Small Smiles defies traditional system - Low-income children haven't been welcome at most dental practices in the region, at least not without tight restrictions

Dentists suffer with a toothache of sorts over treating patients on government programs. The reimbursement is low, and the hassle is often high. Dentists prefer patients with private insurance or cash, on whom a stable, profitable practice can be built.

But a new Roanoke dental clinic has turned the standard business model on its head.

Four dentists courting the business of low-income children in Western Virginia have opened a practice at Crossroads Mall. Small Smiles caters to children age 20 and younger enrolled in any of the state's health insurance programs: Medicaid, FAMIS and FAMIS Plus. Low-income means people at or below 200 percent of the poverty level, which is $40,000 for a family of four.

It has drawn a huge response, with 2,100 patients booked for appointments before it opened July 31, drawn only by TV commercials and a postcard mailing.

"I think it's going to be successful," said dentist David Jones, who closed his private Roanoke practice to work at Small Smiles. There's so much work, "we could probably keep another clinic like this one afloat."

If the niche sounds unusual, it is: Low-income children haven't been welcome at most dental practices across the region -- at least not without restrictions that close access to new patients when the dentist feels he or she can no longer afford to treat any more.

But last year, Virginia lawmakers intervened. They increased reimbursement for dentists who treat Medicaid-insured children and chopped away red tape for both patient and dentist. Attention was directed at reducing missed appointments; people on Medicaid and related programs miss up to 50 percent of scheduled dental appointments.

National companies that cater to those on government programs have been setting up shop in Virginia. The Small Smiles group, from Pueblo, Colo., has opened 46 practices across the country, including in Roanoke and Richmond. A similar enterprise, Kool Smiles, based in Decatur, Ga., has 17 sites nationwide, including four in Virginia, its Web site said.

"We have a business model that works because this is all we do five days a week, 12 months of the year," said Todd Cruse, speaking for Small Smiles in Roanoke. "We typically average somewhere around 72 to 75 patients a day."

Cruse is chief development officer at FORBA LLC, a dental practice management company in Pueblo, Colo. FORBA manages the Roanoke practice for its owner, Colorado dentist Robert Andrus.

Terry Dickinson, executive director of the Virginia Dental Association, was wary when he first heard that a for-proft, corporate dental practice focused on the poor was preparing to operate in Richmond this past spring.

It appeared to be a low-margin business dependent on moving a high volume of patients through, Dickinson said. Might Small Smiles be a "mill" providing the least acceptable care, Dickinson wondered.

So he met with Small Smiles officials. "We made it clear if they chose to come into the state that we would have our eyes on their operation," Dickinson said. Company officials pledged to give quality care and invited state dental industry leaders to drop by unannounced.

Now that the Richmond practice has been up and running for several months, Dickinson is satisfied that Small Smiles is meeting the needs of Virginians, he said, adding there haven't been any patient complaints to his association.

"We are very pleased with what they're doing," Dickinson said.