the dental work. But shortly after returning home, he found a University of Louisville dental clinic that catered to people just like him. At that clinic, he’s had nine cavities filled, two crowns, a bridge and a partial denture, all in five years.

There's Help in Kentucky

There are four HIV/AIDS medical clinics in Kentucky funded through the federal Ryan White grant program. In addition, the University of Louisville operates an oral health program that focuses on providing dental care for people with HIV/AIDS. This includes a satellite, community-based clinic. (WFPL is not disclosing the location of the clinic -- as requested by the program -- out of concerns for patient safety.) The dental program accepts Medicaid and other insurance, and federal and state grants pay for what isn’t covered.

U of L has offered dental care to HIV/AIDS patients since 1999. And in 2014, the state partnered with the program to acquire funding to help better connect people living with HIV/AIDS with the clinics.

Bucy and other patients earning up to 500 percent of federal poverty limit ($59,400) pay $10 per visit, no matter how advanced or expensive the procedure. People who earn under $11,880 per year pay nothing.

Bucy worked at Kay Jewelers and Barnes and Noble as a regional and training manager for most of his career, and had good dental insurance through those jobs. At 57, he has Medicare coverage because of his disability -- the result of a suicide attempt before he kicked his crystal meth habit. He said without the U of L clinic, he wouldn’t have any teeth.

“I guess I would just lose my teeth, I’d have to have them all pulled," Bucy said. "Dental work is too expensive, I couldn’t afford it.”

Bucy buys a supplemental dental policy every month through Medicare, but it mainly covers extractions and cleanings.

“I couldn’t afford the crowns, and obviously I couldn’t afford the implants or the partials,” he said.

What Role Does Medicaid Play?

Since Kentucky expanded Medicaid under the Affordable Care Act in 2014, people living with HIV/AIDS who make up to 400 percent of the federal poverty limit qualify for Medicaid and the dental coverage that comes with it.

But dental benefits under Medicaid are sparse. Coverage includes an oral exam, x-rays and extraction, fillings and emergency visits.

Brandon Stapleton is a dentist at a U of L clinic and also runs his own practice in Lexington. He said Medicaid doesn’t cover some basic procedures, like replacing a tooth that's been pulled.

“They’ll pay for the removal of the tooth," he said. "There are a couple of states that will pay for a denture, but Kentucky’s not one of them."

Recent federal funding awarded to the clinics -- $2 million -- comes from the Ryan White grant program. The money is given to states to pay for services such as dental care, home health care and transportation services for HIV/AIDS patients. Money from the grant given to the U of L School of Dentistry is intended to fund its program through 2018. 

Medication Can Make Dental Health Worse

The common drugs prescribed to HIV/AIDS patients like Complera, Combivir and Crixivan
often cause the amount of saliva in a person's mouth to decrease, leading to dry mouth. That results in cavity-producing bacteria, which causes teeth to dry out. Then, bacteria gets into the gums, which can cause gum disease.

Deborah Wade, manager of the Ryan White grants for the U of L outpatients clinics, said it's a common occurrence among patients who visit.

“We see people who say, ‘My teeth are just kind of breaking off,’ and it’s not that they’re trying to crack walnut shells,” Wade said. “One day they’re talking, and it will just break off.”

The Stigma

There's a shortage of dentists who both accept Medicaid and will see HIV/AIDS patients.

In 2014, Kentucky Medicaid only paid 41.4 percent of what private insurance pays for a dental service, according to the American Dental Association. Kentucky Medicaid pays $44 for a simple front-tooth filling for a person over the age of 21, which according to the ADA is likely almost half of what private insurers pay.

There’s also the stigma that comes from having HIV/AIDS, even at the dentist.

“You’ll have a dentist who might feel uncomfortable treating someone who has HIV because there’s a lot of bleeding with oral health care, especially if it’s been neglected,” said Aaron Guldenschuh-Gatten, executive director at the AIDS Interfaith Ministries of Kentuckiana.

But following routine protocol, like sterilizing equipment and using gloves, doesn’t expose dentists to risk.

People with HIV/AIDS might also be reluctant to to see a dentist because of an open office environment.

“Imagine you’re a HIV-positive person and you have to go to a dentist you don’t know well, and when they ask about HIV status, and they may or may not lean in, you have to tell them you’re HIV-positive,” Guldenschuh-Gatten said.

Coming Home

A total of 9,550 HIV infections were diagnosed and reported in Kentucky as of June 30, 2015. Eighty-three percent of people diagnosed are male, and 35 percent were in their thirties at the time.

When it comes to the number of people newly diagnosed with HIV, Kentucky fares better than most of the South. In 2013, there were 364 new people diagnosed in Kentucky, or 8.3 people per 100,000. In 2014, it was 9.9 people per 100,000. That's compared with 14.7 people per 100,000 in Tennessee, 17 people per 100,000 in North Carolina and 27 people per 100,000 in Georgia that same year.

“The epidemic is really worse and has been for some time in the rural South, Kentucky on down," Deborah Wade said. "Many left home when they came out as gay because it’s the Bible Belt. And they went to New York and California, that’s where they got infected, and they came back home to die but they didn’t die."

That narrative applies to Bucy. In 2011, he moved back to Kentucky to take care of his aging mother and to start taking care of himself again. He said dental care plays a critical role in his overall health.

“Dental infections are the worst infections the body produces," Bucy said. "It would attack my immune system, which would be deadly.”

Bucy is looking forward to two months from now, when his jaw will have healed from implant surgery, and his partial dentures will look natural.

“They had to cut my gums and drill into the jaw bone, and twist the metal into the jaw bone to get the implants ready to go in," he said. "That part wasn’t fun, but the dental part will be fun. I’m looking forward to that part."

For more information about the U of L School of Dentistry's HIV/AIDS program, call 502-852-2559.

This post has been updated.

Lisa Gillespie is WFPL's Health and Innovation Reporter.