ST. LOUIS -- For the past two years, Missouri budget-makers have said dental and prescription eyeglass care for poor adults is expendable, an optional health benefit the state Medicaid program could no longer afford.

But Betty Brent and other poor Missourians maintain it's a service they can't do without. They successfully sued the state to win back the services they say they're entitled to.

"It's very important. I'd be messed up," said Brent, 46, of St. Louis, who suffers from multiple sclerosis. Brent has relied on Medicaid-reimbursed services for tooth infections and pain, cavities and extractions.

She's typical of patients that a relative handful of Missouri dentists serve all the time -- poor, in urgent need of dental care and with nowhere else to go. Without a judge's ruling in their favor Sept. 29, the state's poor would have had even fewer outlets for care.

"It's medically necessary. It is a vital service," said Archie Griffin, president and CEO of the nonprofit Myrtle Hilliard Davis Comprehensive Health Centers Inc. in St. Louis.

"It's something the state should cover ..." Medicaid patients are "at the bottom of the health stratosphere."

Medicaid, a federal and state entitlement program, pays for medical services for America's poorest people.

Ruling in two separate lawsuits, St. Louis Circuit Judge Steven Ohmer said the Missouri Department of Social Services violated state law when it ended free dental and prescription eyeglass coverage for hundreds of thousands of poor Missourians on Medicaid.

Preliminary injunctions last August and in February restored the two services. Ohmer's rulings make those injunctions permanent.

Plaintiffs had argued that Missouri law entitles Medicaid-eligible adults to those services. Ohmer agreed they can't be eliminated short of enacting a law taking away the entitlement. The state has tried.

Few dentists take Medicaid

A failed bill introduced by Sen. Wayne Goode, D-St. Louis, for Gov. Bob Holden last session would have given the state flexibility in prioritizing Medicaid expenditures in difficult economic times. He said dental and prescription eyeglass coverage is above and beyond basic care the state is obligated to provide.

Pamela Victor, deputy director of the state's Division of Medical Services, said the services are medically necessary. But she predicted that every Medicaid program will be reevaluated in the upcoming legislative session. "Tough choices are being made," she said. "They hurt."

Just having Medicaid entitlement doesn't make finding a dentist any easier.

About 600 dentists in Missouri see Medicaid patients, but fewer than 250 see any in substantial numbers. Fewer than 10 serve Medicaid patients exclusively, according to the Missouri Dental Association.

That's because there's little to motivate them except altruism. Reimbursement is less than half the actual cost. Payment is often months late, and some claims are rejected. The income doesn't cover most dentists' high overhead.

Lippert won a commitment from former Gov. Mel Carnahan to raise reimbursements gradually, but the state's economic crisis halted that.

If the state ever does eliminate the dental care entitlement, Lippert said, people will seek relief in pain medicine and antibiotics from hospital emergency rooms, a far more expensive alternative.

"We're willing to pay a hospital visit for a Band-Aid, but we won't pay for them to go to the dentist," Lippert said. "My contention is the state is turning these people into drug addicts."

Barnes-Jewish Hospital in St. Louis said a combination of antibiotics, pain medicine and a referral to discounted dental services is its most common approach to Medicaid walk-ins with toothaches. "But unfortunately, they're overloaded," said Barb Quick, patient care director. "It takes months to get an appointment."

Just before Missouri suspended Medicaid dental care last year, patients thronged to clinics for last-minute extractions, fillings and crowns. The crowd was so large at Cass Avenue Dental Group, the lawsuit said, police were called to maintain order.

"Dental care could mean the difference between welfare and a job for a 25-year-old woman with a couple of kids, or glasses for an 80-year-old woman who can't play bingo or see her food," said John Ammann, an attorney in the lawsuit, and director of Saint Louis University's law clinic.

"We don't want to spend $100 every couple of years for her glasses, but we'll give $40 million to build a new stadium. It's kind of crazy."