Dr. Brandie Ard examines patient Denny Fernandez at the Dental Health Center, in Pawtucket. At right is dental assistant Kim Vale with an x-ray of the painful tooth.

The Providence Journal / Frieda Squires

PAWTUCKET — Denny Fernandez is no dentist, but he once pulled out his own tooth.

Back then, he was a young truck driver hauling through Texas when he bit down too hard on a sparerib. His tooth cracked. So, he reached for his needle-nose pliers. He wound up in a hospital emergency room.

People with no access to a dentist have been known to take desperate measures.

Fernandez, now 56, recalled that painful day in Texas while lying in a dentist’s chair last week, cupping his swollen cheek.

He is 1 of 180,000 Rhode Islanders who are eligible for dental coverage through Medicaid, the government financed health-care program for the elderly, poor and disabled.

But doctors and staff here at the Blackstone Valley Community Health Care’s dental clinic worry that they may not be able to afford to treat people such as Fernandez for much longer.

State lawmakers are considering an agreement with the federal government to cap Medicaid spending over the next five years. In return, the federal government would lift some of the regulations that now govern Medicaid coverage. A hearing on the agreement will continue tomorrow. Dental coverage for adults — which is “optional” under the current Medicaid program — stands as an easy target.

Last year, 2,700 people on the state’s Medicaid plan were treated at this dental clinic in a former bank building on Main Street in Pawtucket where Fernandez showed up with an infected gum.

Inside, the waiting room is carpeted and spacious; the brightly-lit exam rooms equipped with a state-of-the-art computerized record system that rivals those of most private dentists’ offices.

But this is far from the world of braces and bleaching. Here, dentistry is about survival. Decayed teeth, diseased gums and the legacy of poor dental hygiene are the norm. Many patients suffer from a lifetime of poor dental care, or none at all. Gum pain or tooth loss can make it difficult to eat. And infections in the mouth, left untreated, can kill.

In one exam room, a 56-year-old factory worker’s gums are so decayed that two of her teeth are loose. Across the hall, a 3-year-old girl’s first trip to the dentist reveals a mouth full of cavities.

“I am trained to save teeth,” said Dr. Lalita Bhattacharya, the clinic’s dental director. But her clients cannot always afford the “cosmetic treatment” required to save teeth.

The clinic’s oral surgeon pulled 20 teeth last Monday. And that isn’t counting the other, routine extractions performed by the dentists.

Extractions, which are fully covered by Medicaid, cost anywhere from $90 to $200 at the clinic, said Jerald Fingerut, the health center’s medical director. If the patient with an infected tooth winds up in a hospital emergency room, he said, it costs “somewhere between $500 and $1,000.”

Emergency room doctors generally prescribe antibiotics and pain medications, and refer the patient to a dentist, said Dr. Geoffrey Dodge, president of the Rhode Island Dental Association. “Of course,” he added, “if they’re in the E.R., usually ninety or ninety-five percent of them don’t have a dentist.”

Back in 1991, during the state’s last major financial crisis, the state withdrew dental benefits for 30,000 Rhode Island adults, including thousands of nursing-home residents, as part of an effort to balance the budget. Dentists told stories of turning down patients who they couldn’t afford to treat for free.

People with no dental coverage would show up with abscessed teeth and swollen faces at Rhode Island Hospital’s emergency room, recalled Dr. Clark A. Sammartino, a retired oral surgeon who treated many of those patients.

One of Sammartino’s patients told The Providence Journal at the time that she was scheduled for oral surgery for gum disease when her Medicaid benefits were cut off. She couldn’t afford the $3,500 for the procedure, so it was canceled. Unable to eat because of the pain, she pulled out her own teeth.

Dental coverage for Medicaid patients in Rhode Island cost $22.8 million in fiscal 2007, or one-third of 1 percent of the Medicaid program’s total cost, said Gary D. Alexander director of the state Department of Human Services. This year, Medicaid consumes roughly $1.8 billion in state and federal spending, or 25 percent of the total state budget.

State law currently requires dental coverage for children, but not for adults on Medicaid.

At the Blackstone Valley dental clinic, more than a half-million dollars, or 41 percent of the clinic’s $1.32 million of revenue last year, came from adults on Medicaid, said Mario Rosario, the dental clinic’s office manager. If Medicaid dental coverage for adults is dropped, the clinic will be forced to shift into “survival mode,” Rosario said, and drum up more paying clients to make up the lost revenue.

That would likely squeeze out patients such as Fernandez, the retired truck driver, who without Medicaid could not afford to see a dentist.

Fernandez no longer works. After years of driving tractor-trailers, he has undergone four back surgeries and is now disabled. A card tucked into his wallet lists his medications.

He gets $753 a month in Social Security, of which $400 goes to pay his rent. He has no car, and usually rides two buses from his apartment on Plainfield Street, in Providence, to get to the clinic in Pawtucket. On this morning, though, he was in so much pain that a neighbor loaned him his car.

In the dentist’s chair, Fernandez twists a Yankees baseball cap in his hands as if he was trying to wring out the pain. The hygienist leans over him.

“On a scale of 1 to 10, how bad is it?”

“I’m gonna say 9.”

larditi@projo.com