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