Profit Over Patient? Small Smiles Accused of Mistreating Children

Nov. 7, 2007 — -- The national dental chain Small Smiles is facing allegations it allowed its smallest patients to suffer in order to turn a profit.

Small Smiles dental clinics treat some of the nation's poorest children. But, a five-month investigation by ABC News' Washington D.C. affiliate WJLA and investigative correspondent Roberta Baskin uncovered frightened children who were separated from their parents and cried for their mothers while they were strapped into restraining devices.

The restraint procedure is just one way Small Smiles does business. The clinics do business that most dentists won't handle — treating children on Medicaid. The government reimburses less for dental care than private insurance, but Small Smiles makes up for that by seeing a large volume of patients.

"We've submitted so many claims to one particular management care organization that they threw up the white flag and said, 'OK, you don't have to pre-authorize anything. Just do the work.' So, we flooded the system," said Aldred Williams who manages a Small Smiles clinic.

Patient Care

Four-year-old Miguel is one of the patients Small Smiles has treated. During his visit, a dentist restrained him on a device called a papoose board. Miguel's mother was not allowed to watch because that is the policy at Small Smiles.

"[It's]not that we are doing anything wrong, but as a parent you wouldn't want to see your child strapped up like that," said Williams.

Williams said he used the board on small children about half of the time.

"You could potentially spend two hours on a kid who's not stabilized and moving around. That's not cost productive for us," Williams said.

But the restraints weren't the only disturbing thing about patients' treatments. The dentist treating Miguel pinched his nostrils in order to force his mouth open. It's a practice most dentists abandoned years ago.

And even Williams said the pinching treatment was not acceptable.

"I don't personally use it, but some dentists do," he added.

The Company's Response

FORBA, the company that owns Small Smiles, said its dentists and staff are sent to its Colorado offices for training.

"We take very seriously any allegations, which call into question our commitment to deliver quality care," FORBA chairman and CEO Michael Lindley said in a statement. "On Oct. 3, we launched an internal investigation into the allegations at the Langley Park, Md., and Washington, D.C., centers. The story does not accurately reflect the facts and our responsible approach to patient care."

Yet of the 63 Small Smiles clinics across the country, with nearly three new ones opening a month, none of the ones in Maryland, Virginia or Washington, D.C., had a single trained pediatric dentist on staff.

The company's television advertisements promise, "Our trained professionals make kids feel safe and comfortable," but at least one former employee said she was fired for objecting to the way the clinic handled children.

Former Small Smiles dental assistant, Deborah McDaniel, said she was fired for objecting to the way children were being handled.

"They wanted us to tell parents that they needed services on teeth that were healthy," McDaniel said. "They were healthy and they didn't need it."

The clinic even has a bonus system for converting patients from a checkup to a major procedure on the same day.

"It's a competition throughout the country to see who can convert the most patients, not give the patients the most care," said Trina Crosby, another former Small Smiles employee.

The pressure to convert patients may come from FORBA. In fact, every morning Williams and his staff review the production goals set by the managers in Colorado.

One Maryland dentist said he worried Small Smiles performs unnecessary baby root canals when simple fillings would work.

"It does no good for anybody but the dentist, I guess, who's looking for a bonus," said Robert Camps, a nationally recognized authority on pediatric dentistry whose Maryland practice serves mostly patients on Medicaid.

Small Smiles detractors said the way the clinic handles its business may be traumatic for its young patients.

"They're sweating. Sometimes they urinate on themselves. They'll throw up," Crosby said.

When Camps saw video of Miguel's dental visit, he was disturbed deeply.

"It's traumatic for me to watch. I can only imagine how traumatic it is for Miguel," he said..

But despite the assembly-line feel at Small Smiles, Williams insisted it's providing a vital service to children who often don't get regular checkups.

"We aggressively treat these children to eliminate disease in their mouth. Small Smiles makes no apologies for that. I'm not going apologize for being aggressive," Williams said.