Katherine Foster is polite and speaks carefully, but get her on the subject of children’s dental care in California, and she does not mince words.
“We’re seeing a major epidemic,” Foster said. “We are looking at a crisis in dental health. We see children here with rotted-out teeth, where it’s so bad they need to be sedated, put to sleep, so they can get their mouths worked on.”
“These are preschoolers,” she said.
Foster is a pediatrician in Sonoma County, where she helped start the Redwood Empire Surgery Center to deal with children who have dangerous levels of decay. Children with major oral problems can develop tooth abscesses, Foster said. Those abscesses can be life-threatening, she said, as infections in the upper mouth can lead to brain infections.
Children from low-income families can qualify for Denti-Cal, California’s dental program through Medi-Cal, the state’s Medicaid program. However, fewer than half of the 255 pediatric dentists in California participate in the program. Of those California dentists who accept Denti-Cal, two-thirds limit the number of patients they treat because of low reimbursement rates, according to a survey published in the journal Pediatric Dentistry.
Foster estimates that because the state’s Denti-Cal payment rates for sedated dentistry are so low, her clinic loses about $300 per patient. That’s a situation that is potentially disastrous, she said.
“Every single time you have a Denti-Cal kid in your chair,” she said, “you have a grossed-out mouth and no reimbursement.”
California Is Second-Worst
Dental care for children in California ranks second-worst of all states, according to the most recent report by the National Survey of Children’s Health, funded in part by HHS.
Only Texas had a worse percentage of children with good oral health. And it is possible California’s situation could get worse.
State lawmakers are staring at a $19 billion budget deficit — a total that’s about one-fifth of the overall budget. Children with family incomes too high to qualify for Denti-Cal often are eligible for Healthy Families, California’s Children Health Insurance Program. The governor’s budget proposal calls for $16.5 million in cuts to that program and another $523 million to be trimmed from Medi-Cal.
“That kind of cut could be disastrous,” Wynne Grossman, executive director of the Dental Health Foundation in Oakland, said. “They’ve been proposing larger copays, too, which would limit access. But right now, many dentists simply won’t take Denti-Cal; some clinics have closed. And that’s without these cuts.”
Hope on the Horizon?
Lack of preventive care leads to cavities, capped teeth, abscesses and horrible pain, Grossman said.
Experts point out that many low-income infants are given high-sugar juices and drinks. Combine that with a lack of tooth-brushing and access to preventive care, and you have a potential dental mess.
Preventive care would go a long way toward keeping children’s mouths healthy, and according to Grossman, dentists don’t lose money with preventive dental visits the way they might lose money with the more-serious, sedated care.
“It can be part of a practice,” Grossman said. “If dentists are efficient, they can (take Denti-Cal patients and) get reimbursed through Denti-Cal and do fine, if it’s a part of their practice.”
The Oakland-based Dental Health Foundation is developing a program called the WIC Early Intervention for Oral Health. WIC is a federal program for women, infants and childrenÂ that provides supplemental nutrition and other services. Â As an experiment that started two years ago, DHF is providing dental care at WIC sites.
“No one has ever done that before,” Grossman said. “It’s taken off like wildfire.”
Other Possible Solutions
Susan Fisher-Owens is an assistant clinical professor of pediatrics at UC-San Francisco Medical Center. “Children in California make 83,000 visits to the emergency room every year,” she said, “and there are more visits for oral health than for diabetes.”
She calls it the largest chronic health condition in children. “Having your teeth hurt is extremely painful,” Fisher-Owens said. “Children lose school days because of tooth problems. It takes two hospitalizations to get infection under control.”
She said the problem in California is exacerbated by a lack of fluoridation in the water. “San Jose is the largest city in the country with nonfluoridated water,” she said.
“Look, kids are being attacked from all fronts. The cuts in Denti-Cal, lack of preventive care, nonfluoridated water, lots of sodas, a culture where metal on your teeth is common.” For many children, she said, it gets so bad that they don’t want to smile.
The key is early prevention and education, Fisher-Owens said. If parents knew they could spare their children a lifetime of pain and missing teeth just by discouraging sodas and encouraging brushing, they would do it.
Fisher-Owens wouldÂ like to try a different avenue: dental care during primary care doctor visits.
“Physicians are reimbursed for putting fluoride varnish on kids’ teeth,” she said. “If primary care docs can make parents aware of the impact, and get them thinking about the tooth, that could make a huge difference.”
Fisher-Owens spoke recently at the Children’s Oral Health Summit in Santa Barbara, which brought together health providers, administrators and policy experts to address children’s dental needs and how to solve them.
“Whenever there’s a crisis, you have to triage,” she said. “We can’t send every kid to the dentist. We have to find other ways in the system to help those kids. So one of the protective measures could be getting the kid into the pediatrician. They talk about dropping soda, limiting juices — you just have to make the last step to connect the dots.”
Often, when parents are confronted with a child in pain, they default to giving their kids comfort foods — and that often means lollipops or juice, Fisher-Owens said. “And their teeth hurt so bad they can’t eat, so they drink juice or soft drinks, and that really just adds to the problem.”
In Sonoma County, Foster tells a story about a woman who was licensed to practice dentistry in Mexico and recently moved to Sonoma County with her husband.
“She has practiced in Spain, Mexico and Italy,” Foster said, “and she says she has never seen this level of decay anywhere she’s been. She’s just been horrified. Honestly, this is a Third World problem we’re talking about.”
When children have the level of decay where they need to go the surgery center, they’ve crossed the line past prevention, Foster said. They need help, immediately.
“We’re looking for philanthropy to fill the gap,” Foster said. “Literally, I just spent the whole morning looking for grant award money.”
Ironically, the surgery center she helped make reality has the room and is ready to take on those patients.
“It’s all about dollars,” she said. “We have the people, we have the facilities, we have the knowledge, we definitely have the need — but what we’re missing is the dollars, the maintenance dollars.
“Doctors and dentistsÂ provide pro bono care at the Redwood Empire Surgery Center, and the organization has cobbled together help from some grants, but it’s getting more difficult, as more social service organizations in California hit up the same funders for grant money, Foster said.
“We’re actually losing providers who say, ‘I just can’t do anymore,'” she said. “When you actually lose services, when your last hope for public health is a grant-funded position, and that grant is running out, well, I’m just running out of ideas.”