Opinion + Voices

UCLA faculty voice: Low-income children deserve better access to dental care

Dental problems can adversely affect both school attendance and performance

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Childrens dentists
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Childhood tooth decay and gum disease can lead to serious health problems in adults.

Jonathan Fielding
UCLA
Jonathan Fielding

Dr. Jonathan Fielding is a distinguished professor of public health and pediatrics at UCLA. This op-ed was published in U.S. News and World Report.

We are not taking care of our children’s teeth, and it is hurting them in school and later in life.

According to the Centers for Disease Control, tooth decay is among the most common chronic conditions of childhood. One in five children, aged 5 to 11, and one in seven children, aged 12 to 19, have at least one untreated cavity.

These numbers are higher for children from minority and low-income families. African-American and Hispanic children are more likely than white children to have cavities in their primary (baby) teeth and are twice as likely as white children to have untreated cavities. The disparity in untreated cavities continues into the teen years.

A report by the Pew Charitable Trusts states that untreated tooth decay “can cause pain and infection that may lead to difficulty eating, speaking, socializing and sleeping, as well as poor overall health.” Tooth decay can also contribute to low self-esteem and dental health problems.

Dental problems can also adversely affect both school attendance and performance. A report issued by the U.S. Surgeon General in 2000, estimated that more than 51 million school hours were lost annually due to dental-related illnesses. More recent studies confirm these earlier findings. A 2011 study of school children in North Carolina published in the American Journal of Public Health found that “children with poor oral health status were nearly 3 times more likely ... than were their counterparts to miss school as a result of dental pain.”

School absences due to dental pain affect learning. A 2012 study by the Herman Ostrow School of Dentistry at the University of Southern California found that “children who reported having recent tooth pain were four times more likely to have a low grade point average — below the median GPA of 2.8 — when compared to children without oral pain.” This affects academic achievement, employment opportunities and earning potential.

Poor dental health is also driving up costs to American taxpayers. The American Dental Association reports that overall spending on dental care increased from $50 billion in 1990 to $113 billion in 2014. And during this same period the share of total U.S. dental care funded by public sources soared from 2 percent to 11 percent. One major contributor to this increase has been more children getting dental care from Medicaid and through the Children’s Health Insurance Program.

Childhood tooth decay and gum disease can lead to serious health problems in adults. According to the American Dental Association, there are “more than 125 health conditions that may affect or be affected by oral health, including cardiovascular disease, human papillomavirus (HPV) infection, HIV/AIDS, osteoporosis, obesity, and autoimmune disorders like rheumatoid arthritis.” And the association reports that people who have tooth decay as children are more likely to have tooth decay as adults.

The main culprits that lead to tooth decay are sugar and starches, which are complex sugars. But they are not the direct cause. Decay is caused by the bacteria in everyone’s mouth that feast on the sugars, producing acids which erode the enamel of teeth.

What can we do about it?

The best advice is what your parents probably told you: Limit the sweets, and brush your teeth. The more sugar a child eats, the more acid is created to eat away at teeth. But it is a tough challenge. Sugars and starches are in a wide variety of foods, including fruits, vegetables, milk and milk products, bread, candy, cookies and soda. Processed foods contain added sugars, too.

The most obvious way to prevent tooth decay is to have children brush their teeth at least twice a day. And it is important to use toothpaste that contains fluoride to help strengthen tooth enamel.

But beyond brushing, there are a number of public health steps we can take to address tooth decay in children and adults, too.

The first is to expand access to fluoridated water. In 1945, communities across the country began adding fluoride to their public water system to fight tooth decay. According to the CDC, “drinking fluoridated water keeps teeth strong and reduces cavities by about 25 percent in children and adults.” Today, water fluoridation has gained widespread acceptance in the U.S. About three-quarters of Americans on public water systems — 211 million in all — receive fluoridated water. However, 108 million Americans served by public or private water systems, do not.

You can find out if your water service provides fluoridated water here. And the next time you or your child drinks bottled water, remember that many brands of bottled water do not contain fluoride.

The second is direct application of cavity-reducing materials. Fluoride varnish or gel can help protect both primary and permanent teeth from cavities. Sealants, a thin plastic coating, bind to the enamel of each tooth and protect the tooth from the acid created by those sugar-craving bacteria. Sealants are typically applied to permanent teeth but may be applied to baby teeth as well. Many children have sealants applied by their family dentist. School-based sealant programs offer the procedure to low-income children in some communities.

How effective are sealants? The CDC reports that “school-age children without sealants have almost 3 times more cavities than those with sealants.” It is important that more school systems adopt sealant programs.

Third is addressing the dentist shortages. The Pew Charitable Trusts reports that there are two kinds of dentist shortages in the U.S. The first is the uneven distribution of dentists. Some areas have an oversupply of dentists, and some don’t have enough. According to an analysis by Pew, in 25 states and the District of Columbia, at least 10 percent of residents do not have adequate access to a dentist. The number is highest — 36 percent — in Mississippi. We need to create a better balance by providing incentives to new dentists to locate their practice in underserved states and communities, and authorizing the use of dental therapists in these areas.

The other shortage is the relatively small number of dentists who accept Medicaid patients. Medicaid reimbursements for dental care are low, many services are not covered and there are total benefit caps. As a result, many dentists do not participate in the Medicaid program, and many low-income families are unable to receive dental care. Efforts should be made to increase reimbursements, cover more dental services and expand access to dental care for low-income children covered by Medicaid or CHIP.

Finally, the Affordable Care Act significantly expanded the availability of dental insurance for children. The health care law’s health plans offered through health care exchanges must include it in their coverage. However, it may be offered as a separate plan, increasing the cost for participating families. And the set of covered dental services varies from state to state. A report issued in September 2016 by the Center for Children and Families at Georgetown University’s Health Policy Institute outlines the health care law’s shortcomings and changes needed to expand dental care under the law, Medicaid and CHIP.

Be of good cheer this holiday season. But remember that your children’s dental health is important today and for their futures. Let’s resolve to expand access to dental care for all of America’s children.

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