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.

How I Help

Students were obsessed with social media. Here’s what this middle school counselor did about it.

PHOTO: Hero Images | Getty Images

In our “How I Help” series, we feature school counselors, social workers, and psychologists who have been recognized for their work. You can see other pieces in the series here.

Students at Eagle Valley Middle School in western Colorado were spending lots of time on social media, and too often their comments turned mean. Counselor Kayleen Schweitzer decided things needed to change, so last year she spearheaded a schoolwide campaign urging students, staff and parents to take a five-day break from social media. More than 150 people signed the pledge.

The results were encouraging. Participating students reported that they had more free time and were getting to bed earlier. Some even said the break made them realize they had been addicted to social media.

Schweitzer, who was named 2018 Middle School Counselor of the Year by the Colorado School Counselor Association, talked about how campaign organizers got students to participate, what she wants parents to know about middle-schoolers, and why she wants students to regard visiting a counselor as normal.

This interview has been condensed and lightly edited.

Why did you become a school counselor?

When I was 15, I lost my father. It was very unexpected and I found out at school. When I returned to school no one checked on me or followed up to see if I was doing OK. I remember wishing I had more support at school. That was the first time I realized that one day I wanted to be someone who could be there for students going through a hard time or transition.

When I was in college my favorite classes had to do with child development. I went on to pursue a degree in family and human services and a graduate degree in school counseling. I’m definitely happy with my decision to be a school counselor and I look forward to going to work every day.

Tell us about an effort or initiative you spearheaded at your school that you’re particularly proud of?

In the 2016-17 school year, my principal Katie Jarnot and I identified a need for something that would help with some of the conflicts occurring at our school. Katie came across a national program called No Place For Hate. It was just what we were looking for. In the 2017-18 school year, we brought No Place For Hate to our school. It has been amazing and powerful.

We noticed a lot of mean behavior on social media and that our students were spending so much time online. Also, with a surge of recent research into the detrimental effects of screen time, social media, and the correlation to depression and anxiety, it was clear there needed to be a change. So Eagle Valley Middle School’s No Place for Hate Coalition created a schoolwide activity that attempted to give students, staff, and parents a glimpse into positives that can come from limiting social media use and taking back control of our lives. We asked our school community to commit to giving up social media for five days.

During those five days, everyone who took the pledge was asked to do a daily reflection on the differences that they noticed. We offered a chance to win prizes as an incentive. To our surprise, we had 110 students (about one-third of our school), 18 staff, and 30 parents sign up.

Though not everyone completed the five days, we felt we brought some awareness to this problem. Students noticed how much more time they had when not using social media and they were able to get to bed earlier. Some actually admitted this activity helped them realize that they are addicted to social media. A few parents reported they were able to be more present with their family at night and have fewer distractions.

Is there a tool, curriculum or program you couldn’t live without in your job?

The tool I couldn’t live without is Google forms. Students can fill out a form to let me know they need to see me. When they fill out the form it notifies me with an email and I can see who is requesting to see me. It also allows me to keep data on what issues my students need support with. This helps me plan what supports I need to put in place through classroom guidance lessons, small groups, and individual counseling.

What’s the biggest misconception you’ve encountered about your role in the school where you work?

The biggest misconception I have encountered is that it’s a bad thing to go to the school counselor and that you need to have a huge problem. I have noticed that some middle school students are embarrassed to be seen going to the school counselor. I have worked really hard to make it normal to come to me and teach them that the strongest, most successful people need help sometimes.

You spend lots of time with students. Knowing what you know, what advice would you give to parents?

I would remind parents that students’ frontal lobes are not fully developed and when they say they don’t know why they did something, they are probably being honest. I would also let them know that even if a student says they want parents to give them space and leave them alone, it’s not really what they want or need.

Tell us about a time when you managed to connect with a challenging student or a student facing a difficult situation. How did you do it?

I have a student who is now in eighth grade and has been coming to see me on a regular basis when she needs support. As a sixth-grader, she was so closed off and worried about being seen coming to talk to me. I have been very consistent with her and kept reminding her that I’m always here if she needs anything. I ended up running a group with her and a lot of her friends. She saw that her friends loved coming to see me and were willing to talk to work through some of their problems. I also spent time with her and showed her it was a safe place to talk. Over time she broke down her walls and was able to trust me. Today, she stops by when she is doing well and when she is struggling. She loves to come and eat lunch with me. She has grown so much and I’m going to miss her dearly when she goes to high school.

What is the hardest part of your job?

The hardest part of my job is going home and worrying about my students. You always wish you could do more or make students see things can get better and they are enough. Middle school is such a hard time for students as they struggle to find where they fit in and deal with personal changes.

Tell us about a memorable time — good or bad — when contact with a student’s family changed your perspective or approach.

In my first years as a school counselor, I had a student who was consistently falling asleep in class and missing a ton of school. When I had a meeting with his family, I found out that his mother was a single mom and his grandma, who also lived in the house, was very sick. The student was staying home to help take care of his grandma and his siblings so his mom could work and make money for the family. His father was an alcoholic who was in and out of rehab.

I realized that different cultures have unique values and priorities. It also taught me that you never know what someone is going through so we need to really take time to talk to kids to figure out what is happening in their personal lives before jumping to conclusions.

You spend your days trying to help students and staff with any number of things. How do you wind down after a stressful day?

The way I wind down after a stressful day is to come home and spend time with my children. They are still young and innocent. I try to really enjoy this precious time with them when they have fewer worries and just want to have fun. I also love spending time with friends and clearing my mind of the worries of my job. Last, I enjoy catching up with email and work-related tasks as every time I scratch out something on my to-do list I seem to get stress relief.

Chilling effect

Five ways a proposed immigration rule could impact Colorado students and schools

PHOTO: JGI/Jamie Grill | Getty Images

Advocates for immigrant families fear that a proposed federal rule governing green card decisions could lead to more children going hungry and losing housing and health care. That, in turn, could pose challenges for educators and schools.

The proposed rule would allow the government to penalize some legal immigrants who have used public benefits by denying them permanent residency — a possibility that could prompt families to forgo any kind of government help. For children in those families, many of them citizens, the result could be hunger pangs, untreated illness, or outsized worry that their parents won’t be able to stay in the U.S. Inside schools, the new rule could mean more time and energy spent addressing students’ basic needs and the loss of funding from some public programs.

Fear that immigrants will shy away from benefit programs is nothing new. Stricter immigration rules since President Trump took office — stepped-up raids, efforts to discontinue the DACA program, and family separations at the U.S.-Mexico border — have already led to a chilling effect on the legal use of public benefits by immigrants. Advocates say changes to the so-called “public charge” rule will only exacerbate the problem.

The rationale behind the proposed rule, a stricter version of one that’s been in place for years, is to prevent immigration by people who will end up dependent on government help. Opponents of the rule say it punishes working-class immigrants who may need short-term aid, but contribute much more to the country’s economy over the long term.

The existing public charge rule penalizes immigrants for using programs such as Temporary Assistance for Needy Families or long-term care. The proposed version adds several more to the list, including Medicaid, food stamps, and housing vouchers. Free and reduced-price school meals aren’t included in the existing or proposed rule.

Mónica Parra, program manager of the Denver school district’s migrant education program, said families she works with are reluctant to sign up for any kind of help, even assistance heating their homes during the winter.

“They’d rather struggle or find other ways to get support,” she said. “It’s going to be very challenging to keep students motivated, but also safe. Maybe they’re going to be cold. Maybe they’re going to get sick.”

The proposed public charge rule doesn’t apply to refugees and asylum-seekers, and doesn’t penalize immigrants for public benefits used by their children. Still, like other advocates, Parra said she hears anxiety about the proposed rule from all kinds of immigrants, including citizens and those who already hold green cards.

They worry that using public benefits could get their own legal status revoked or hurt their chances to sponsor family members who want to immigrate to the U.S.

“The fear has always been there in these communities,” she said. “Now, people are even more afraid.”

The new public charge rule likely won’t take effect for months. First, there will be a 60-day public comment period, scheduled to start Wednesday, and then Trump administration officials will consider the comments and decide whether to make any adjustments.

Here’s a look at some of the ways the proposed rule could affect Colorado schools and students.

More kids come to school hungry

There are at least two ways schools could see more hungry students walking through their doors due to the public charge rule. First, families may be afraid to take advantage of food stamps — either by deciding not to enroll, or by dis-enrolling current recipients, such as citizen children.

Both Denver and Adams counties have seen dips in the number of people participating in the program over the last couple years. In Denver, about 2,000 fewer children receive the benefit now than in November 2016 when President Trump was elected. However, city officials caution that it’s hard to make a direct connection between falling participation and federal immigration policies since historically low unemployment rates may also be contributing to the trend.

While free and discounted school lunches are not part of the public charge rule, some advocates report that immigrant parents have been wary of enrolling their kids since Trump’s election. By law, public schools must serve students regardless of their immigration status and can’t ask for information regarding a family’s or student’s status.

A week after the Department of Homeland Security released a draft of the new public charge rule on its website, the Eagle County school district emailed parents asking them to help squash the rumor that signing children up for free or reduced-lunches “will inform ICE,” a reference to the U.S. Immigration and Customs Enforcement agency.

The letter concluded, “There is NO RISK in applying for free and reduced lunch, help us spread the word.”

So, what happens when kids go to school hungry? They may have trouble paying attention, misbehave more easily, or suffer from headaches or stomach aches. In short, less learning.

More children without health insurance, more student absences

The public charge rule’s chilling effect could have a major impact on child health, according to a recent Colorado Health Institute analysis. An estimated 48,000 Colorado children — the vast majority of them citizens — could be disenrolled from one of two public health insurance programs, Medicaid or Child Health Plan Plus. That would double the state’s rate of uninsured children from 3 percent to 6.7 percent, according to the institute.

The reason for so much dropoff is that health insurance is typically a family affair. So even when different rules govern adults and children in the same family, they tend to be enrolled as a group or not at all.

When students don’t have health insurance, school attendance and performance can suffer. For example, children may be absent more if they lack help managing chronic conditions like asthma, or if they’re not getting treatment for acute illnesses or painful dental problems.

Loss of health-related funding for schools and school-based clinics

School districts stand to lose two health-related funding streams if the number of uninsured children swells. The first would impact the state’s 62 school-based health clinics, which would likely see a drop in Medicaid and Child Health Plan Plus reimbursements if fewer students enroll in those programs.

Such an enrollment decline, which some clinic leaders have already reported, could make it harder for school-based clinics to stay afloat financially, said Bridget Beatty, executive director of the Colorado Association for School-Based Health Care.

With more uninsured students, “The need will go up,” she said, “but conversely the ability to financially sustain them will get more challenging.” 

In addition, 53 Colorado school districts receive funding through a program that could be affected by the proposed public charge rule. It’s called the School Health Services Program and allows districts to seek Medicaid reimbursements for services provided to low-income students with disabilities. That money can be used for health-related efforts that benefit all students, such as the addition of school nurses, wellness coordinators, or suicide prevention programs.

Funding received through the program ranges from a couple thousand dollars in small districts to a few million in large districts.

High-poverty schools have a harder time offering universal free meals

Nearly 40,000 students in 20 Colorado school districts can eat school meals for free because their schools participate in a federal program designed to make breakfast and lunch easily accessible to low-income students. But that number could drop if the public charge rule decreases food stamp participation.

The special meal program, called Community Eligibility Provision, is open to schools or districts where at least 40 percent of students come from families that use certain public benefits, including food stamps or Temporary Assistance for Needy Families. Unlike in traditional school lunch programs, parents don’t have to fill out applications for free or reduced-price meals.

“Any time when you have eligible families not participating in SNAP, it does have a negative impact on community eligibility,” said Crystal FitzSimons, director of school programs at the national nonprofit Food Research and Action Center.

Even if schools or districts remain eligible for the program, a drop in students getting public benefits could mean a change in how schools are reimbursed for the free meals, she said. That, in turn, could make the program less financially viable for schools or districts to participate.

Immigrants could turn away from publicly funded early childhood programs

Crystal Munoz, who heads the nonprofit Roots Family Center in southwest Denver, worries that the Spanish-speaking families her program serves will stop using programs like Head Start, state child care subsidies, and the Denver Preschool Program, which provides tuition assistance to the city’s 4-year-olds.

Even though those programs aren’t part of the proposed rule, there’s still trepidation, she said. It’s because of the constant flurry of rule changes and the generally negative tone around immigration right now.

“We find ourselves very afraid to even give out resources or referrals to certain programs because we’re not sure,” she said. “For us, it’s waiting and seeing.”

She said if families do drop out of Head Start or other child care programs, it could push children — many of them citizens — into unlicensed care with relatives or neighbors, or force parents to cut back work hours to stay at home with them.