On Wednesday, 8-year-old Evelin Cobarrubias from Modesto went for her six-month dental checkup at Golden Valley Health Center’s dental clinic at Hanshaw Middle School.
Good news — no new cavities!
Evelin’s smile beamed with the news — just six months ago she needed oral surgery to remove a decayed tooth. She has also needed fillings in six of her 20 primary teeth.
Teresa Medina, her mother, said through a Spanish interpreter that Evelin’s first visit to a dentist was when she was 7, because it was needed for school.
California law requires children to have an oral health assessment for entering kindergarten. But, by age 5, it may be too late.
By kindergarten, 50% of California kids have tooth decay and nearly 1 in 5 have severe decay, according to the California Dental Association.
“Parents were waiving due to financial limitations or because they couldn’t get into see a dentist,” said Sharrie Sprouse, referring to the required kindergarten assessments. Sprouse is the coordinator for the oral health program for Stanislaus County Health Services Agency. She also said only two-thirds of assessments were completed and of those, 24% of the kids had caries, or decaying of the tooth and bone. About 9,350 children were enrolled in public kindergarten in 2016.
Although smiling is important, dental health for kids is more than pretty teeth.
Dental disease is the No. 1 chronic condition in children, surpassing asthma, obesity and allergies. Oral health affects a child’s physical health, language development and self-confidence. In addition, poor oral health may increase the risk for diabetes, obesity and cardiovascular disease in adulthood. Untreated caries is painful and can lead to facial infections, dental emergencies and hospitalizations.
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In California, poor children and Latino children have the highest rates of decay and unmet dental needs. Compared to 1% of all California children, more than 4% of Stanislaus kids went to the ER for dental care last year — that’s almost 6,000 ER visits.
The burden of dental problems in the United States is expensive, costing more than $124 billion annually. The need for many of the costly treatments, such as tooth extractions, root canals, ER visits and treatment of oral infections, could be avoided with routine preventive dental care.
Unfortunately, many low-income kids don’t have access to preventive care.
The rates of dental disease for toddlers and preschool children has not declined in the past decade, despite notable decreases for older children. Still, California kids miss 874,000 school days each year due to dental problems — costing school districts about $41 million in funding.
“It prevents them from missing school and prevents them from going to the emergency room” said Michael Wu, GVCH dentist, when talking about school-based dental clinics. GVCH operates three school-based dental clinics in the area.
In 2018, the Stanislaus County oral health program completed an inventory looking at the dental needs and resources in the county. This was supported through Proposition 56, which gets money from a voter-approved tax on tobacco products. The goal is to improve oral health of Californians through operations in local communities. Improving early childhood oral health is one of the priorities.
The inventory showed that the county doesn’t have enough dentists to meet the demands. There is 1 dentist for every 1,640 residents, which is much fewer than the national average of 1 dentist for every 1,280 people and the 1 to every 1,210 ratio for California overall.
Of the 442 dentists in the county, only 10% accept Medi-Cal Dental insurance, California’s Medicaid insurance for low-income people. This is compared to the statewide rate of 15%. Almost half of the 147,000 kids younger than 21 in the county have Medi-Cal or Child Health Insurance Program, CHIP.
“Our disease burden is great,” said Heather Duvall, a health services manager at the county Health Service Agency. “We’re thrilled to have Prop. 56 funds to help our county.”
Fluoride - A missing piece in prevention
Fluoridation has proven to decrease decay across the lifespan, prevent the need for dentures in later life and save money. For every $1 spent, $32 is saved in dental treatments, according to the Centers for Disease Control and Prevention.
Modesto and many area communities do not fluoridate their public water. In 2001, Modesto City Council was in favor of fluoridating the water but were concerned about the expense (about $10 per household per year). It was placed on the ballot and defeated — cost was the main reason cited for no votes. Fluoridation has not been discussed by the council since.
Also, some local water sources are considered unsafe to drink, leading to high use of bottle water, which is usually not fluoridated. Only two-thirds of Californians have public fluoridated water.
Opponents argue that fluoride poses a health risk, despite CDC research negating these claims. Others express concern that there’s a risk for fluoride toxicity and people get enough fluoride from toothpaste. However, fluoride in toothpaste alone is not sufficient for strengthening teeth.
In reality, many of the children at highest risk for decay do not practice routine brushing, nor do they have regular dental visits.
Jasmine Serrano, mother of 2-year-old Leandro Serrano, knows about the importance of fluoride for her son’s baby teeth. “His pediatrician prescribed vitamin drops with fluoride and she gave him a fluoride treatment in her office,” said Serrano. Leandro loves to brush his teeth, but he has not seen a dentist.
“We recommend children as young as 1 year old come in,” said Wu. Parents don’t know kids need oral health care long before they have teeth, according to pediatric experts. Education about how to clean a baby’s gums, not having them sleep with a bottle and avoiding sugary drinks are all part of a dental visit for infants and toddlers.
What can be done to promote oral health for children?
Multiple factors contribute to the poor oral health of children in the area. So, solutions also will need to come from many levels, including individuals and systems.
Parents, especially mothers, need good oral hygiene. They’re one of the prime indicators of a child’s oral health. One reason is cavity-causing mouth bacteria can be spread from parents to kids. Pregnant women have higher risk for gum and tooth disease, which may cause health problems for them and their infants, including preterm birth. Also, parents are the first teachers of good oral hygiene practices, such as tooth brushing and flossing. Adults are encouraged to stop using tobacco products, as their use contributes to caries and increases the risk of oral cancers.
At systems level — the state government is making changes to improve the oral health of Californians. In 2014, the legislature approved funding to establish an oral health program within the state Department of Public Health. One of the top priorities is education for the public about oral health care across the lifespan. Government agencies are looking at ways to expand the dental workforce. Prop. 56 also permits some financial incentives to entice dentists to accept Medi-Cal Dental patients.
At a local government level, it may be time to revisit the CDC recommendation to fluoridate public water sources, a proven and cost-effective preventive measure.
“Our overarching goals are the three P’s — protect, prevent and promote,” said Sprouse.
The next steps for the county program include promoting public awareness, counseling about healthy diet, limiting sugary drink consumption and tobacco cessation, increasing use of dental sealants, involving primary care medical providers in dental care and finding ways to deliver dental care where people are. School-based clinics are an example of easier access for kids.
Evelin and her mother have learned the value of preventive dental care. She now brushes her teeth twice a day and has regular dental visits every six months - and an irresistible smile.
This story was produced with financial support from The Stanislaus County Office of Education and the Stanislaus Community Foundation, along with the GroundTruth Project’s Report for America initiative. The Modesto Bee maintains full editorial control of this work.
Obstacles to Dental Care
Even with insurance, three main obstacles keep the kids from having healthy teeth:
- Few children have access to preventive measures, such as sealants and fluoridation
- Some local communities don’t have enough dentists
- Not enough dentists accept Medi-Cal Dental, in part because payments have been low
Resources for Parents
1. To find out if your water has fluoride, visit: https://www.waterboards.ca.gov/drinking_water/certlic/drinkingwater/Fluoridation.html
2. For tips from American Association of Pediatric Dentists to care for oral health of infants and toddlers, visit: https://www.aapd.org/assets/1/7/FastFacts.pdf
3. For information about Stanislaus County Oral Health Program, visit: http://www.schsa.org/PublicHealth/