The accusations in the media and in lawsuits were shocking: Needlessly drilling into baby teeth. Filling children’s mouths with stainless-steel crowns they didn’t need. Strapping patients down on boards, so their writhing wouldn’t interfere with the pace of work — all so the company could soak up as many Medicaid dollars as possible.
“My baby was in pain. And she was 5,” one mother of a former patient told The Atlanta Journal-Constitution, describing a tooth extraction that she stopped mid-procedure. “Her ankles are strapped. Her arms are strapped. And she’s trying to move out of these restraints, and she’s just crying.”
But as allegations were swirling around the Marietta-based Kool Smiles chain of dental clinics, something peculiar happened at the highest level of Georgia state government.
One of the company's top officers got appointed to a state regulatory board with the power to discipline fellow practitioners and set policies for their profession. Out of the thousands of dentists working in Georgia, Gov. Nathan Deal appointed Dale G. Mayfield, a corporate executive for Kool Smiles, to the state Board of Dentistry.
Now, after the company recently agreed to settle a U.S. Justice Department lawsuit alleging Medicaid fraud for nearly $24 million, without admitting wrongdoing, the governor's office has clammed up about the February 2016 appointment. Deal's staff has repeatedly declined to answer the AJC's questions about who nominated or suggested Mayfield for the post, if anyone.
If any Deal staffers looked into Mayfield's background, his office won't say. Nor will it make anyone available who could explain the vetting process and whether Deal knew beforehand about the fraud case or about the myriad allegations circulating in news reports.
“They would have to know about that,” Thomas Eberhardt, a retired pediatric dentist from Cumming, said. “It’s just out there. The thing that gets me is that, I can’t believe that the board accepted him, that other members of the board didn’t rise up and say, ‘Hey, wait a minute. Do you understand this? We don’t need this kind of guy on here.’”
A few keystrokes on Google, or phone calls to other Georgia officials, would have been all it would take for the governor to be cautious.
Kool Smiles had once been ordered to return more than $190,000 in Medicaid funds to Georgia after the state Department of Community Health’s inspector general investigated allegations of unnecessary dental work, unusual patterns of patient restraint and other concerns. Other states’ concerns about the company had been publicized. Lawsuits had been filed and settled. Local TV news stations had run critical reports in Indiana, Virginia and even Atlanta, all available on YouTube. The U.S. Senate had issued a report calling for reforms in corporate dentistry after examining five chains, including Kool Smiles.
While the Justice Department's case was still under seal when Deal appointed Mayfield to the board, Georgia was a party to the complaint, along with seven other states, and a copy of the lawsuit had been provided to then-state Attorney General Sam Olens as early as 2013. The case was unsealed as the settlement with Kool Smiles and its parent company, Benevis, was announced. The companies admitted no wrongdoing, with Benevis saying it agreed to settle because of the time and expense of the case.
Mayfield, the chief dental officer for Kool Smiles, turned down an interview request for this story. When he resigned from the dental board in January, at Deal's urging, Kool Smiles released a statement from him saying that "given the distractions that might be caused by news of the voluntary settlement," it was best to step down.
But his appointment calls into question how Deal's office chooses and vets nominees for the 300-plus boards, commissions and authorities he's responsible for seating. One critic, in a 2017 online article for Concerned Dentists of Texas, called Mayfield's appointment "regulatory capture," where "the fox guards the henhouse."
“Governor Deal may have memory problems,” the article by New Mexico dentist and industry consultant Michael Davis said.
Strapped down, screaming
Carrissa Ma’at is among those wondering what the governor was thinking. Ma’at says that when she took her then-5-year-old daughter to a Kool Smiles clinic about two years ago, she got a look at the kinds of practices that drew the interest of government investigators.
She’d been taking her daughter there for years, since she’s on Medicaid and Kool Smiles is in their Amerigroup network. Then her daughter broke a tooth in half, either from biting into hard candy or an un-popped popcorn kernel.
The dentist said she would have to pull the tooth. Ma’at said she asked about laughing gas or putting her daughter to sleep, but the dentist told her they weren’t equipped for that, only to numb her gums. The mother said she saw the staff putting Velcro restraints on her daughter’s ankles and arms as she left the room.
Credit: REANN HUBER
Credit: REANN HUBER
About 10 minutes later, Ma’at said, she heard hysterical screaming. She recognized her daughter’s voice, and charged back to her daughter’s room.
“And I opened the door, and my baby has blood coming out of her mouth,” Ma’at said. “She’s crying. You see her choking – at this point I’m assuming she’s choking on her blood. The assistant was trying to calm my daughter, like, ‘Shh, shh, shh. It’s OK. It’s OK.’”
Ma’at said she used profanity as she pushed the dentist out of her way, pulled off the restraints, and pulled her daughter from the chair. A manager urged her to let her finish extracting the tooth, but Ma’at said she stormed out and has not returned.
Kool Smiles said in a statement that it can’t talk about a patient because of privacy laws, but that it has no record of Ma’at filing a complaint and that parents are welcome to accompany their children during procedures. The company also said its treatment protocols follow American Dental Association and American Academy of Pediatric Dentistry guidelines.
But Tara Schafer, chairwoman of pediatric dentistry for the Dental College of Georgia at Augusta University, said the scene described by the mother, if accurate, would be an unwarranted use of restraints on a child.
Restraints can traumatize children and cause them to fear dentists, Schafer said. In dentistry school, she said, dentists are taught to use them only in extreme situations — such as an emergency room procedure involving a child with severe facial injuries, or a child who is being heavily sedated where there’s a risk she could wake up and paw at a dentist’s instruments.
“For us, an emergency would be like excessive bleeding, or facial swelling, or difficulty breathing,” Schafer said. “Pain is not an emergency.”
According to the federal complaint, a Kool Smiles regional director encouraged dentists to use papoose boards — where children are wrapped cocoon-like in a series of straps — “to deliver treatment to young, reluctant patients instead of referring them to a pediatric dentist.” The federal complaint also cites Georgia’s concerns over restraints, but doesn’t detail what kinds of restraints those were.
Connecticut attorney James Brennan represented one of the whistleblowers in the federal case, former Kool Smiles dentist Michael Greenwald. Brennan told the AJC that his client once found a hair dryer in a supply cabinet and asked around to find out what it was for.
“What they were doing a lot of times is, the kids would be so upset during something, they’d wet themselves,” Brennan said. “And he said they would use the hair dryer to dry them off, dry off their pants.”
The stories were out there
Gov. Deal called for Mayfield to quit the board in late January after the AJC inquired about his position. The newspaper then spent weeks seeking answers about how he came to be appointed in the first place. The only response from the governor's office has been releasing 14 pages of documents, requested under the state open records act, containing Mayfield's application for the post and Deal's formal orders appointing him.
The application asked Mayfield if he’d ever been investigated, reprimanded, or fined by a state or federal agency. He checked yes and disclosed complaints against his licenses in Indiana and Washington, alleging that he directed dentists to do medically unnecessary procedures. These were false accusations, he wrote, and neither led to any disciplinary actions.
“Are you aware of anything about your past which, if disclosed, would be embarrassing for the Governor?” the application asked.
Mayfield checked no.
His application did not note the earlier Georgia Department of Community Health investigation of the company. Kool Smiles, in a written statement, says it has no knowledge of an investigation but rather an audit of 18 dentists over billing problems such as lost X-ray films and signatures in the wrong place.
According to Kool Smiles, the audit covered a period before Mayfield’s start date with the company. (The company’s website recently changed the start date given in Mayfield’s bio from 2006 to 2007.)
However, the case was hashed out and resolved well into his tenure. According to a 2007 DCH news release, its investigation also involved unnecessary services, unusual patterns of patient restraint and over-use of stainless steel crowns.
The case ended with DCH recouping $193,508 in overpayments. “Kool Smiles disagreed with DCH’s findings,” a company statement said, “but agreed to reimburse the Medicaid program to avoid the time and expense of litigation.”
There was more that Deal’s staff could have found out by scouring the web.
In 2010, Connecticut's Department of Social Services had admonished the company for "malpractice" after a review of multiple root canals and stainless steel crown fittings. The state said the company failed to protect children from physical and mental harm and demanded a corrective action plan.
In 2015, Kool Smiles settled a Texas lawsuit with the parents of 618 children. The case alleged painful, unnecessary work such as root canals without sedation and strapping children to papoose boards. The parents' attorney, George Mauze of San Antonio, said he couldn't discuss the case because of a confidential settlement.
The Georgia Dental Association, which lobbies for Georgia dentists, said in an email that it doesn’t know how Deal’s office vets his Board of Dentistry appointees. Though state law sets up a system where the Dental Association nominates dentists for the governor to select from, it’s an optional system, and the association said Deal has only picked one of its nominees since taking office.
Mayfield had not donated to Deal’s campaigns, nor had Kool Smiles. While Mayfield, like others appointed to state boards, had a background check by the Georgia Bureau of Investigation, it only covers such things as criminal and driving records, credit history and tax liabilities.
Dental board member Rebecca Bynum, a dental hygienist in Valdosta, said she doesn’t know how Mayfield came to be chosen. She said she only knew him as a colleague, and she didn’t know the allegations against his company.
“We deal with individuals, not companies,” she said. “I was shocked to see the article that the governor had asked him to resign.”
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