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.

Kids eat free

Colorado could expand lunch subsidy to high school students

PHOTO: Helen H. Richardson/The Denver Post
Bernadette Cole serves food to students at Prairie View High School in Brighton.

When Colorado expanded a school lunch subsidy to middle school students, the number of sixth- through eighth-graders eating lunch at school went up in districts across the state.

Twenty-sixth percent more middle school students ate lunch at school in the Greeley-Evans district, where a majority of students live in poverty, but even in the more affluent Littleton district in Denver’s south suburbs, 11 percent more middle school students ate lunch.

For school nutritionists and children’s advocates, these kinds of results make the case for extending this same lunch subsidy to high school students.

“We know the co-pay is a barrier because of the large uptick in participation when it goes away,” said Erin Miller, vice president of health initiatives for the Colorado Children’s Campaign.

The “co-pay” is the 40 cents per meal that families who qualify for reduced-price lunch — but who make too much money to qualify for free lunch — are responsible for. The federal government picks up most of the cost for these lunches, and since 2008, Colorado has covered the 40 cents for the youngest students, rendering those lunches free to their families. This program has gradually expanded, reaching middle school students in legislation passed last year.

A bill that passed out of the House Education Committee Thursday would cover the 40-cent cost difference for high school students, a longtime goal of advocates.

“The state of Colorado has been trying to ensure that kids in poverty have access to food for a decade,” said Danielle Bock, nutrition services director for the Greeley-Evans district and a public policy and legislative consultant with the Colorado School Nutrition Association. “This is the final step.”

Miller said hunger affects children in school not just academically but also emotionally, with hunger even associated with higher suicide rates. Advocates have pushed to expand the state subsidy because participation in school lunch goes down as children get older, even as their caloric needs go up.

Currently, households that earn less than 130 percent of the federal poverty level, or $32,630 for a family of four, qualify for free lunch through the federal program. Families who earn between 130 and 185 percent of the federal poverty limit, or up to $46,435 for a family of four, qualify for a reduced-price lunch. It’s children from that second category families who will benefit if this bill becomes law.

Bock said the vast majority of school food service agencies in Colorado have unpaid lunch debt that, under federal law, they can’t just write off. School districts either pick up the costs out of their general fund or try to collect from parents, which sometimes leads to the controversial practice of “lunch shaming,” in which schools serve less nutritious and appealing alternative lunches to students whose parents owe money.

Lawmakers started out wanting to ban lunch-shaming, but school nutritionists convinced them it would be better to have the state cover some of the extra lunch cost for families who are struggling to make ends meet.

When Denver ended the practice of serving “alternative” meals to families who hadn’t paid for lunch, the amount of lunch debt skyrocketed, with a large portion of it coming from families who had not signed up for subsidized lunches and might have the means to pay.

According to a fiscal analysis, Colorado plans to spend $2.2 million on lunch subsidies this school year. Expanding the program to high school students would cost an additional $464,000 next year, with that money going into school food service budgets.

pass the microphone

This Memphis senior was kicked out of three high schools. Here’s how he got on track to graduate.

PHOTO: Gillian Wenhold, The Social Exchange
Despite what John Chatman calls a “really tough childhood” where he was often left on his own, he’s on track to graduate from alternative school G.W. Carver College and Career Academy this year.

In front of more than 100 people, John Chatman recalled the bullying he endured as a child for having a stutter.

Chatman was one of seven educators and students who took the mic at Chalkbeat’s February story storytelling night. The stories centered around school discipline practices, a topic we recently covered in this special report.

“Growing up in the area I grew up in, it’s hard to deal with that,” said the 18-year-old. “You’re an outcast. … It made me hate school, because I never could enjoy it. I may answer a question and stutter, [and other students would] get to laughing and cracking jokes.”

Kids stopped making fun of him in middle school when Chatman became a star middle school football player in Memphis — but the prestige that came with playing football disappeared when he was injured on the field.

“I took my injuries and replaced them with the streets,” Chatman said. “Throughout my ninth-grade year, I was starting to lose myself. … By 11th grade, I didn’t know who I even was.”

During that period, Chatman said he was kicked out of three high schools and eventually wound up at G.W. Carver College and Career Academy, an alternative school for expelled students, housed in former Carver High School.

“This school changed my life forever, Chatman said.

To hear more about how Chatman’s life changed, watch the video (or read the excerpt) below.

The storytelling night was hosted by Chalkbeat Tennessee, Spillit, and The Knowledge Tree. The video was filmed by Gillian Wenhold for The Social Exchange, a pay-as-you-can public relations and content creation firm for nonprofits, and businesses owned by women and people of color.

My 11th-grade year was the time I decided I had to change. The change was when I finally got kicked out of school. Well, I’d been kicked out of school but this was the kick-out-of-school that kicked me in my back real hard and said you only have one strike left. If you mess this up, this is it. It’s over with. You’re not going to see the light of day. Due to that, I ended up going to Northeast, and it still didn’t get better. In fact, I’m going to tell y’all the transitions of my schools. It started at ninth grade at Central, couldn’t come back to Central and I had to go to East , got kicked out of East and went to Northeast. Got kicked out of Northeast and now I’m back at Carver.

I’ll tell y’all, this school changed my life forever. I wouldn’t be here right now if it wasn’t for that school. It happened like this. There was a guy named Roger. We used to run together during the same time period. …

[During a presentation of past Carver graduates], an image of Roger popped up clear on the screen. It wasn’t up for nothing bad, he was on the road to making a six-figure [salary]. I was like, ‘This was the same person I used to shoot dice with?’… Now he’s living a life and I’m stuck here. I’m still doing the same stuff I’ve been doing and not getting no different result, and that’s called insanity… I took it, and I told myself if he can do it, I know I can.

Spillit, storytelling
PHOTO: Xzavier Bonds
Chatman speaks to a packed room during Chalkbeat’s storytelling event.