Promising Trends in Children’s Oral Health

Success stories can seem rare in the world of public health. And stories about the dentist in popular culture aren’t often the most enthusiastic.

But November’s SNAC Lab featured important dental success stories: Children’s oral health in Colorado is improving. At the same time, more Coloradans have dental insurance. These improvements have tracked with investments from local foundations, state spending, and changes in Medicaid’s oral health policies.

The SNAC Lab covered two new sets of data on oral health.

• Sara Schmitt, Director of Community Health Policy for the Colorado Health Institute (CHI), shared data about insurance coverage and dental care for adults and children from the 2017 Colorado Health Access Survey (CHAS).
• Epidemiologist Renee Calanan and Dental Director Katya Mauritson, both of the Colorado Department of Public Health and Environment (CDPHE), shared the fiscal year 2016-17 results of Colorado’s Oral Health Basic Screening Survey.

Healthier Teeth and More Coverage, But Disparities Remain

Physical and oral health are closely connected, Schmitt said. Nearly 90 percent of Coloradans in good physical health reported having good oral health on the 2017 CHAS while only half of those with poor physical health reported good oral health.

Seven of 10 Coloradans now have dental insurance (70 percent), up from 63 percent in 2009, according to the CHAS.

Low-income adults are less likely to have dental insurance than higher-income adults, though the rates for both have improved since 2013. Children are more likely to have dental insurance than adults: 85.3 percent of children are insured compared with 65.2 percent of adults.

But the percentage of Coloradans who actually visited the dentist held steady at around 66 percent.

Unequal access to dental care may be to blame. Some counties don’t have dentists at all, and some have none that accept Medicaid, according to the CHAS. (See map.)

Children and Dental Disparities

New data from Colorado’s Oral Health Basic Screening Survey are striking, according to CDPHE’s Calanan and Mauritson. Fewer than one of three (31 percent) kindergartners had tooth decay or missing teeth or fillings in 2016-17, down from nearly half (46 percent) in the 2003-04 survey. Fewer students had untreated decay, and fewer had urgent need for dental care. That’s evidence that the oral health of Colorado children has improved notably, they said.

For the survey, dental hygienists examined the teeth of kindergartens and third grade students from 59 elementary schools across the state and reported on their observations. Schools from a variety of socioeconomic backgrounds in each of the state’s 21 Health Statistics Regions were represented.

Trends were similar among third graders: 47 percent had tooth decay, missing teeth or fillings in 2016-17, down from 57 percent in 2003-04. Another positive trend: Third graders were much more likely to have dental sealants, which protect teeth from cavities and decay: 57 percent in 2016-17, an improvement from 35 percent in 2003-04.

The data show improvement for children in every socioeconomic group. But disparities remain. In both kindergarten and third grade, students at schools with the highest poverty rates had significantly worse oral health.

Structural inequities based on race, country of origin, and other factors have led to the disparities in oral health, Mauritson said. The disparities matter because good oral health often has wide-ranging impacts on a child’s life: A kindergartner who is not suffering from tooth pain is less likely to miss school or to be distracted by pain.

“It’s about school readiness, being able to set yourself up for reaching potential across the lifespan,” she said. “Kids with toothaches are four times more likely to have lower grade point averages. They’ve missed school because of pain; they’re sitting in pain silently.”

Mauritson said data like these from the oral health survey help illuminate patterns: “When we don’t count people, we don’t see disparities. That’s neglectful.”  

Panel Discussion: Cause for Celebration

CHI’s Alex Caldwell, Associate Director of Program Development and Analysis, moderated a panel with Gina Schmidt, a dental hygienist at the School Oral Health Program at Denver Public Schools and Denver Health; Linda Reiner, vice president of the Caring for Colorado Foundation; and Jennifer Goodrum, director of government relations for the Colorado Dental Association.

Reiner celebrated the CDPHE data.

“I hope people can appreciate how amazing that is,” she said. “When I think about all the people who had a role in those gains, it’s pretty incredible.”

Reiner said a number of factors, including the adult dental benefit that Colorado’s Medicaid program began offering in 2014 and the work of early childhood councils, health departments and other groups that had focused on oral health in the state, combined to produce the better results. “No group could have done that alone.”

Goodrum said the improvements are evidence that policy change has an impact. The dental association, for instance, focused on connecting dentists with those who weren’t getting care.

Schmidt said that as a hygienist, she was particularly heartened by the increase in children with dental sealants. “It’s a simple service we can provide that can save so much pain and so many health problems at a later date,” she said.

A theme of the panel discussion was integrating dentists into schools, homeless shelters and medical clinics to help encourage people to access oral health care. Schmidt described her work in school-based health centers in Denver with children and families who might not otherwise have come to a clinic. A grant from Delta Dental Foundation has allowed some Denver Public Schools students to get dental care free of charge.

Caring for Colorado’s Reiner shared a few examples of how access to dental care can be improved by integrating with other medical or community services. A Boulder clinic, for instance, embeds a hygienist in a mental health center to provide basic services and refer patients to a dentist where necessary.

Questions from the audience centered around the barriers that prevent people from going to the dentist.

One attendee asked why people chose not to travel a mile to get care. Reiner and Schmidt pointed out that a combination of logistical reasons and fear can prevent people from receiving dental care.

Another attendee raised the point that, by the time many people make it into get dental care, they need multiple visits to treat serious problems. It can take a long time, and patients’ insurance status might change over time.

Another attendee noted that many people avoid dental care after bad experiences with dentists. The dental association’s Goodrum said bad dental experiences have been in the spotlight in Colorado: The state was the site of a high-profile case around whether children can be restrained during dental care. The problem is particularly common among people who don’t speak English. Goodrum said that there are regulations relating to the use of restraints in dental care, and dental schools have begun addressing this issue, encouraging new dentist to be more community minded and offering training on navigating cultural differences.

Conclusion

Oral health status and access to dental care are improving in Colorado, especially among children. But gaps in access remain, and many Coloradans do not see the dentist regularly. Policymakers can and should celebrate the improvements while continuing to focus on policies related to reimbursement, education for providers and patients, and overcoming barriers to dental care.