The problem with Sara Armas’ teeth began when she was a child.

The academic and artist, who is autistic, struggled to take care of her teeth when she was young. She always hated the sensations and sounds of going to the dentist. You cannot tell just from looking at her smile, but many of her back teeth are pockmarked with filled cavities and crowns.

Armas was advised when she was young that most of the fillings would only last 30 years. At age 41, she said she takes better care of her teeth – but decided 2023 was the year to replace those old fillings.

Armas thought it would not be too challenging because Maine had expanded MaineCare, the state’s version of Medicaid, to include adult dental care in 2022. But since the spring, the Stonington resident has been unable to find a practice near her that accepts MaineCare and does not have a months-long waitlist. Her partner was able to find a dentist in York County, who she said told her they also would see her — provided she was available to make the multi-hour drive on short notice.

Armas isn’t the only one struggling to get an appointment with a dental clinic. More than a year since adults with MaineCare coverage were able to access preventive and comprehensive dental care, providers say they are booking people out months at a time, often making routine tooth issues much worse by delaying care.

Months after she began looking, Armas has not made much progress. She found a dentist who was willing to do X-rays and an exam if she paid out of pocket, but was told they would not redo her fillings. With work being inconsistent and a potential plan to move south for the winter, Armas said she has run out of money to fix her teeth.

“I don’t want to be one of those people who start losing teeth,” Armas said. “I don’t want to degrade people who don’t have teeth, but in Downeast Maine and rural areas, I feel like many people’s solution is to pull the tooth, and I’m like, ‘What? No.’ ”

The U.S. Bureau of Labor Statistics shows employment for dental care in Maine has been relatively stagnant from 2019-22, the latest data available. The number of dentists decreased by 5 percent, lab techs decreased by 16.6 percent and dental assistants decreased by 8 percent. Only dental hygienists saw an increase by 5 percent. 

Things could get worse. A study from the American Dental Association found one-third of dentists and hygienists in the country are expected to retire within five years.

The challenges Maine and other states face are ripple effects from the COVID-19 pandemic, which worsened healthcare workforce shortages, said Jackie Farwell, a spokesperson for the Department of Health and Human Services.

Maine has tried to retain dentists by offering student loan repayments of up to $75,000 for a health care practitioner who commits to working in the state for three years starting in 2024. That program was part of a one-time expense approved in Gov. Janet Mills’ supplemental budget this year.

A healthcare training initiative also aims to connect employers with education programs where participants can get tuition assistance.

Access challenges are exacerbated by the fact that only 141 general dentists — or 25 percent — accept MaineCare, according to a directory of enrolled providers. That’s the dentist patients see for routine care, like fillings and cleanings.

Only one dentist in the state accepts MaineCare for root canals, according to the directory. Oral diseases require a pathologist, and only three in Maine take MaineCare. Some providers might only take government-run insurance for certain procedures. The directory does not show if dentists are taking new patients, said Farwell.

The stigma of low reimbursement rates and challenges getting providers credentialed has kept many dentists from accepting MaineCare for years, said Melissa Watson, the executive director of Community Dental, one of the few nonprofit dental groups that provide care to low-income patients and accept MaineCare or use a sliding fee scale for payment.

But even though Maine upped reimbursement rates by an average of 70 percent, they are not near what dentists who take private insurance or offer fee-for-service care make, Watson said. 

Given the costs associated with the profession, Watson said she understands why dentists might hesitate to take MaineCare.The average student loan debt of a dentist in 2022 was around $304,824, according to the American Dental Education Association, and the cost of equipment and overhead to start a practice is expensive.

“This one doctor, when they were doing the expansion, put it nicely,” Watson said. “He said, ‘I don’t mind breaking even, but I can’t consistently see patients at a loss.’ ”

Watson estimates about 70 percent of patients qualify for MaineCare or use a sliding fee. All four of Community Dental’s locations have a waitlist of about nine months to see a new patient. 

“We’re lucky that the dentists that come to us understand our mission,” Watson said. “They know we can’t pay competitively but that we are a safety net, and someone needs to be there for our patients.”

The problems facing dental care were well-known going into the 2022 legislative season when legislators voted to expand coverage, she said — after all, activists had pushed for over 30 years to include it under MaineCare. Prior to expansion, a tooth had to be considered an imminent loss before coverage kicked in.

“We haven’t tended to the needs of MaineCare members’ oral health for years,” she said. “You can’t fix that in a year.”

But Kilrain del Rio said the MaineCare utilization of benefits data is showing progress. In 2020, fewer than 1 percent of MaineCare members, just over 1,000 people, had gotten some kind of preventative service, such as an oral evaluation. By May of this year, 12,135 people, or 4.75 percent of members, had done so. A MaineCare report notes adult members are getting preventative care at a rate of 1,000 unique members per month.

“A bunch of people, they wouldn’t have had that service before that,” said Kilrain del Rio.

Despite the wait times, Laura Callan, a general dentist at Community Dental, said the level of care she is able to provide is getting better. People no longer have to wait until a tooth is so severely decayed that it requires “heroic” efforts such as root canals, crowns or even extractions to keep an infection from getting worse. 

“If patients want to get work done, and it’s moderate and a good idea, you should be able to do it,” said Callan.

For Sara Armas, a change in life circumstances might finally help get her the care she needs. She recently was offered an adjunct teaching job at a southern Maine college, which will take her out of rural Hancock County and make her no longer eligible for MaineCare. She hopes that after a few years, she will receive decent enough pay and benefits to get the dental care she needs.

“The point is to get somewhere I can be healthy and thrive,” said Armas. “That’s the goal.”