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.

raising the curtain

Aurora high school students started rehearsing a musical about an earlier time — and discovered ‘harsh truths’ about today

Ebony Nash, left, sings during a rehearsal of Ragtime at Hinkley High School. (Photo by Yesenia Robles, Chalkbeat)

Nine weeks ago, more than 50 theater and choir students at Aurora’s Hinkley High School came together to begin work on a musical set in turn-of-the-20th-century New York.

At first, the kids did what high school students often do — cluster into familiar cliques, or self-segregate by race. Then the students started immersing themselves in the material.

The musical, “Ragtime,” intertwines the stories of a white family, a Jewish immigrant family and an African-American couple to spotlight differences and commonalities in the American experience.

At the urging of their teachers and directors, the Hinkley students began to use the plot and characters to examine their own actions, prejudice and biases. About 92 percent of Hinkley’s more than 2,100 students are students of color, the vast majority of them Latino.

The cliques and segregation slipped away. The production began taking shape.

“Ragtime” gets its Hinkley High School debut on Thursday and will be performed again on Friday and Saturday.

Chalkbeat sat down with a group of students involved in the production as they were in final preparations to learn about what their experience had taught them. The following is a portion of that conversation, slightly condensed and rearranged for clarity:

Janelle Douglas, a 17-year-old senior who portrays a friend of one of the story’s main characters, said the first time she saw and read through Ragtime, “it was intense.” She often cries as she rehearses her solo, sung during a funeral.

DOUGLAS: “I thought, this is powerful. This is overwhelming. This is amazing.”

Pamela Arzate, 17, plays the role of Evelyn Nesbit, a real model and actress who is incorporated into the fictional story and accused of being shallow.

ARZATE: “It’s very eye-opening because you look at it and it’s just a simple musical, but if you take a step back and go to the real world, it’s the exact same thing that’s going on today.”

Hodaly Sotelo, 17, plays the role of Mother, a woman whose attitudes toward her identity as a wife and woman evolve throughout the story.

SOTELO: “It reminds me of when I was younger and I was like, ‘Oh yeah, we’re over all that racism.’ But now, I look back and I think, what the heck? This stuff is still going on and we thought it was way over.”

Brianna Mauricio-Perez, 17, is one of two student directors.

MAURICIO-PEREZ: “It talks about all of the harsh truths that no one wants to talk about.”

DOUGLAS: “I think it’s safe to say it shows the true colors of our history.”

MAURICIO-PEREZ: “Even within our cast we did have to have a talk about how we were so separated because we were at the very beginning. Everyone was in their little groups and with their friends. You just want to keep to yourself.”

DOUGLAS: “It was literally ‘Ragtime.’”

MAURICIO-PEREZ: “We had a big talk with everybody. Things have gotten so much better. By the end of Act Two, we were all mixed up.”

Brenda Castellanos, 17, plays the role of Emma Goldman, drawn from a real-life political activist and anarchist.

CASTELLANOS: “Now that we’re closer, now that we’re all comfortable, we put in more effort.”

After nearly every rehearsal, teachers and directors give students a talk, urging them to immerse themselves in the feelings of their characters, relating to them if necessary through their parents, grandparents or ancestors who were immigrants, or through current events.

“What if you saw someone beaten, and bloodied and killed in front of you?” one director asked.

They also remind students of why the play should be impactful. “You have to figure out how for two-and-a-half hours you can give hope to that audience,” Marie Hayden, Hinkley’s choir director told students last week.

CASTELLANOS: “I think it it helps us. Every day, we get more into it and more into it until we actually believe it. You actually feel it — like how Janelle feels when she’s singing and she starts crying and makes everybody cry. We all feel connected.”

Students say they have different scenes that impact them the most, but they don’t hesitate to find how the scenes relate to their life despite the story being set in the first decade of the 1900s. Hayden’s class and the practice for the musical are safe places where they can discuss those parallels, they said.

Shavaun Mar, 16, is a junior who plays the main character of Coalhouse Walker Jr., a ragtime piano player who is the target of racial attacks and struggles with revenge and forgiveness.

MAR: “I feel like that is crucial that we give people those opportunities to talk because a lot of people have very valid things to say but they just don’t have a way to get it out.”

CASTELLANOS: “The shootings.”

ARZATE: “The racism. They help us discuss it because there’s so many things that are going on. Pretty much everyday there’s a tragedy going on. And so, in a way, we can use that sentiment, that emotion that we feel with the real world and convey it when we’re doing this show. We use those feelings and we try to think about it in that way. To display that emotion. To display it to everyone else. And not directly represent what’s going on today but just to give them that ‘aha’ moment, like ‘wow.’”

Ebony Nash, 17, plays the character of Sarah, an innocent girl who wants to help her boyfriend settle his problems.

NASH: “It just makes us want justice in real life because these things are still going on even though it’s not out there. It just makes us want justice for our community. This musical showed me that I need to become better within myself because I’m not perfect.”

SOTELO: “It opened my eyes a lot more for sure. This kind of just makes me realize the problems I have. It makes me realize yea, I’m having immigration issues with my father right now, but that also my friends, you know, they’re going through the same thing too. This DACA stuff or this coming out stuff. I became more accepting of what other people might be going through and how I can help.”

MAR: “The past few years, I have been in a bit of a shell. So putting myself in this situation and pushing myself to be this other person has really shown me what I’m capable of and it’s helping me break out of that shell and realize who I am as a person.”

NASH: “Basically, this is our getaway from real life because we get to come on stage and be somebody else. It also makes us want to put the story out right so people can understand. So people can feel what we want them to feel.”

CASTELLANOS: “That there’s hope after all this corruption that’s going on.”

DOUGLAS: “That even in your bad times you can still laugh, cry, dance.”

NASH: “What I want people to get from this is change. To learn how to change and learn how to forgive and learn how to come together as a community and just, like their worth.”

SOTELO: “And to be strong. To stand up for what’s right.”

ARZATE: “And it might sound weird, but I feel like they should feel a certain level of uncomfort because that means that they’re going to look at themselves while seeing the musical. Maybe they’ll go ‘I’m uncomfortable because I do that’ or ‘I have that prejudice’ or ‘I feel that certain way,’ so if they come out and they feel uncomfortable and then at the end they’re like, ‘Wow. There’s that hope for change.’ Hopefully that like…”

DOUGLAS: “… It inspires them to do better.”

ARZATE: “Like, you can do it.”

SOTELO: “It’s kind of like a water droplet. One small move can domino-effect to something bigger.”

 



Taking attendance

Want to make middle school admissions more fair? Stop looking at this measure, parents say

PHOTO: Monica Disare
Middle school students write their names down at a high school fair in Brooklyn.

Parents across New York City have pushed for changes in the way selective middle schools pick their students, saying the process is unfair.

Now, a group of Manhattan parents has come up with a novel solution: Stop looking at students’ attendance records.

The parent council in District 2 — where about 70 percent of middle schools admit students based on their academic records — points to research showing that students from low-income families are far more likely to miss school. Those children are at a distinct disadvantage in the competition for the district’s top middle school seats, the council argues, even though factors beyond the control of any fourth-grader — especially family homelessness — often account for poor attendance and tardiness.

“This outsized focus on attendance disproportionately impacts students who don’t have secure housing and may not have secure healthcare, and that is troubling to me,” said Eric Goldberg, a member of the community education council in District 2, which includes stretches of Lower Manhattan and the Upper East Side. “There are many factors that should not impact a student’s educational opportunities — and the way the system is set up, it does.”

Eighteen of the district’s 24 middle schools are “screened,” meaning they rank applicants based on factors including test scores, grades, and interviews. Of those, all but one school also considers how often students were late or absent in fourth grade, according to the parent council.

Most of the schools assign points to each factor they consider. Some give absences 10 times more weight than science or social studies grades, the council found, while others penalize students for even a single absence or instance of tardiness.

Disadvantaged students are especially likely to miss school.

A recent report by the city’s Independent Budget Office found that homeless students are more likely than other students to be chronically absent — typically defined as missing about 10 percent of the school year.

Schools with the highest chronic absenteeism are in communities in “deep poverty,” which have the highest rates of unemployment and family involvement with the child-welfare system, according to a 2014 report by the New School at the Center for New York City Affairs.

“We can use chronic absenteeism as a good guess of all the other things kids are dealing with,” said Nicole Mader, a senior research fellow at the New School and a co-author of the report. “If these middle schools are using absenteeism to weed kids out, that means they’re going to automatically weed out those kids who have the most barriers to academic success already.”

The attendance requirement can put pressure on any family, regardless of their financial status or housing situation.

Banghee Chi, a parent of two children in District 2, said she sometimes sent her younger daughter to school with a fever when she was in fourth grade rather than have her marked absent.

Her daughter would show up to class only to be sent to the school’s health clinic — which would call Chi to pick her up. Chi was thinking ahead to middle school, when a missed day of class could hurt her chances of getting into the most sought-after schools.

“It was something I was really conscious and aware of during my child’s fourth-grade year,” she said. “I think it’s unfair.”

The education council’s resolution, which will be put to vote in December, is nonbinding because middle schools set their own admissions criteria. But a show of support from parents could lead to action from the education department, which has been prodded by integration advocates to make other changes in high school and middle school admissions.

This summer, the department announced it would end the practice of “revealed rankings,” which allowed middle schools to select only those students who listed them first or second on their applications. The city is also appointing a committee of parents, educators, and community leaders in Brooklyn’s District 15 to come up with a proposal for making that district’s middle school applications process more fair.

“We’re collaborating with communities across the city to make school admissions more equitable and inclusive, including in District 2,” said department spokesman Will Mantell in an email. The department looks forward “to further conversations about this resolution and other efforts to improve middle school admissions in District 2.”