Myths vs. Facts. Cavities are simply the isolated result of decaying food sitting on teeth.

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1 Each day thousands of Orange County children go to school with a painful, transmittable disease. Tooth decay may affect a child s speech, nutritional health, self-esteem and social development. The condition is largely preventable and curable with early detection. Oral health affects everyone throughout his or her lifetime. Early prevention is key to the long-term health of our teeth. Dental caries, more commonly known as cavities, may affect children sooner than most people think. A baby may develop cavities soon after they get their first tooth. This underscores the importance of following the American Academy of Pediatric Dentistry and American Academy of Pediatrics guidelines stating that the first visit to a dentist should be at 12 months or when the first tooth erupts. Surveys on oral health have shown that dental caries are the most common chronic childhood disease, five times more common than asthma. Although there are many children in Orange County with inadequate health coverage, statistics show that approximately 152,089 children in the county have no dental coverage. 1 For every child that does not have health coverage, two do not have dental coverage. 2 Myths vs. Facts There are many misunderstandings about what dental disease is and what can be done about it. With so much misinformation, it can be an easy issue to dismiss as unimportant. Presented below are some common myths about oral health. Myth: Cavities are simply the isolated result of decaying food sitting on teeth. Oral health is not essential to maintaining the primary health of a child. Only permanent teeth need to be cared for; baby teeth are temporary and of little importance. Fact: In actuality, dental caries is an infectious, transmissible and progressive disease. The acid-producing bacteria that cause dental caries (tooth decay) are passed on from family members, playmates and infected children in classrooms or at daycares. See the four factors that lead to caries on page 26. Dental caries, and the pain associated with them, can negatively influence a child s ability to sleep and eat properly, both of which are vital components of a child s general health. Additionally, when there is an infection in the mouth, pathogens can enter the body and spread multiple infections throughout. An overwhelming number of systemic diseases and conditions are first found in the mouth, before physicians find them in the rest of the body. Many systemic diseases and conditions are worsened by the presence of oral infections, both cavities and gum infections. Deciduous teeth, also known as baby or primary teeth, play a vital role in guiding permanent teeth into their correct positions. If a dentist has to extract a deciduous tooth before it comes out naturally, the permanent tooth will not have a placeholder to preserve the necessary space. Severe crowding or twisting of the teeth may affect the health of the gums and the ability to chew. Children who lose their teeth early can also develop speech problems because they do not learn how to place their tongue correctly against their teeth for proper articulation. In addition, oral pain or discomfort may undermine a child s ability to pay attention in class, making learning a difficult and frustrating experience. A cavity, even in a baby tooth, is an infection in the mouth. 22 Note: Please see page 186 for footnote references.

2 California California s children experience more tooth decay and have less access to care than most of the country s children. The advocacy group, Children Now, recently gave California a C- for dental coverage and access. In a 25-state survey, the National Oral Health Surveillance Survey ranked California 24 th in the prevalence of decay experience, only Arkansas ranked lower. In California, 71% of children have experienced decay by the third grade, 28% of elementary school children have untreated decay and 4% require urgent dental care. 4 Urgent care is required when a child needs immediate treatment for painful cavities, infections and/or an abscess. Orange County While the oral health of California s children is dismal, the dental health of Orange County s children is worse. The Dental Health Foundation, in collaboration with Healthy Smiles for Kids of Orange County and Seals on Wheels, conducted a countywide oral health needs assessment during the school year. Nearly 35% of kindergarteners required some type of dental care, including decay removal or urgent treatment, compared with approximately 20% of California kindergarteners. The report also found that 33% of children in Orange County have untreated decay, 5% higher than the state average. 5 Myth: Fact: Decaying primary teeth do not cause pain. The physical appearance of a child s teeth is insignificant and will not concern them or those around them. If my general dentist says that they do not work on children under five years old, it is ok to wait a couple years until my child can see this dentist. My child has excellent oral health; the dental needs of other children do not affect me. Decay is decay, whether it is on a baby tooth or a permanent one. Baby teeth have nerves, just as permanent teeth do. When acid eats through the enamel of the tooth, it causes nerves to elicit pain. Children who are in constant oral pain often suffer in silence, not realizing that their teeth should not hurt and that there are ways to alleviate the pain. Even children face discrimination based on their appearance. When children grow up feeling ashamed of their teeth, self-esteem and social development are affected. Children with very crooked, missing and/or decayed teeth may be afraid to smile and be hesitant to meet new people. These feelings of inadequacy may continue into adulthood. Children learn many social skills when they are quite young, and when they are unable to practice these necessary skills, it is less likely that they will grow into confident, secure adults. Most general dentists will refer children who are very young or difficult to manage to pediatric dentists. Pediatric dentists study for two additional years following dental school in order to learn the special techniques required in children s dentistry. This specialty deals with newborns, toddlers and children who require early treatment and, especially, early preventive care. Treatment for children with special healthcare needs is also a large part of the practice of pediatric dentistry. The American Academy of Pediatric Dentistry recommends all children see a dentist before their first birthday. Dental caries is a transmissible disease. Children with poor oral health may transmit the cavity-causing bacteria to other children. Poor oral health has a negative fiscal impact on public schools. Nationwide, children miss an estimated 51 million school hours per year because of dental problems. 3 Each absence amounts to significant financial losses for schools that rely on attendance-based funding. Note: Plase see page 186 for footnote references. 23

3 Orange County s Poor and Minority Children: Disproportionately Affected by Poor Oral Health Low-income children are at the greatest risk for suffering from untreated oral health problems. Thirteen percent of children less than 18 years old live below the federal poverty level. 6 Children living in poverty are more than twice as likely to have untreated decay as their affluent peers. 7 It is clear that a child s socioeconomic status has a direct relationship with their oral health, but children in families of all income levels are at risk. Using the free and/or reduced price lunch (FRL) program as an indicator, significant differences are observable between those who qualify for the program (family of 4 with an annual household income of $34,873 or less) 8 and those who do not. 9 80% 70% 60% 50% 40% 30% 20% 10% 0% Experienced Decay Untreated Decay Data indicate that racial and ethnic disparities exist, with minorities suffering more dental disease than their white, non-hispanic peers. Oral disease and poverty affect Hispanic children at an especially disproportionate rate. The table below illustrates this imbalance. 10 CHILDREN S ORAL HEALTH Need Emergency Oral Care Have Private Dental Coverage Access to Care There are about 260,000 children under the age of six in Orange County. With only 65 pediatric dentists in the entire county, there is only one pediatric dentist for every 4,000 children in this age bracket. In Orange County, 19% (152,089) of children do not have dental coverage; this number has increased 5% since Compared to children with coverage, uninsured children are 2½ times less likely to visit a dentist. For children between the ages of 0-5 years old, 17.5% (44,654) are without any form of dental health coverage and another 18.3% (47,579) have publicly funded health coverage such as Denti-Cal, the dental segment of Medi-Cal. 11 These children and their families often encounter problems accessing the care they need because few of the pediatric dentists in the County accept new Denti-Cal patients. Many children with special health care needs and/or physical impairments are insured by government programs and require the specialized assistance of pediatric dentists and/or sedation services. Because of their unique needs and frequent requirements for sedation, general anesthesia and specialized equipment, there is a severe shortage of facilities and providers for this population of children. Usually, the safety net clinics are not viable options because most do not have the resources to treat children with special needs. Children who participate in FRL Children who do not participate in FRL Hispanic Children Other Minority White, Non- Children Hispanic Children History of Decay Untreated Decay Need Urgent Dental Care Have Private Coverage Participate in FRL (All numbers are percentages) In Orange County, families without dental insurance often seek out safety-net dental providers that provide free or low-cost services to children. The map on page 25 shows the location of clinics and pediatric dentists in the county. The community clinics in Orange County offer varying levels of dental care. The Assistance Leagues and the Health Care Agency see schoolage children on referral from school nurses for basic dental services. Seals on Wheels, The Ayuda Program and Puente a La Salud are all mobile or school-based outreach programs that provide 24 Note: Please see page 186 for footnote references.

4 primary dental services and education. Only one clinic in the county, Healthy Smiles for Kids of Orange County, offers specialty services, including conscious and IV sedation, on a sliding-fee scale for children who are uninsured. In December 2005, the University of the Pacific s School of Dentistry completed an evaluation of California community care clinics. The study found that there are only 14 clinics in Orange County that have dental facilities. 12 In total, the safety-net clinics serve only 18% of the target population of children age 17 and younger who live in households at 200% of the Federal Poverty Level. 13 Survey of Seven Low-Income Dental Clinics in Orange County Recently, clinics in San Juan Capistrano, La Habra (2), Santa Ana, Buena Park, Garden Grove and Orange (mobile unit), collected information on approximately 1,120 children. The dental clinics provide free and/or affordable dental services to children who would not be able to afford treatment otherwise. Six of the clinics are part of the Pediatric Dental Care Collaborative (serving children age zero to five) and the Together as One Program (serving children over 5). The Garden Grove location is operated by Healthy Smiles for Kids of Orange County, and serves children of all ages. Note:Please see page 186 for footnote references. 25

5 Parents who brought their child to the clinics between January and April 2005 answered questions about their child s oral-health habits and history. More than 90% of the patients were Hispanic and ranged in age from birth to 17 years old. In order to examine key milestones in oral health, the data were broken into two age categories: birth to five years, and six to 17 years. 14 Children Five Years Old and Younger 54% had never been to a dentist. The average age of first dental visit was four years old 72% did not visit the dentist until after their third birthday 61% had not had a check-up in the year before the survey Not knowing what age to take a child to the first check-up was the most common reason these parents gave for not taking their child to a dentist Children 6 to 17 Years Old 26% had never been to the dentist. The average age of first dental visit was about seven-and-a-half years old 58% of the children had not had a check-up in the year before the survey 65% of the children did not have a single dental sealant (plastic material applied to teeth, forming a barrier against decay-causing bacteria) Cost was the most common reason these parents gave for not taking their child to the dentist The Good and The Bad: Orange County s Oral Health Though there is much room for improvement for children s oral health in Orange County, identifying and addressing the gaps in care will advance the goal of ensuring better overall health for the county s children. Bad News Everyday children are in pain caused by tooth decay, caries and abscesses Dental caries is an infectious, transmissible and progressive oral disease Decayed and missing deciduous (baby) teeth can negatively impact the overall health of adult teeth throughout their lifespan Dental care is not given the same priority as medical care There is a serious shortage of pediatric dentists in Orange County Good News Dental caries are almost entirely preventable Prevention is cost-effective Treatment is becoming more available, even for the most extreme cases Policy-makers, healthcare workers and caregivers are becoming educated about the need for and the benefits of early care Xylitol, a natural sugar substitute, is becoming more readily available The public is becoming more aware that oral health matters Causes and Prevention Four factors lead to caries An at-risk tooth surface Infectious, transmissible bacteria these will ferment with carbohydrates and produce an acidic waste, which can break down tooth enamel. The bacteria is passed from one person to another when saliva is transferred, this can happen when sharing utensils or cleaning a baby s pacifier with one s own mouth Excessive ingestion of carbohydrates such as sweets, juice, milk and formula. Be cautious of sweet, sticky and acidic foods, which are especially problematic Length and frequency of exposure to the fermentation process and the acidic waste Protecting Teeth Surfaces No matter how many preventive measures parents and children take, an unprotected tooth surface is still at risk for decay. Luckily, there are ways to reinforce teeth. Fluoride When used appropriately, fluoride is the best way to reduce the risk for developing tooth decay. Even in fluoridated areas, children often do not reap the benefits of the supplementation because drinking bottled water is common practice. If children and infants are not getting adequate fluoride from their water source, they should be considered for fluoride supplementation. Dentists can talk to children and their caregivers about additional ways to incorporate fluoride into their regular routine. Dentists and pediatricians can evaluate the need to prescribe topical or dietary fluoride supplements. 26 Note: Please see page 186 for footnote references.

6 Reducing the Exposure to Bacteria There is a risk that a child will be infected with the decay-causing bacteria anytime saliva is passed to him or her. People transfer saliva when they share utensils, clean a child s pacifier or bottle with their mouth or share toothbrushes. To reduce the risk of crosscontamination, everyone around the child should have regular dental visits and should floss and brush regularly. To make sure all oral problems are treated, people who will be in contact with the child should visit the dentist for regular exams before the baby is born. Dental Sealants As molars come in, one of the best ways to prevent caries is by applying dental sealants. A dental sealant is a clear plastic material that creates a barrier that protects all the fissures, or breaks in tooth enamel. Molars are the teeth most commonly sealed because one tends to engage them more than any other teeth when chewing food. Fissures in molars can also be difficult to reach when brushing. When applied correctly, sealants are extremely effective in protecting teeth for an average of five to seven years. Dentists will ensure that sealants do not develop holes during regular check-ups. While sealants are a safe, extremely effective way to prevent caries, only 30% of children in Orange County have them. 15 The Healthy People 2010 objective is to ensure that at least 50% of children have sealants. Preventing Transmission By setting up preventive techniques, even before the child is born, it is possible to lessen his or her chances of suffering caries. Because dental caries is a transmissible infection, the first preventive step is reducing the amount of bacteria to which the child is exposed. Notes: Please see page 186 for footnote references. Incorporating xylitol gum or lozenges into a daily routine can also reduce the amount of bacteria in the mouth. Xylitol is a natural sugar substitute that is not only tooth-friendly, it may also aid in preventing tooth decay and reducing plaque. When bacteria-levels in the mouth are kept at a minimum, it reduces the chances of passing the disease. Two is Too Late Although not born with the bacteria, most children are eventually infected; therefore, early dental visits are crucial. Young children can develop tooth decay soon after their first teeth erupt. The American Academy of Pediatric Dentists recommends that children see a dentist when their first tooth erupts or before the child s first birthday, whichever comes first. 16 Many people do not know what preventive steps pediatric dentists can take for very young children. The dentist can make sure teeth (deciduous and permanent) are coming in correctly, monitor baby teeth for the first signs of plaque and decay, apply topical fluoride varnish, recommend systematic fluoride supplements if appropriate and demonstrate proper brushing and flossing techniques. In addition, when a child establishes a trusted dental home early in their life, they have a reliable place to go should a dental emergency arise. The dentist can also provide anticipatory guidance for the family in areas of nutrition and hygiene. 27

7 Baby Bottle Tooth Decay (Early Childhood Caries) One of the big culprits of decayed baby teeth is baby bottle decay. It is a common practice to put children to sleep with bottles full of formula or juice or to let children carry a bottle or sippy-cup with them throughout the day. Children should never fall asleep with a bottle that contains anything other than unsweetened water. Even while breastfeeding, mothers need to stop feeding when their child is beginning to fall asleep. Oftentimes, the child s last gulp sits in their mouth and on their teeth, whipping bacteria into a feeding frenzy. Children should be drinking out of a cup by the time they celebrate their first birthday. Treatment While caries are treatable, it is often a costly process. Children who visit the dentist by their first birthday and who get regular check-ups reduce their dental-related costs by almost 40% over a five-year period when compared to children who wait longer to see a dentist. 17 Baby teeth cannot be ignored on the premise that they are going to fall out; healthy baby teeth set the stage for healthy permanent teeth. Pediatric dentists can take early action that will have positive, lifelong effects. Preventing Fermentation Carbs and Time The longer carbohydrates and starchy foods are on the teeth the longer bacteria have to feed on them, leading to fermentation and the production of acidic waste, which causes tooth decay. There are several ways to minimize the fermentation effects and reduce acid production. Smarter Snacking Children do not need to eliminate all foods with sugars and starches, but should eat appropriate quantities of these foods at suitable times; sugary and starchy foods are easier on teeth when eaten with an entire meal. Children should not regularly snack on sweet, chewy or starchy foods. Children who eat more frequently give bacteria more time to feed and produce acidic waste. It is best for children to eat these treats as a dessert, immediately after a meal, and to brush their teeth when they are finished. Although prevention is more cost-effective, there are ways to treat dental caries. Even children who have not had preventive dental care can live free of the pain that abscesses and cavities can cause. Fillings The dentist scrapes the decay out and places a filling inside the tooth, stopping the progression of damage. Fillings are used to treat mild to moderate decay. Crowns When filling the tooth is not an option, due to extensive damage, the dentist may remove the entire decayed portion and put a crown over the salvageable tooth. Extractions When the damage has advanced beyond repair and the tooth is not vital, a dentist may remove the tooth. The dentist may fit the patient with a bridge or a partial plate (simulated tooth) if there is a visible gap in their smile or if the location impairs the patient s ability to tear and chew food. Root Canals If the damaged tooth is vital and most of the tooth is salvageable, the dentist may choose to perform a root canal in order to preserve the tooth. During this procedure, the dentist will remove the nerves and the decayed portion of the tooth, eliminating pain, but keeping the tooth intact. Note: Please see page 186 for footnote references. 28

8 Education: Laying a Solid Foundation One strategy in promoting healthy dietary habits has been the education of mothers and caregivers. Education has focused on preventing disease transmission and encouraging healthy feeding practices. Primary care providers, general dentists and social marketing efforts should educate individuals in order to prevent early childhood caries. Because resources for and access to preventive services are limited, primary care providers and general dentists should receive professional training. The Dental Health Foundation, in collaboration with Healthy Smiles for Kids of Orange County and the American Academy of Pediatrics, provides training programs to guide and educate pediatric and obstetric offices throughout Orange County. Additionally, other caregivers, such as school nurses, early-childhood educators and primary-care nurses have participated in these sessions to integrate oral health education into their practices. Kaiser Permanente has selected oral health as a strategic initiative for 2006 and is incorporating oral health messaging into its pediatric practices in Southern California. Recognizing the need for more pediatric dentists in Orange County, the Children s Hospital of Orange County has teamed with the University of Southern California s School of Dentistry in order to expand its Advanced Program in Pediatric Dentistry. USC will provide two pediatric residents, based at CHOC and Healthy Smiles, beginning summer This expanded program will help produce the next generation of pediatric dentists for our county. Early and frequent dental visits are critical to the prevention of tooth decay. The goal is to promote regular dental check-ups, fluoride treatments and education. When Orange County residents are educated about this important issue, we can work collectively to address the dental health problems of the county s children. Orange County: Working Together For Our Children Education is key, if it works as part of a larger system of care. Recently, the Institute of Medicine issued two reports on improving quality that include education but take a systems look. One report provided a clarion call for improving the quality of chronic-illness care, including oral disease. 18 In Orange County, a concerted effort is underway in the communities and in the dental healthcare organizations to improve the quality of dental healthcare and ultimately dental health outcomes. In 2003, Healthy Smiles for Kids of Orange County was founded as a funded program of the Children and Families Commission of Orange County after initial incubation by the Health Funders Partnership of Orange County. Healthy Smiles implements strategies to improve the oral health of children in Orange County through a comprehensive and collaborative approach to prevention, education and treatment services. Since Healthy Smiles was initiated, the Commission, Healthy Smiles, Children's Hospital of Orange County (CHOC) and the Boys & Girls Clubs of Garden Grove collaborated to develop a comprehensive children's health and dental center in Garden Grove. The center represents a culmination of incredible collaboration between funders, providers and the community for the benefit of our low-income children. During 2005/06, the Children and Families Commission funding resulted in 10,612 children being screened for dental services. 47% of children served had not seen a dentist before receiving Commission funded services. This effort should improve interactions between informed and empowered patients and prepared proactive providers. In doing so, we can hope to see improvements in dental health outcomes for Orange County children who one day will be Orange County s adults. 29