Children's Oral Health-

Preventable disease causes pain and suffering for Sonoma County children

Thousands of children in Sonoma County suffer from tooth decay, pain, and infection that can cause eating, learning and speech problems.

The cause is oral disease, which involves not only the teeth, but also the gums, palate, tongue, the inside of the cheeks, bones and other structures that support the teeth. By the age of 8, approximately 52% of children have decayed teeth, and by the age of 17, decay affects 78% of children.

Oral disease is entirely preventable. However thousands of children in our community do not receive regular care from a dentist or fluoride supplements, either because their families cannot afford it or because there are no dentists that accept their insurance, or because their parents do not know how to prevent oral disease.

The Facts About Children's Oral Health in Sonoma County

While there is little comprehensive data collected on children's oral health, what is available suggests that many Sonoma County children are suffering:

Dental problems are seen in a high percentage of poor children. In one low-income elementary school, the St. Joseph Mobile Dental Screening and Sealant Program found that over 50% of the children screened had either emergency or urgent dental needs.

Parents and teachers rank dental care as the number one health problem for children. Parents in recent surveys in the greater Petaluma area and parents and teachers in West Santa Rosa listed dental problems as their top priority or concern.2, 3

There are not enough dental services for children. Four clinics, with approximat-ely 10 dental chairs and a handful of private dentists (none are pediatric dentists), provide the majority of services to about 32,000 low-income children in Sonoma County. Due to the high volume of patients, children in some parts of the county must wait longer than three months for an appointment or travel out of the area.

Sonoma County children are at a high risk for dental disease because Sonoma County water is not fluoridated. Sonoma County has not achieved the Healthy People 2000 goal of fluoridating 75% of community water supplies. Currently, only the City of Healdsburg fluoridates its drinking water. As a result, Sonoma County children need to supplement the fluoride they are missing in the water through drops, pills, rinses and dental applications.

Dental disease is the most commonly documented new health problem in Sonoma County according to the Child Health and Disability Prevention Program (CHDP). In 1998 and 1999 more than 4,600 dental conditions-37% of all health problems-were identified in the children screened by CHDP.

Few oral health services exist for children with special care needs. Children with special needs such as mental health issues, develop-mental disabilities and physical handicaps are likely to go without proper dental care as many dentists will not accept them as patients. Sonoma County has only ten pediatric dentists and few other dentists with training in the care of these children.

How Does Oral Disease Affect Young Children?

I see severely decayed mouths-young children who can't eat or sleep-children with active infections that can be life threatening.

Dr. Elizabeth Van Tassell, DDS
Private Dentist

Early Childhood Caries (ECC) better known as "baby bottle tooth decay," is one of the most common diseases affecting infants and young children. It is a distinctive pattern of severe tooth decay present in an estimated 5 to 10 percent of preschool-age children.

ECC occurs when a child's teeth are exposed to sugary liquids, such as formula, fruit juices, soft drinks, and other sweetened liquids for a continuous, extended period of time. The practice of putting a baby in bed with a bottle, which the baby can suck on for hours, is the major cause of this dental condition.

To prevent ECC, parents should hold their children for feedings and introduce children to a cup (when they are sitting up) as they approach one year of age. Children should stop drinking from a bottle soon after their first birthday.

ECC is now recognized as essentially an infectious disease. Unlike other infectious diseases, tooth decay is not self-limiting. Decayed teeth require professional treatment to remove infection and restore tooth function.

What are the 5 Barriers to Oral Health Care for Children?

1. Parents do not understand the importance of dental care.

Many parents do not understand the importance of regular dental visits, cleanings, daily fluoride and brushing. Studies show that parents with limited education (fewer than 12 years of school) are less likely to take their children to the dentist regularly and less likely to follow prevention regimens, such as regular brushing with fluoride toothpaste, fluoride supplements, flossing, etc.

Families who lack dental insurance are less likely to receive routine care that can correct problems before they become serious. More than 25 percent of California's preschool and elementary school children and more than 40 percent of high school students have no dental insurance.

Parents may delay care until their children are older or in pain, missing critical opportunities to keep them disease-free because they recall their own negative dental experiences or don't understand the importance of healthy primary teeth in children.

2. Problems with insurance affect many families.

Even families who have private dental insurance, sometimes offered through a parent's employer, often face problems such as long waits for preventive care, large co-pays, limited coverage, and difficulty finding approved providers in small towns and rural areas.

Families who have medical insurance but no dental insurance are not eligible for just dental insurance through Healthy Families, even though they meet the income criteria.

3. Many dental health providers fail to accommodate the underserved population.

Although children may be covered by dental insurance, most Sonoma County dentists choose not to accept government sponsored insurances such as Healthy Families or Denti-Cal. In 1995, fewer than one in five children in the U.S. who were eligible for dental services under Medicaid (called Denti-Cal in California) received a preventive dental service.

Some children may not receive care because few dentists see patients in the evenings or on weekends and parents cannot miss work to go to weekday appointments.

There is a need for greater cultural competency and sensitivity to the special needs of at-risk populations (families with low incomes, children in minority groups, and children with special health needs).

4. Culture can affect a family's decisions about oral health.

Not all ethnic groups or cultures accept "mainstream" beliefs about oral health, or practice "mainstream" preventive dental practices. Symptoms of disease may be viewed as normal and some families perceive preventive dentistry as unnecessary.

There is a shortage of health providers from the many diverse cultural groups represented in Sonoma County.

5. Publicly funded dental services for low-income children are drastically under-funded.

In the United States, 30 percent of all children's health expenditures are devoted to children's dental care-however only 2.4 percent of Medicaid children's health care costs are spent on oral health services.

Recently there have been moderate improvements in reimbursement rates and administrative requirements for Denti-Cal. However, reimbursement rates to dental providers are still not sufficient to cover the cost of care or to attract new providers.

How do Low-Income Families Obtain Dental Care for Their Children?

Insurance programs are available for families that meet certain eligibility requirements:

Denti-Cal Denti-Cal is the dental component to Medi-Cal, which is California's program that provides health care services to low-income individuals. In Sonoma County, a total of 13,345 children under the age of 19 were enrolled in Medi-Cal as of April 2000. Sonoma County Health professionals and community groups are trying to reach the estimated 2,000 to 3,000 children who are not enrolled but are eligible for Medi-Cal.

Healthy Families Program (HFP) HFP offers comprehensive health benefits that include dental care, vision care, immunizations, and regular preventive health care services for children under age 19, who are eligible. Family incomes must not exceed 250 percent of the Federal Poverty Level. Low monthly premiums are based on income, with minimal co-payments for a few services. As of November 2000, there were 4,420 children enrolled in Sonoma County. Many more are eligible but not yet enrolled.

CaliforniaKids CaliforniaKids is a health insurance program for low-income children not eligible for Medi-Cal or Healthy Families. It offers basic dental insurance but many services are not covered. Currently about 1,200 children are covered by this insurance sponsored by St. Joseph Health System and CaliforniaKids Healthcare Foundation.

Children's Treatment Program This program pays for services for children who receive a Child Health and Disability Prevention Program (CHDP) health assessment screening and have no other way to pay for treatment when a new health condition is found.

Call 1-800-427-8982 for more information about eligibility for these health insurances.

What Can Parents and Caregivers do to Promote Oral Health as Kids Grow?

If you are pregnant, get prenatal care and eat a healthy diet that includes folic acid to prevent neural tube defects and possibly cleft lip/palate. During pregnancy see a dentist and care for your teeth and gums, avoid tobacco and alcohol, and check with a doctor before taking any medications.

Put only water in your baby's bottle if one is needed at bedtime or nap-time. Milk, formula, juices, soft drinks and other drinks contain sugar. Prolonged exposure to sugary drinks while baby sleeps-when saliva flow is reduced-increases the risk of tooth decay.

Clean your infant's teeth with a soft brush or cloth beginning with the eruption of the first tooth. Ask your dentist when to bring your child for an oral health assessment.

Protect your child's teeth with fluoride. Use fluoridated toothpaste, putting only a pea-sized amount on your child's toothbrush. If your drinking water is not fluoridated, talk to a dentist or physician about effective use of fluoride supplements.

Encourage your children to eat regular nutritious meals and to avoid frequent between-meal snacking especially with sugary or sticky foods.

Talk to your child's dentist about dental sealants, which protect teeth from decay. Dental sealants are transparent or tooth-colored, plastic-like coatings that cover the pits and grooves that harbor decay-causing bacteria. Sealants are safe, painless and take only a few minutes to apply.

Make sure your child wears a helmet when bicycling and uses protective headgear and mouth guards in other sports activities.

Tell your children that smokeless tobacco can cause cancer and that smoking will give them bad breath, yellow teeth, and greater chance of mouth sores.

For more information, contact: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Oral Health, 1-887-CDC-2020 or http://www.cdc.gov

How Does Tobacco Use Affect Adolescent Oral Health?

Smokeless tobacco can cause cancer and a number of non-cancerous oral conditions and can lead to nicotine addiction and dependence. According to the National Cancer Institute, the dangers of smokeless tobacco include tooth decay, gum damage, lost teeth, mouth lesions and sores and mouth cancer. The Centers for Disease Control and Prevention's National Youth Risk Behavior Survey reports that 15.8% of male high school students currently use chewing tobacco or snuff.

Dentists and other health professionals can be effective in educating the public about the risks associated with using tobacco:

• Advise tobacco-using adolescent patients about quitting
• Feature "no-tobacco-use" messages in waiting rooms
• Speak at school assemblies
• Distribute media messages that highlight the link between tobacco use and oral disease

A Tobacco Control Mini-Grant from the County of Sonoma Department of Health Services supports the tobacco control component of this campaign.

Two Reports Focus Attention on Children's Oral Health

The Oral Health of California's Children: Halting a Neglected Epidemic

A report from the Dental Health Advisory Committee convened by the California Dental Health Foundation (2000) calls for communities to:

• Expand access to community water fluoridation.
• Improve access to dental care.
• Expand school-and community-based dental programs.
• Expand efforts to prevent tooth decay in very young children.
• Involve the dental profession in programs to prevent children's use of tobacco.

Oral Health in America: A Report of the Surgeon General of the United States

The intent of the first-ever Surgeon General's Report on Oral Health (2000) is to alert Americans to the importance of oral health and its relationship to general health and well-being:

• Oral diseases and conditions affect health and well-being throughout an individual's life.
• Safe and effective measures exist for preventing the most common oral health diseases.
• Not all members of society are informed about or able to use appropriate oral health promoting behaviors.
• The mouth provides a "window" on general health status.
• Scientific research is needed to further reduce diseases affecting oral health.

Family Action joins the Dental Health Foundation and the Surgeon General in a call to action on behalf of children's oral health.

You can be an advocate for children:

• Support fluoridation of the water supply.
• Tell your elected officials that oral health should be included in publicly funded health programs.
• Speak out regarding the need for parent education about oral health.
• Encourage the media to write about oral health.
• Ask your school to include oral health education for students and parents.
• Join Family Action as we campaign to improve oral health outcomes for children in Sonoma County.

Community-wide Planning for Children

Family Action and St. Joseph Health System brought together more than 40 different individuals concerned about children's oral health to set outcomes and indicators of good oral health. This group has begun planning to improve the oral health of Sonoma County children.

Outcomes are what we collectively desire for our children.

Outcome:
Children with Good Oral Health

Sub-outcomes:
Access: Every child will have a dental "home."

Disease Free: Every child will be free of dental disease.

Fluoride: Every child will receive optimum fluoride for oral health.

Action Plan

1. More services for children: Identify how we can increase capacity to meet the oral health needs of low income children.

• Identify existing resources
• Encourage private dentists to accept entitlement insurances
• Add two new dental clinics in the South County
• Increase capacity of existing clinics to serve children
• Utilize volunteer oral health providers

2. Health Education for good oral health behaviors: Create a comprehensive education campaign about oral health for parents, care takers, allied health, parent educators and health professionals.

• Explore opportunities for reaching parents
• Encourage media coverage of oral health
• Educate allied health professionals through their associa-tions, newsletters, and continuing education opportunities

3. Fluoride for children: Identify effective strategies to increase use of fluoride by Sonoma County children.

• Develop a community education campaign about benefits of fluoride
• Investigate local water fluoridation options
• Increase availability of low-cost and free fluoride supplements