LAFAYETTE, La. - The cane fields and the bayous of Louisiana's Cajun heartland whir past the pickup's cracked windshield. Gregory Folse is at the wheel. He wears green scrubs. His dental instruments and a grinding tool he uses to repair dentures are stowed behind the seat.
Most of his 1,800 patients are too fragile to go out for dental appointments or denture fittings, so he goes to them, riding a circuit of eight parishes. He visits them in nursing homes and isolated residences, traveling 40,000 to 50,000 miles a year.
They represent a cross section of the region's elderly, poor, and disabled: Cajun fishermen, retired farmers and oil field workers, younger people crippled by illness or trauma, and frail Hurricane Katrina nursing home evacuees. Many have not had an oral exam for years, and when Folse looks into their mouths he often finds the ravages of neglect.
Studies show that the old, frail, and poor have the worst dental conditions of anyone in the country. Most of those who had dental insurance during their working lives lost it when they retired.
Medicare, the national health insurance program for senior citizens, does not cover routine oral health or dental services. Private dental insurance is limited and too costly for many. And the price of dental care can overwhelm people on fixed incomes: A pair of dentures can cost hundreds, sometimes thousands, of dollars.
Most of Folse's patients are on Medicaid, the public healthcare program for the poor, which offers few dental benefits.
Even in states that subsidize some care, there is a shortage of dentists who will treat seniors and the homebound and who are willing to accept Medicaid, with its complexities and low reimbursement rates.
In Louisiana, for instance, fewer than 50 of about 2,000 dentists provide dentures, said Ward Blackwell, executive director of the Louisiana Dental Association. Fewer than five attempt to meet the broader oral healthcare needs of the frail and old in nursing homes.
Folse estimates that he donates more services than he bills to Medicaid. But he draws deep satisfaction from his work - and sometimes a sack of crawfish along the way.
During a recent trip to Abbeville, Folse pulled up to a little house with crawfish traps stacked out front. He was there to adjust Elaine Sherman's dentures.
At the River Oaks Retirement Manor in Lafayette, southwest of Baton Rouge, he checked the chart of a 74-year-old man who suffers from dementia and is delusional. Sometimes such appointments "can get pretty wild," Folse says.
But he thinks that everything, not just dental school, but also his years as a cowboy and his experience riding along with his country doctor grandfather, Phillip Robichaux, prepared him for this work.
A nurse gently but firmly brings the patient. His gum disease is advanced, and some of his teeth are so loose he could swallow them or inhale them. A timely $100 extraction can save $50,000 worth of surgery, hospitalization, and complications.
The nursing homes on Folse's circuit pay him a monthly stipend of $6 a patient. He serves as their medical director. With an office manager who keeps track of the caseload and a young part-time dentist and hygienist, Folse provides exams, responds to emergencies, and tries to meet the overwhelming need he sees.
After graduating from dental school, Folse worked in an office with healthy patients. But he started visiting nursing homes on his day off. He was overwhelmed by what he saw and how he felt treating the frail, the deranged, the forgotten, the truly grateful.
He thought, "This is really what I want to do."
"I help them as best I can - with funding, without funding," Folse said. "The family pays some, the nursing homes. Sometimes no one pays. It doesn't matter. I do it."
The rewards are often intangible.
"I had a patient in a wheelchair. She had a stroke. She was so happy to get her dentures. She reached down and grabbed her purse. She reached inside. She found a piece of bread. " 'Here, doc,' she said. 'Take it.' "
"We have to give out of being wealthy," Folse said. "She gave to me out of her poverty."
