BY: STEPHEN HOLLISTER, M.A.
In the poorest neighborhoods of Orange County, Calif., 1 in 3 schoolchildren screened during 2010 had visible, extensive, dental decay, making dental disease the most common chronic childhood disease in the nation's sixth most populous county -- far more prevalent than even asthma, obesity and childhood diabetes. This is a problem that demands more attention than it is getting. We cannot adequately help these children without also helping the adults from whom they learn their dietary and oral hygiene habits. We need to educate, screen and treat the entire family, including pregnant women, who often fail to get the care they need because they fear dental care will harm their babies.
ORAL HEALTH IS PART OF OVERALL HEALTH
People talk about dental care as if it were something apart from medicine. For a problem with any other part of the body, we take our children to a doctor. He or she may specialize in treating the brain, heart or feet, but we definitely think of that person as a doctor. However, when it comes to the teeth, we take our children to a dentist. Few of us stop to realize that a dentist is also a doctor who specializes in a particular part of the body. It is as if oral health were not an integral part of overall health. As a result, many of us do not take dental care seriously enough — including parents and health care funders.
St. Joseph Hospital in Orange, Calif., is committed to addressing oral health needs as part of its effort to provide high-quality accessible primary care to the poorest and most vulnerable residents of our service area. Our hospital operates the La Amistad de Jose (Friends of Joseph) Family Health Center and Puente a La Salud (Bridge to Health) mobile community clinics to provide primary health care services, including oral health care, to the most vulnerable members of our communities. La Amistad is a fixed-site community medical and dental clinic. Puente consists of three licensed mobile clinics providing dental, vision and primary medical care. La Amistad and Puente collaborate with one another and with dozens of clinics, community organizations and schools throughout our county to address the poor state of oral health among our poorest residents through education, prevention and treatment.
CRITICAL EARLY CARE
We find that many parents assume baby teeth aren't important because the teeth will fall out anyway. Our oral health care providers teach them that such thinking puts children's physical and psychological health at risk. Left untreated, tooth decay in baby teeth can become very serious, and late treatment becomes much more expensive. What's more, adult teeth are likely to come in crooked and crowded if the baby teeth they replace weren't healthy. Not only can that create social repercussions based on the way the teeth look, but crowded teeth also are harder to clean, making children more susceptible to cavities and gum disease throughout their lives.
A child whose baby teeth haven't received proper care may suffer constant pain from tooth decay. Chronically painful teeth can make chewing unbearable, causing a child to eat less, affecting his or her nutrition which, in turn, affects growth and development. Constant pain makes paying attention and concentrating in school difficult. It also interferes with sleep, which further diminishes the child's ability to focus on schoolwork.
Cavities are not simply the isolated result of decaying food sitting on the teeth. They are caused by acid-producing bacteria and are an infectious and progressive disease. Infected teeth flood the body with pathogens, causing infections throughout, including the ears, sinuses and kidneys. These pathogens also can cause the minor cuts and scrapes of childhood to become infected. Physicians sometimes fail to notice where the infection ultimately originated, and these infections not only add to a child's suffering, they can cause missed days of school, require higher level treatment and sometimes lead to hospitalization. It's possible for children with untreated caries to spread the bacteria to other children and, although fortunately it isn't common, both children and adults sometimes die from infections originating with poor oral hygiene.
Dental health can also affect a child's psychological health, for as tooth decay progresses, appearance and smell become factors, harming self-esteem and social development. Broken, rotting and missing teeth also affect the pronunciation of words, which can have additional social impact.
There are striking disparities in dental disease. Poor children suffer twice as many dental caries and are more likely to go untreated than their more affluent peers. These differences between poor and non-poor continue into adolescence. Unfortunately, those at highest risk of dental disease are also the least likely to have access to routine professional dental care. Those without dental insurance are three times less likely to receive dental care than children who have coverage.
In addition to poverty and lack of insurance, other barriers to dental care include transportation issues and a lack of available providers. Few dentists are willing to accept low-income children who depend on public assistance. Even among patients with basic insurance coverage, many low-income individuals can't afford the high out-of-pocket deductibles and co-pays for dental services, thus they may be forced to go without the care they need.
We believe that to improve overall community health in Orange County, families need to have a dental home responsible for delivering comprehensive, coordinated and continuously accessible care, along with referrals for specialized care as necessary.
EDUCATION IS KEY
Treating tooth decay and associated infections is crucial for a child's health; however that will not stop dental disease from reoccurring. Prevention is necessary. To learn and develop healthy habits related to oral hygiene, children need the support of their families. It is necessary, therefore, to educate the parents too. According to the American Academy of Pediatrics, young children especially benefit when their mothers have access to good dental care and then model good oral hygiene habits at home.
Recent research shows that teaching both adults and children while they are in the dentist's chair helps them learn better about how to take care of their teeth and gums. When instruction takes place during dental treatment, patients focus their attention, improving their learning and retention.
Unfortunately, our pediatric dental patients tend to have such extensive decay that to treat them in a single visit would be overwhelming and even torturous for them. We therefore develop multi-visit treatment plans, but we find that parents tend to stop keeping appointments once the child's pain has subsided, usually because taking a child to the dentist means taking time off from work without pay.
Our patient care coordinator works with families to ensure they understand the child's oral health depends on completing the full course of treatment. This often requires many phone calls and sometimes a significant amount of one-on-one education. We have found it effective to offer dental care to the parents and schedule the adults' appointments at times adjacent to their children's follow-up visits. This tactic helps ensure more of our pediatric patients complete their full treatment plans.
ORAL HEALTH CRITICAL IN PREGNANCY
Adults with poor oral health can suffer many of the same consequences as children do. For pregnant women, however, dental care is especially important — their hormonal changes during pregnancy make them more prone to gum infection, often called pregnancy gingivitis, and they may need more frequent dental cleanings than usual to keep their teeth and gums healthy.
Pregnancy gingivitis can destroy bone that anchors teeth in place, and it is associated with one of the most common and dangerous complications of pregnancy, preeclampsia — a hypertensive disorder that decreases blood flow to the placenta which can cause low birth weight and other complications.
Also, oral infections require the immune system to fight back. It is the body's response to infection that can cause a pregnancy to be cut short. Babies born prematurely face a dramatically increased risk of cerebral palsy, visual problems and other disorders and account for more than half of all health care costs for newborns.
We find that many women mistakenly believe poor oral health — even losing teeth — is a natural part of pregnancy, plus they are afraid dental treatment will harm the unborn child. We teach that while it is wise to avoid X-rays during pregnancy, it is necessary and safe for an expectant mother to floss and brush regularly and have her dentist screen for periodontal disease. If she suffers from this condition, a woman should have her teeth and gums carefully cleaned and disinfected during the second trimester of pregnancy.
OUT TO THE COMMUNITY
St. Joseph Hospital's community dental program seeks to reduce access barriers and increase dental services directed to low-income families. Our fully equipped mobile clinic takes low-cost services right into the community, thus removing barriers of cost and lack of transportation. The clinic goes out to schools, low-income housing apartments and community centers around the county in order to provide dental services in convenient, accessible locations to help ensure more families will receive the oral health care they need.
More than 90 percent of our dental patients are Latino and many are monolingual speakers of Spanish. Our bilingual, bicultural staff is vital to our efforts to remove the barriers of language and cultural differences and to provide dental education appropriate to the levels of our patients' literacy and dental health knowledge. We teach children and their parents about proper brushing and flossing. We also teach them how nutrition and eating practices affect their oral health.
Puente visits schools where at least 50 percent of students are from low-income families. Puente is the only mobile dental clinic in our county of more than 3 million people that currently provides a broad range of dental care (dental examinations, X-rays, fillings, extractions, teeth cleaning and restorative treatment) on school campuses. We work closely with school nurses and principals to make this possible. Principals help secure the necessary permissions for us to offer dental services at each school. School nurses secure parental consent for screening and treatment. They also do initial visual screenings to ensure the children most in need receive treatment first.
School nurses in particular really appreciate the opportunity to work with our mobile clinic staff to bring these dental services to their schools, and they continuously implore us to visit many more schools than we have the capacity to serve.
We also receive referrals from various community organizations, including Healthy Smiles for Kids of Orange County, founded by our hospital's former director of community services. Healthy Smiles conducts dental and sealant screenings three times throughout the elementary school years (kindergarten, second and fifth or sixth grades). Approximately 10 percent of the children are found to need urgent dental treatment, which most can receive in the mobile clinic right at their school. Children who require sedation for certain procedures or who are unable to sit through treatment because of special needs affecting cognition or behavior go to Healthy Smiles for care at its fixed-site dental clinic.
Our patients often refer friends and family to our mobile clinics, where we focus on reinforcing oral health education and prevention messages at every encounter. Our team also meets one-on-one with parents to discuss their children's dental health and treatment needs. Our patient-care coordinator moves each child through the continuum of dental services and helps families gain access to other needed medical or social services. We have found that well case-managed families have a much higher probability of completing treatment and adopting lifelong healthy behaviors.
In addition to schools, Puente visits other community sites, including nonprofit community organizations and even a large Latino supermarket where we provide services in the parking lot. Mobile dental clinics have the advantage of being able to take services to where the people are. This reduces problems with lack of transportation and reduces the amount of time people need to take off from work — a particularly important issue for our patients, many of whom are paid by the hour and receive no compensation for time missed, even for health care.
COST ISSUES
The largest disadvantage we have faced with our mobile clinic is that its equipment and temperature control are powered by a generator. High fuel costs have made running the generator quite expensive; furthermore, running it for eight hours a day is hard on the generator itself. It is prone to frequent breakdowns, and time needed to take it down for maintenance and repairs reduces the amount of time it is available to run the mobile clinic.
We have been working with schools and other partners to find ways to plug into their electrical systems. When we are able to do so, it spares the generator and helps us increase the average number of patients we can see per week while decreasing the per-patient cost of care.
La Amistad primarily serves adults, including pregnant women. Within community health, adult oral health is perhaps the most neglected area. We have found it far easier to raise money to support dental programs for children than for adults. In California, the public insurance for the indigent, Medi-Cal, no longer funds adults except for pregnant women. Private funders tend to focus on children. They don't realize that full success in improving children's oral health comes only with caring for and educating their role models — the parents or guardians who are responsible for the child's diet and oral hygiene. Our clinics see adults every day who either have never seen a dentist or have not seen one in many years. As a result, they have rampant tooth decay, gum disease, bone loss and tooth loss. This is a huge gap in the safety net that needs far more attention from community clinics and funders.
STAYING CLOSE
Both La Amistad and Puente advance oral disease prevention by increasing the number of low-income individuals who receive preventive and restorative dental services and by providing a closed-loop system of care with diligent and appropriate case coordination, comprehensive treatment, and educational interventions. We also help families to obtain dental and medical homes, if they don't already have them.
The most important thing we do to ensure that we provide the care our patients need — and to do so effectively — is to stay close to our patients. We employ care providers who are themselves members of the communities we serve, and we listen to our patients. We learn what they know, what they believe and what they desire. We can help them achieve their health care goals by meeting them in their own community, filling gaps in their knowledge and empowering them to do their part to improve their own health and that of their children.
PROGRAM SUSTAINABILITY
Keeping our services financially sustainable is a constant challenge. Our community clinic dental program is largely funded by our hospital. Part of the support is in-kind contribution of both indirect costs and direct costs. The hospital provides space for the fixed-site community clinic and, as departments of our hospital, both the mobile and the fixed-site dental clinics receive the support services they need to operate, including utilities, human resources, security, accounting, insurance, etc.
The hospital commits 7.5 percent of its bottom line to caring for the poor. Our Care for the Poor program provides funding for direct patient care services including our community clinics' medical, vision and dental services. An additional 2.5 percent of the hospital's bottom line goes to the St. Joseph Health System Foundation which makes grants available to nonprofit organizations working to improve community health.
Our dental program has a contract with Orange County, which provides a level of reimbursement for a portion of our patients. Other funding comes mostly from private foundations and some from individual donors. Because our hospital provides the infrastructure for our clinics, including direct costs, we are able to offer donors the opportunity for all of their contributions to directly benefit patients. Many find this appealing; yet maintaining a funding level that allows us to always operate our clinics at full capacity remains a significant challenge.
To improve future sustainability, we recently established a new permanent endowment for our clinics that has quickly received considerable donor support. We continue to raise much-needed funding for both this endowment and current operating expenses.
STEPHEN HOLLISTER is grants director for the St. Joseph Hospital Foundation, Orange, Calif.
TIPS FOR STARTING A PROGRAM
The need for high quality, community oral health care in low-income communities is enormous. There are many designing and funding challenges for such programs, and based on what we have learned, we offer these pointers:
- It is important to employ staff who can relate linguistically, culturally and even situationally to the people the program will serve
- It is important to partner with other organizations that have good relationships and knowledge about the communities to be served, including a full understanding of their social determinants of health
- Consult with others who are already operating these kinds of programs for input about what things need to be addressed to allow for success
- Consult an experienced community dentist to help ensure that your operatories are designed and equipped to meet the needs of your target group and can appropriately accommodate the disabled
- Line up an experienced manager to advise you on appropriate software and procedures for medical records, case management and business functions
Copyright © 2012 by the Catholic Health Association of the United States
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