Gita Aminloo, his dental hygienist, tries to calm him by singing “Itsy Bitsy Spider,” the classic children’s song.

Rising, 42, is mentally disabled and blind. He has cerebral palsy and suffers from seizures. It’s hard for him to get to a dentist’s office, so Aminloo brought her dental picks, brushes and other tools to him at the residential care facility he shares with several other people who have developmental disabilities.

Rising is among a vulnerable class of patients who are poor and so frail they can’t leave the nursing home or, in his case, the board-and-care home to visit dentists. Instead, they rely on specially trained dental hygienists like Aminloo, who come to them.

But this may be the last time Aminloo cleans Rising’s teeth. And it’s not because of his resistance.

Hygienists say some of their patients are no longer getting the critical dental care they need because of recent policy changes: The state dramatically slashed payment to providers and created a preauthorization process they call cumbersome.

In 2016, Denti-Cal, the publicly funded dental program for the poor, cut the rate for a common cleaning procedure for these fragile patients from $130 to $55. Hygienists say they can’t afford to continue treating many of them for that kind of money. They also claim that half of their requests to perform the cleanings are rejected — an assertion not supported by state data.

The Department of Health Care Services, which runs Denti-Cal, said it made the changes to bring the program’s reimbursement policy in line with other states and to reduce “unnecessary dental treatment.”

But Aminloo insists the new state regulations victimize the most vulnerable people, who she said are losing their access to routine dental care.

“If these patients don’t get preventive oral care, their overall health is going to suffer,” she warned.

Dental hygienists are generally allowed to practice without the direct supervision of a dentist , including Nevada, Texas, Colorado, Michigan and Florida. But the type of patients they can see varies by state. So do reimbursement and preauthorization rules.

Washington state’s Medicaid program pays providers $46 for a similar cleaning procedure, said Anita Rodriguez, a member of the Washington State Dental Hygienists’ Association. Hygienists there don’t have to obtain preauthorization to perform cleanings, but they are required to explain why the cleaning was necessary when they bill Medicaid.

“Our state makes access for our independent hygienists relatively uncomplicated though, like other Medicaid providers, we make pennies on the dollar for our care,” she said.

Since California reduced payments for “maintenance” cleanings for these patients — usually performed every three months to treat gum disease — many hygienists have stopped seeing them. Eight hygienists, including Aminloo, filed a lawsuit in Los Angeles County Superior Court in 2016, arguing that the health care services department cut the reimbursement rate without first obtaining necessary federal approval.

At one point, it appeared as if the department had agreed to settle and cancel its rate change but then backed out, court documents show. The department said it will not comment on pending litigation.

At the time of the rate reduction, the state also started requiring dental hygienists to obtain prior authorization to treat gum disease in patients who live in special care facilities. Hygienists must submit X-rays along with their authorization requests. But they say it’s almost impossible to take decent X-rays of elderly or disabled patients who have a hard time controlling their head movements, or who refuse to open their mouths widely.

When hygienists do manage to get X-rays, their requests are often denied anyway, hygienists from across the state told California Healthline.

In a letter to the state legislature last year, the California Dental Hygienists’ Association wrote that more than half of their authorization requests had been denied since the change. “Denti-Cal’s sweeping new rules are destroying the lives of fragile patients and the women who own small businesses providing care at the bedside,” the letter said.

But state statistics show a much lower denial rate.

From the time the change took effect in July 2016 through June 2017, the health care services department approved 10,000 of nearly 13,000 deep cleanings requested by these dental hygienists to treat gum infections, according to the data. It also approved 31,300 of the nearly 33,000 requests for routine cleanings that follow a deep cleaning. The state said it paid more than $2.5 million to dental hygienists for these procedures.

Darla Dale, a hygienist in Eureka and a vice president of , said the department’s denial numbers don’t reflect what her organization is seeing.

“There’s no way that’s true,” Dale said. “We’re in contact with these hygienists. … Many have stopped working because we can’t spend our lives trying to get authorization.”

Darci Trill, a hygienist working in Alameda and Contra Costa counties, is among those who stopped seeing patients in nursing homes after denial letters piled up. “I lost about 70 percent of my Denti-Cal clients,” she said.

State health officials pointed to the American Academy of Periodontology, which considers the new authorization guidelines standard, including X-rays to diagnose gum disease.

An by the Little Hoover Commission, an independent state watchdog agency, said the state health services department found it “unusual” that nearly 88,000 out of 100,000 Denti-Cal-eligible patients in nursing homes had received deep cleanings during the 2013-14 fiscal year. This figure and other factors raised “questions about their necessity ­— and hence the new policy requiring X-ray documentation,” the report said.

In frail patients, advanced gum disease can cause not only tooth loss, but pneumonia and other respiratory issues, Trill said.

Maureen Titus, a hygienist in the San Luis Obispo area, said her clients rely entirely on caregivers for their dental hygiene, and that brushing and flossing is neither easy nor effective. “Most have bleeding gums, inflamed gums and tartar buildup,” she said.

Among patients who are attached to feeding tubes, tartar builds up quickly because they don’t chew their food, Aminloo said. “After two or three months, you can’t even see their teeth.”

The independent practice of dental hygienists in California dates to 1997, when the state legislature allowed them, with additional training and certification, to work without the direct supervision of dentists. Some started their own mobile businesses. This is the first time in the intervening 20 years that they’ve had to obtain preauthorization to perform dental cleanings, Trill said.

, which represents dentists, said dentists have long been required to get prior approval for cleanings for patients in special care facilities.

“We supported the department’s decision to equalize requirements for periodontal services, regardless of whether a dentist or hygienist provides the service,” said Alicia Malaby, the association’s spokeswoman.

Dr. Leon Assael, the director of community-based education and practice at the University of California-San Francisco’s School of Dentistry, said preauthorization requirements in other states, including Minnesota and Kentucky, where he used to work, have also delayed or limited care for homebound patients.

The requirements have driven providers out of the system, he said, leaving patients behind.

“If this were toes being lost, this would be a scandal,” Assael said, “but with teeth, it’s been accepted.”

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Allen’s crying may be distressing, but his wide-open mouth allows Calvo to begin the exam. She counts his baby teeth and checks for dental decay.

“Nothing I am going to do will hurt him,” Calvo tells Allen’s mother, Maritza Barron, who is holding her son’s hands.

To some, the 20-month-old toddler may seem far too young for a dental exam. In fact, he’s on the late side, according to .

To stave off a lifetime of dental problems and make sure parents learn how to prevent children’s tooth decay, babies should have their first exam when they get their first tooth, or no later than their 1st birthday, according to from the American Academy of Pediatric Dentistry.

However, many dentists are uncomfortable treating babies, and that has created a significant gap in dental care for infants and toddlers of all backgrounds, experts say. The shortfall is hard to quantify because professional organizations, such as the American Dental Association, do not survey their members on whether they care for infants.

“People think that children are afraid of dentists, but really it’s that dentists are afraid of children,” said Pamela Alston, who is a dentist and dental director of the Oakland-based Eastmont Wellness Center, a publicly funded clinic that is part of the county-run Alameda Health System.

Hoping to narrow the gap in care, the public health agencies of San Francisco and Alameda counties are launching pilot programs to train dentists to treat babies. About 70 dentists will learn over the next three years how to coax infants into cooperating and help parents guard against tooth decay. The first training session in Alameda County is scheduled for early November; San Francisco will begin its training in January. The American Dental Association was not aware of any similar programs in other states.

The guidelines calling for earlier dental visits stemmed from a growing awareness that cavity-causing bacteria , through shared utensils, for example. Giving babies bottles of fruit juice or sugar water also can cause cavities. Decay in baby teeth has been linked to adult tooth decay.

“By the time children are age 3, they are often so far down the road that prevention is no longer an option,” said Ray Stewart, a pediatric dental professor at UCSF, who has treated infants for more than 15 years and is among the professionals enlisted by Alameda and San Francisco to train the dentists.

Dentists don’t regard exams of very young children as a means of boosting their income, said Alicia Malaby, spokeswoman for the California Dental Association. “Denti-Cal reimbursements are below actual costs for many procedures,” she said. Rather, they want to help “improve community health outcomes.”

Low-income children, who are and have to care than their affluent peers, present the greatest need for early oral exams, dental professionals say.

A portion of the revenue from California’s new tobacco tax will be earmarked to help very young children from low-income families get the dental care they need. The money will be used to give dentists a 40 percent increase on top of the standard reimbursement for services to Denti-Cal patients, including oral exams of children age 3 and under. Denti-Cal provides dental care to beneficiaries of Medi-Cal, California’s version of Medicaid.

Alameda County will offer dentists an extra $20, on top of that statewide increase for appointments with Denti-Cal-covered children that include a thorough exam of the baby’s mouth, a fluoride varnish if needed, a talk with parents about prevention and a demonstration of how to brush their baby’s teeth.

The Alameda and San Francisco training programs, funded by grants from Medi-Cal, could be replicated throughout California if they are successful, according to the Department of Health Care Services.

Maritza Barron came to UCSF after her own dentist — despite the best of intentions — was unable to examine her baby’s mouth. “He tried to say ‘open up’ to him but he wouldn’t do it,” Barron said of the failed attempt, which left her son in tears.

Alston, the Oakland dentist, once faced similar challenges treating very young children, but she has since undergone a transformation. She blames dentists’ wariness of young patients on a lack of experience. When she graduated from dental school in 1982, she said, she had no training that prepared her to work with children younger than 6.

“I didn’t feel like I could manage their behavior,” Alston said.

Over time, however, it became increasingly clear to her that she wasn’t seeing children early enough.

Almost all of the kids who came to her for their first dental visit at age 6 had mouths riddled with tooth decay, Alston said. She had to refer them to specialists for treatment that required sedation. She kept lowering the minimum age for a first visit in her practice, then left it at age 3 for a long time.

But even 3-year-olds were coming in with cavities. Ultimately, she learned how to treat infants and toddlers through a program run by Alameda County’s public health department — not unlike the training to be offered by the new pilot programs.

Today, Alston is passionate about treating very young children and has lined up pediatricians to refer infants to her. And she has revised her guidance on when kids should get their first oral exam, advising parents to bring their children in when their first tooth starts to erupt.

People think that children are afraid of dentists, but really it’s that dentists are afraid of children.

Pamela Alston, Eastmont Wellness Center

She also trains dental students to examine infants. An important trick she teaches them is how to avoid being bitten: “Put your finger behind the last tooth!”

Communicating directly with children during dental exams can help reduce their stress, saod both Alston and Stewart, the UCSF dental professor.

At a recent visit to UCSF’s Pediatric Dentistry Faculty Clinic, 18-month-old Sebastian King scrutinized the dental mirror Stewart handed to him.

“That’s what I’m going to put in your mouth to look at your teeth!” Stewart told him exuberantly.

He asked the young boy to show him where his mouth was. Sebastian smiled with delight as Stewart handed him a blue exam glove he’d blown up into a balloon, and the young boy remained calm throughout the exam.

Helping parents understand their role is also critical, dentists say.

In addition to advising parents not to share eating utensils with their children, Stewart urges them not to let their kids fall asleep with a bottle of milk and to limit their consumption of fruit juice. He also says they should wipe their infants’ gums and teeth with a cloth after feeding them to remove residue that can cause cavities.

That’s the message Calvo, the dental resident, gave to Barron, whose baby sat happily on his mother’s lap after his exam. The boy had cavities because he had been falling asleep with his bottle.

Barron said she recognized that weaning Allen from the bottle at night would be a challenge.

But “it’s really logical,” she told Calvo, adding that she was determined to give it a try.

This story was produced by , which publishes , an editorially independent service of the .

KHN’s coverage of children’s health care issues is supported in part by a grant from .

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The proposed legislation, mostly sponsored by Republicans, is among the first public bids for revenue from the statewide tobacco tax that voters approved in November.

The bill, introduced by Assemblyman Brian Maienschein, R-San Diego, would require the Department of Health Care Services, which oversees Denti-Cal, to boost pay for participating dentists. California’s reimbursements for these dentists have long been among the lowest in the nation, and they have not changed since 2001.

The bill would increase reimbursements for the 15 most common services for prevention and treatment, such as teeth cleaning and cavity filling. Rates would be increased to average commercial rates and would take effect in 2018.

California dental providers receive about a third of what their colleagues in other states get when treating Medicaid-eligible patients, according to an April by the state’s Little Hoover Commission, an independent oversight agency.

As a result, the shortage of dentists willing to take Denti-Cal has contributed to an “epidemic of tooth disease in which toddlers by the thousands have mouthfuls of cavities,” the report says. Denti-Cal, part of California’s Medi-Cal program, serves half of California’s children and about a third of adults.

The bill itself does not detail where additional funding for Denti-Cal would come from. But in a letter to Gov. Jerry Brown, Senate and Assembly Republican leaders said funding should come from proceeds of Prop. 56, the new statewide tax raising the price of a pack of cigarettes by $2.

The new tax “specifically provides new funding to address the shortage of dentists, prevent and treat dental diseases, and improve existing programs to provide quality healthcare and access to healthcare services for families and children,” wrote Assembly Republican Leader Chad Mayes, R-Yucca Valley and Senate Republican Leader Jean Fuller, R-Bakersfield.

One Democratic lawmaker, Sen. Toni Atkins, D-San Diego, is among the bill’s cosponsors.

The letter notes that the Legislative Analyst’s Office estimated the tobacco tax would bring in about $1 billion in revenue to the state. “These funds are clearly available to fix Denti-Cal,” the leaders wrote.

The state’s Department of Health Care Services declined comment on pending legislation.

According to the bill, the goal is to attract and keep more providers in the Denti-Cal program, which serves 13 million Californians. Low reimbursement rates have been noted as a big reason for the short supply of Denti-Cal providers across the state.

For instance, the Denti-Cal reimbursement payment to California dentists for an oral exam is about $15. This compares to the national average of $45.61 for the same exam, according to 2015 state data.

A found that only about 44 percent of children enrolled in Denti-Cal had seen a dentist in the previous year. The review also found that there were no Denti-Cal providers in five counties and in 11 other counties Denti-Cal providers were not accepting new patients.

Dentists who do take Denti-Cal patients are often inundated.

Dr. Santosh Sundaresan, the chair of community dental programs at the Herman Ostrow School of Dentistry at USC, said the prospect of higher pay is good news for both dentists and patients. When Denti-Cal providers have to see as many as 40 patients a day to sustain their business, at some point quality is compromised, he said.

“Increased rates make it more realistic for dentists to take care of the general population,” Sundaresan said. “I would like to see the scope of services [covered by Denti-Cal] expand, too. But one step at a time.”

Dr. Naina Bhoot, a dentist in Glendale, Calif., says the gaping need for dental services keeps her from cutting ties with the state program.

About half of her patients are covered through Denti-Cal. Her reimbursement for services rendered to these patients is about 25 percent of her usual service fee for patients with other coverage, she says.

Bhoot, who has been practicing for 27 years, said she has formed bonds with many of her patients, but she also needs an incentive and some reassurance that she can keep her practice afloat.

News that legislators are looking into the issue, she said, gives her some hope.

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