The Other 60 Percent

Preventable disease endangers kids’ health

Dr. Avani Khatri spent several minutes examining the small mouth of the boy in the dental chair, then pronounced her findings.

“We can probably get away with doing fillings and not crowns,” she said through her mask.

Khatri, a University of Colorado Dentistry School graduate, and dental assistants Nancy Vigil and Taylir Scott-Hall rotate among young patients who occupy each of three dental chairs at the Kids In Need of Dentistry or KIND clinic at Morey Middle School in Denver.

Every Thursday, the clinic treats a steady stream of pediatric patients, many with a mouthful of problems. Mondays through Wednesdays, the team sees patients at Tri-County Health Department. Another clinic in Colorado Springs, staffed by volunteers, will lose its current home at the end of May. The clinic accepts Medicaid and parents pay 20 percent of usual fees for the procedures.

“Mostly we see kids with generalized gross decay. We do a lot of hygiene, fillings, crowns, run-of-the-mill general dentistry,” said Khatri.

Colorado below average in dental care

Colorado ranks 38th among the 50 states in the number of children receiving preventive dental visits in the previous year, contributing to a C- grade in the Healthy Children category of the Colorado Health Foundation’s 2011 Colorado Health Report Card.

Partnership
  • This story is made available to EdNews’ readers through our partnership with Solutions, a non-profit news site focused on health issues.

Of 39 categories on the report card, the adolescent dental category was the state’s second-lowest ranking. Colorado stood 39th in the percentage of babies with low birth weight.

Colorado ranks 30th nationally in the percentage – 70.6 – of residents served by water fluoridation. In 2002, the state was 24th with 75.4 percent of the state’s water supply being treated with fluoride.

Untreated dental caries, the disease process that causes cavities, is the leading disease in children, occurring five times more often than asthma. Dental disease causes children and parents to miss millions of hours of school and work. The incidence of cavities in children ages 2-5 has increased nationally in the face of an overall decrease among the general population.

What is both encouraging and frustrating to health officials is that dental disease is considered 100 percent preventable. Oral health has been tabbed as one of Colorado’s 10 winnable health battles and has a role in the governor’s TBD “listening tour.”

Millions spent on ‘preventable’ dental surgery

Pediatricians say far too many youngsters have surgery for dental disease that could have been prevented. During 2011, nearly 3,000 children visited the operating room at Children’s Hospital for dental surgery.

By the numbers: Dental disease
  • In 2011, nearly 3,000 children visited Children’s Hospital for dental surgery
  • 57 percent of 3-year-olds seen at Dental Health have dental disease
  • The mean number of cavities is 11
  • Add white spot lesions indicating early signs of cavities and the figure increases to more than 70 percent

“That number has been increasing for every year for the past decade,” said Dr. Patricia Braun, a pediatrician at Denver Health.

“It is a large economic issue. Studies have shown that restoring dental disease in an operating room costs about $10,000 to $15,000 per case. If you take 3,000 kids to the OR, that’s $35 to $45 million spent each year restoring a preventable disease.”

Fifty-seven percent of 3-year-olds seen at Denver Health have dental disease and the mean number of cavities is 11.

“If you include white spot lesions that indicate early signs of cavities forming, over 70 percent have dental disease,” said Braun.

Dental disease in children is prevalent across income levels but disproportionately affects low-income children.

Poor kids hit hardest
“Seventy-five percent of the disease is in 25 percent of low-income kids.”
— Dr. Patricia Braun

“Seventy-five percent of the disease is in 25 percent of low-income kids,” she said.

Health officials believe the twin tools of education and early intervention are keys to reversing the trend of increasing cavities.

“We truly have an achievement gap,” said Dr. Katya Mauritson, a dentist and director of the oral health unit of the Colorado Department of Public Health and Environment. “With millions of school hours missed, how does that translate to lifelong core outcomes for a vulnerable population and how do we change behaviors at an early age?

“We need to look at very young children and make sure they’re getting in for their age-one dental visit so if there is a problem they’re not going to be sent to the OR to have 20 teeth capped at age 4 and they’re not going to suffer the pain of that treatment.”

No mystery why pediatric cavities increasing

The causes of the rise in pediatric cavities are evident, providers say.

“It’s a combination of things. One is dietary factors. The more sugar kids have puts them at a higher risk. It’s a lack of good oral hygiene, brushing teeth,” said Dr. Mark Deutchman, a professor of family medicine at the University of Colorado School of Medicine.

“It’s also because it’s a vertically transmitted disease. The bacteria that are associated with causing caries are transmitted from the primary caregiver to the child at about the time the kid’s teeth start to erupt.”

Dentists and Medicaid
“We have to get more general dentists to take Medicaid and to see young kids.”
— Dr. Mark Deutchman

Deutchman is one of the authors of Smiles For Life, a national oral health curriculum used to train doctors and dentists.

“The mythology is that ‘they’re just baby teeth and it doesn’t really matter,’ but the best predictor of your adult teeth health is your child teeth. Those baby teeth are in your mouth while the adult teeth are coming in. If you have the bacteria and poor oral hygiene habits, it’s going to spread to your adult teeth,” he said.

“Children get abscesses, facial infections, pain. They can’t pay attention in school, have to go to the emergency room and parents have to take off work,” Deutchman said.

A grant from Delta Dental Foundation was used to develop the Frontier Center at CU to improve communication between medical and dental professionals. Deutchman teaches oral health education in the medical school and medical condition education in the dental school.

“We have to get more general dentists to take Medicaid and to see young kids, and continue to get more physicians to include dental health as part of their well-child check,” he said.

About 27 percent of Colorado dentists accept Medicaid.

Foundations try to plug Medicaid gap

Colorado foundations are providing the financial fluoride for a number of dental health initiatives, including Cavity Free at 3 or CF3, a statewide initiative to raise awareness about dental disease in young children and pregnant women.

CF3’s funders include the Caring for Colorado Foundation, Colorado Health Foundation, Colorado Trust, Rose Community Foundation, Kaiser Permanente Foundation and Delta Dental of Colorado Foundation.

“We train providers (physicians, physicians assistants and nurses) in the skills to do oral screening, identify disease, do a risk assessment and, when indicated, a fluoride varnish as part of well-child visits,” said Karen Savoie, director of education for CF3.

CF3 has trained more than 1,500 providers throughout Colorado since its founding in 2008.

“We focus on areas of the state with the greatest barriers of access to care: rural areas, where dental services are limited,” said Savoie.

CF3 also focuses on dental issues during pregnancies. Only 39.7 percent of all Colorado women receive dental care immediately prior to or just after pregnancy, according to Colorado’s Risk Assessment and Monitoring System. Among Medicaid-eligible women, the number drops to 25.6 percent.

“We train providers that dental care is not only safe but recommended during pregnancy,” said Savoie. “We’re asking primary care providers to endorse that message. It’s been very well received. We want them to ask pregnant women if they’ve had a dental appointment and if they say no to encourage them to have one.”

Pregnant women in Colorado have no Medicaid dental benefits except for certain state-defined “concurrent conditions,” including tumors and emergencies. A 2007 report by State Health Policy Monitor found Colorado to be one of only six states with no regular adult dental benefits under Medicaid.

Focus on mom’s dental needs in pregnancy, rural areas

Colorado Senate Bill 12-108, sponsored by Sen. Jeanne Nicholson, D-Gilpin County, which has been passed by the Senate Health Committee, would provide preventive periodontal, minor restorative care and extraction for pregnant Medicaid recipients.

Moms and dental care
  • Only 39.7 percent of all Colorado women receive dental care immediately prior to or just after pregnancy
  • Among Medicaid-eligible women, the number drops to 25.6 percent
  • Lawmakers are considering a bill to provide preventive periodontal, minor restorative care and extraction for pregnant Medicaid recipients

“The theory is if we can take care of the mom’s dental needs in pregnancy, we can help delay the transmission of dental disease to the child, which gives the child a healthier foundation, which can in turn reduce the high expenses that can be involved treating a child,” said Molly Pereira, associate executive director of the Colorado Dental Association.

The CF3 foundation funders plan to launch in June a $2.25 million statewide program with the dual mission of getting more dentists to accept Medicaid and to see more young patients.

The Colorado Partnership for Children’s Oral Health “is the result of our collective efforts with Cavity Free at 3,” said Linda Reiner, director of planning and evaluation for Caring For Colorado. “What we learned from that is we still had two big barriers: Cavity Free at 3 teaches dentists they need to get kids into a dental home by age 1, but what we kept hearing all around the state was, ‘That’s great but we don’t have any dentists who will see a kid at age 1 and we don’t have any dentists who will take Medicaid.’ ”

The focus on mom
“The theory is if we can take care of the mom’s dental needs in pregnancy, we can help delay the transmission of dental disease to the child.”
— Molly Pereira

Reiner said Colorado only has about 100 pediatric dentists and they are concentrated in the Front Range.

“In rural areas, they’re not part of the solution because they’re just not there,” she said. “People say anecdotally that about 30 percent of pediatric dentists take Medicaid. We started modeling this after Colorado Children’s Healthcare Access Program. When Dr. Steve Poole (a pediatrician and founder of CCHAP) started his project in 2006, about 20 percent of pediatricians took Medicaid, and he now has 95 percent of pediatricians taking Medicaid patients.

“We’d like to see all general and pediatric dentists have Medicaid be at least part of their practice.”

To that end, the partnership will send trainers to dentists’ offices to provide information on how to treat young children following the CF3 protocols as well instruction on how to deal with various Medicaid issues.

The partnership will also offer mini-grants in the $25,000 range to local public health agencies, community resource centers, nonprofits or local government entities in mostly rural areas

Families’ lack of access to dental care is key issue

The crux of the problem, she said, “boils down to families who have no access to dental care.”

Twenty-two of Colorado’s counties have designations or are partly designated as geographic Dental Health Professional Shortage areas based on their dentist-to-population ratio, reports the Colorado Rural Health Policy and Advocacy News.

Clinics such as KIND are where the enamel meets the drill for many children who are least likely to be able to afford dental treatment on their own.

Kids in need of care
“They’ve learned to live with pain. They know their parents are trying to put food on the table or gas in the car. They’re in pain, they’re sitting in school and can’t concentrate, can’t function.”
— Julie Collett, KIND

“We tend to do a lot of oral hygiene education, not just with kids but with their parents,” said Khatri, while she waited for a local anesthetic to take hold before working on another young patient.

“A lot of parents think, ‘We’ll give them a juice pack because it’s 100 percent juice. But have you looked at the sugar content? Apple juice is one of the most sugary juices on the market. People think, ‘I’m not giving them pop, juice is better for them’ and their logic is right but look at how much sugar is in these boxes. I had a patient’s mom tell me ‘I went home and looked at all the boxes and threw them all away.’ Many people are unaware of the hidden sugar in what we eat and drink.”

“We see kids who come in with their mouths pretty much bombed out with decay but not complaining,” said Julie Collett, KIND’s executive director. “They’ve learned to live with pain. They know their parents are trying to put food on the table or gas in the car. They’re in pain, they’re sitting in school and can’t concentrate, can’t function.”

Sasha Dillavou contributed to this story.

Frequently asked

There are lots of ways schools teach English learners. Here’s how it works.

PHOTO: Andy Cross/The Denver Post
Lindsey Erisman works with 6-year-old students in an English Language Acquisition class at Denver's Cole Arts & Science Academy.

School district officials in Westminster this year signed an agreement with federal officials to change how they educate students who are learning English as a second language.

Similar agreements have also shaped how districts in Denver, Aurora, Adams 14, and Adams 12 educate their English language learner students. But many people, including parents and district insiders, may still have questions about the various complicated programs and requirements.

Although many of the language-education agreements are years old, most of the issues haven’t been resolved. In Adams 14, for instance, parents and advocates have protested a district decision to stop biliteracy programming, and have questioned the district’s compliance with its agreement to better serve English learners. District officials have pointed out that their obligation is teaching students English, not making them bilingual.

Now at least one charter school, KIPP, is looking to fill in that programming gap. Many other states have had a number of biliteracy and other bilingual programs at various schools for years, but Colorado has only more recently started to follow those trends.

So what’s the difference between the various language programs and services? And what is required by law and what isn’t? The following questions and answers might help clarify some of those questions as you follow the news around these issues.

Which students are designated as English language learners? Do parents get to decide, or do schools decide?

Federal guidance requires school districts have some way to identify English learners. Most commonly, districts survey all parents at school registration about their home language and the student’s first language. If that survey finds there might be an influence of another language at home, the student must be assessed to determine fluency in English. While the district has to identify all students who aren’t fluent in English as language learners, parents in Colorado can choose to waive the federally required services for their children. If so, the district doesn’t have to provide special services, but would still be required to monitor that the student is making progress toward acquiring English.

What educational rights do English language learners have?

English language learners have specific rights under the Lau v. Nichols Supreme Court case from 1974 and the subsequent Castañeda standards released in 1981. State laws also outline some requirements for school districts. Specifically, school districts must provide programs for all identified language learners to give them the opportunity to learn English and to access a comprehensive curriculum. The government does not state what that program should be, but provides some standards requiring that any program is theoretically sound and has a research base to support it. The program has to have qualified teachers, and a way to demonstrate that students are making progress in learning English and their academic content. While the civil rights officials consider many details to verify compliance, simply put, school districts have the legal obligation to identify students, serve them in a sound program, and monitor their progress.

What is the difference between bilingual education and “ELL services?”

Bilingual education (which is the program that has the most support for efficacy from the research community) offers students opportunities to learn in their native language while they are learning English. Bilingual programs can vary from short-term, or early-exit programs, to more longer-term developmental programs.

English language learner services do not need to provide opportunities for students to learn in the native language. Most commonly these services only offer English language development classes (generally 45 minutes per day). All other content instruction is offered only in English. ELL services are not bilingual.

What is English language development?

English language development must be a part of any program or model a district or school adopts. It is the class time when students are taught the English language. The government wants to see that English learners are given a dedicated time to learn English, when they are not competing with native English speakers. That means, often, English language development is offered as a time when students are pulled out of class to practice English, or as a special elective period students must take without their English-speaking peers.

The structure of this time period, who has access to it, or who teaches it, are areas commonly cited as problems by the federal Department of Education’s Office for Civil Rights.

Do students who are identified as English language learners retain that designation forever? What does it mean to be an “exited ELL?”

They’re not supposed to. Students who are English learners should be tested at least once a year to determine their English proficiency. When a student reaches a high enough level, school staff must determine if the student is now fluent in English. If so, the student becomes an “exited ELL.” The law requires districts to monitor for two years students who have exited and are no longer receiving services. There are, however, students who do not reach English fluency before graduating or leaving school.

What is the difference between being bilingual and being biliterate?

Bilingual generally refers to oral language in that bilingual people can understand and speak two languages but may not be able to read and write in those languages. Biliterate refers to being able to understand, speak, read, and write in two languages. Many people are bilingual but not biliterate. Biliteracy is considered to be a higher form of bilingualism.

What is the difference between dual language and biliteracy models?

Dual language and biliteracy models share many common components. Both models usually have biliteracy as their end goal for students. Dual language models may be “one-way” or “two-way.” One-way programs generally serve students who are designated as English language learners (also sometimes called emerging bilinguals). Two-way dual language programs include students who are native English speakers. The only major difference is that biliteracy models focus on using two languages in the language arts or literacy classes (reading and writing in two languages) whereas dual language focuses on using two languages across the entire school day’s curriculum.

What is an immersion model?

Immersion models traditionally are thought of as referring to programs primarily intended for students from the dominant language population to learn a second language. This is different from programs meant to teach English.

While native English students can choose whether or not to learn a second language, students who are English language learners do not have a choice in learning English.

What is sheltered instruction?

This type of instruction takes place in non-dual language schools, during regular content classes (such as math or science), and it’s one way schools try to make the content understandable to students who aren’t yet fluent in English.

This is especially common in schools where English learners speak a variety of languages. Crawford Elementary in Aurora, for instance, has had up to 35 different languages represented among its approximately 560 students. If there aren’t enough students who speak a common first language and also a teacher who speaks the same language as those students, then schools must teach through English, while making the English as accessible as possible.

In practice, this means an English-speaking teacher would use sheltered instruction techniques to help all children understand the lessons such as, physical props, a focus on building vocabulary, and sentence stems.

Denver designates schools as TNLI schools. What does that mean?

Denver created the TNLI label in 1999 to set the district apart from other bilingual program models. TNLI stands for Transitional Native Language Instruction. The Denver TNLI program is a transitional bilingual education program model with a label created just for Denver. It’s a model where instruction in Spanish is used to help students learn while they’re acquiring English, but still has a goal of making students fluent in English as soon as possible, at which point students move into mainstream English classrooms.

Is one of these models best suited for English learners?

Among researchers, it is commonly accepted that dual language or biliteracy models are the most effective to put English learners on par with their native speaking peers, in the long run.

Why do teachers have to be trained specifically to teach this population of students? What are teachers learning?

Educators and researchers say that teachers need to learn the differences and similarities between learning in one language and learning bilingually. Teachers need to learn about literacy methodology and how teaching literacy in Spanish (for example) is the same and different as teaching literacy in English. They have to learn how to teach English language development to students who are beginning to learn English (it is different than just teaching in English). These trainings also help teachers learn about cultural similarities and differences and about sources of culture conflict. Teachers need to be able to teach children English; how to use English to learn; and how the English language works. In bilingual settings teachers need to learn those three things for two languages. In short, the training needed to be a bilingual teacher is quite different. Colorado will soon require some of this training for all teachers.

What are the challenges districts have in offering these different programs? How do schools decide which type of model to offer?

The demographics of a district’s student population, and district politics play a large part in helping a district decide what model or program to use. Resources can also be a factor in deciding how to structure services or what programs to offer. In Adams 14, when the district leadership decided to pause the roll out of a biliteracy program, the district cited a lack of qualified bilingual teachers, among other things.

In Westminster, the school district’s unique competency-based approach, which removes grade levels and seeks to personalize instruction, was cited as a reason why the district had structured its English language development the way it had before the investigation by the Office for Civil Rights sought to change it.

Does Colorado provide guidance or oversight for how districts are doing this work?

The Colorado Department of Education offers some guidance for districts, but oversight of the districts’ compliance with what is required is limited. In practice, when parents suspect their children aren’t educated well, they have filed complaints with the federal government. In Denver, the complaints went through the Department of Justice. Investigations of most other metro-area districts have been conducted by the Department of Education’s Office for Civil Rights.

task force

Jeffco takes collaborative approach as it considers later school start times

File photo of Wheat Ridge High School students. (Photo by Nic Garcia/Chalkbeat)

The Jeffco school district is weighing pushing back start times at its middle and high schools, and the community task force set up to offer recommendations is asking for public input.

Nearby school districts, such as those in Cherry Creek and Greeley, have rolled out later start times, and Jeffco — the second largest school district in Colorado — in December announced its decision to study the issue.

Thompson and Brighton’s 27J school districts are pushing back start times at their secondary schools this fall.

The 50-person Jeffco task force has until January to present their recommendations to the district.

Supporters of the idea to start the school day later cite research showing that teenagers benefit from sleeping in and often do better in school as a result.

Jeffco is considering changing start times after parents and community members began pressing superintendent Jason Glass to look at the issue. Middle and high schools in the Jeffco district currently start at around 7:30 a.m.

The task force is inviting community members to offer their feedback this summer on the group’s website, its Facebook page, or the district’s form, and to come to its meetings in the fall.

Katie Winner, a Jeffco parent of two and one of three chairs of the start times task force, said she’s excited about how collaborative the work is this year.

“It’s a little shocking,” Winner said. “It’s really hard to convey to people that Jeffco schools wants your feedback. But I can say [definitively], I don’t believe this is a waste of time.”

The task force is currently split into three committees focusing on reviewing research on school start times, considering outcomes in other districts that have changed start times, and gathering community input. The group as a whole will also consider how schedule changes could affect transportation, sports and other after school activities, student employment, and district budgets.

Members of the task force are not appointed by the district, as has been typical in district decision-making in years past. Instead, as a way to try to generate the most community engagement, everyone who expressed interest was accepted into the group. Meetings are open to the public, and people can still join the task force.

“These groups are short-term work groups, not school board advisory committees. They are targeting some current issues that our families are interested in,” said Diana Wilson, the district’s chief communications officer. “Since the topics likely have a broad range of perspectives, gathering people that (hopefully) represent those perspectives to look at options seems like a good way to find some solutions or ideas for positive/constructive changes.”

How such a large group will reach a consensus remains to be seen. Winner knows the prospect could appear daunting, but “it’s actually a challenge to the group to say: be inclusive.”

For now the group is seeking recommendations that won’t require the district to spend more money. But Winner said the group will keep a close eye on potential tax measures that could give the district new funds after November. If some measure were to pass, it could give the group more flexibility in its recommendations.