Schools struggle to provide dental health safety net

March 31, 2013
Photo of student and adult at James Madison Middle School in Oakland

Students learn how to care for their teeth and receive preventive care at a dental clinic at James Madison Middle School in Oakland. Credit: Alameda County Public Health Department

As California educators grapple with boosting student achievement across economic lines, the teeth of poor children are holding them back.

Hundreds of thousands of children suffering from dental disease, some with teeth rotted to the gum line, are presenting California school districts with a widespread public health problem.

Increasingly, dental health advocates are looking to school districts to help solve the crisis. Innovative oral health care projects have been launched around the state, including on-campus dental clinics in the Oakland Unified School District, the El Monte City School District and the San Diego Unified School District, that provide students with no-cost dental screening or treatment. Third-party insurance companies are billed whenever possible.

Dental disease is at “epidemic” levels among California children, according to the U.S. Surgeon General, and low-income children are disproportionately affected. They are 12 times more likely to miss school because of dental problems than children from higher-income families, according to a 2008 report by the Healthy States Initiative, a coalition sponsored by the Council of State Governments to study state health problems.

“The issue is huge,” said Gordon Jackson, director of the state Department of Education’s Coordinated Student Support and Adult Education Division, which oversees health, counseling and other support programs provided at schools. “Tooth decay remains one of the most chronic diseases for children and adolescents. As we’re having the conversation about California’s future and student academic achievement, we have to have a conversation about oral health as well.”

But many districts lack the resources, or balk at being asked to provide dental care on top of a rigorous curriculum. In a school day packed with academics, and with schools under pressure to improve test scores, taking kids out of class to see the dentist or hygienist can be a tricky negotiation between health providers and school principals.

“It’s a great idea to bring universal prevention programs of all types, including dental, to schools,” said Kimberly Uyeda, director of student medical services for the Los Angeles Unified School District. “Whether there’s enough time in the day is another question.”

Lost revenue

Still, schools have a vested interest in helping solve the problem.

Dental problems keep California students out of school an estimated 874,000 days a year, costing schools about $29.7 million in lost attendance based-funding, according to the 2007 California Health Interview Survey, an ongoing statewide survey by the Center for Health Policy Research at UC Los Angeles. The study is still considered the benchmark for children’s oral health.

Credit: Lillian Mongeau, EdSource Today

Dental health also affects student performance. Students with toothaches were almost four times as likely to have a lower grade point average than students with healthy teeth, according to a 2012 study by the Herman Ostrow School of Dentistry at the University of Southern California.

Advocates say the dental health crisis is exacerbated by the failure of Medi-Cal’s dental program, called Denti-Cal, to adequately serve low-income children, lack of funding for a state school-based dental disease prevention program for low-income children, and the lack of money to enforce existing state laws requiring oral screenings and preventive care for school children.

School-based dental clinics can play a large part in the solution, given the holes in the state’s safety net. One model is to house dental care inside a school-based medical clinic. Some 61 school-based health clinics, out of about 200 in the state, offer dental disease prevention, which means having a dental hygienist who screens and refers students out to full-scale dental clinics. Of these 61 school heath clinics, 36 offer full dental treatment services and can provide on-site oral health care to students.

Outside of a school setting, finding a dentist who accepts Denti-Cal is a significant obstacle for low-income children. California’s reimbursement rates to Denti-Cal dentists are among the lowest in the nation, according to a January 2013 report by The Children’s Partnership, a nonprofit that studies dental care in California. And according to a recent survey of 300 dentists conducted by Barbara Aved Associates, a Sacramento-based health consulting firm, low reimbursement rates are the main reason why dentists don’t sign up with Denti-Cal.

The numbers of low-income children who need care are expected to increase as of January 2014, when the Affordable Care Act will give all California children access to dental insurance for the first time. Children covered by the Affordable Care Act, combined with the transfer of children from the Healthy Families Program to Medi-Cal coverage this year, will swell enrollment in Denti-Cal to nearly 5 million. This means that nearly half of California’s children will be Denti-Cal patients, according to The Children’s Partnership report.

The implications are clear, advocates say. “You’ve got to bring the services to the children,” said Roseann Mulligan, chair of Dental Public Health and Pediatric Dentistry at the Ostrow School of Dentistry and one of the authors of the study about oral health and student achievement.

Reaching students

A number of districts are doing just that. Some of the dental services are financially self-sustaining through billing to third-party insurers, while others rely on grants and partnerships. The goal is for all clinics to become self-sustaining.

Inside the sleek new student health center housed at James Madison Middle School in Oakland, dental hygienist Linda G. Cannon beams her headlamp into the mouths of hundreds of students from the middle school and nearby Sobrante Park Elementary School. Two days a week, during physical education class period or the “sixth period” extra time, students spend about 50 minutes in the baby-blue dental chair. With the whoosh of the suction tool as a soundtrack, Cannon screens for decay, cleans teeth, applies fluoride varnish, which can help prevent tooth decay, and applies tooth sealant, which is an effective barrier to cavities, particularly on molars. The clinic, which doesn’t provide fillings or other restorative dentistry, accepts dental insurance and Denti-Cal, and provides free service to the uninsured. Services are funded by the Alameda County Public Health Department and The Atlantic Philanthropies, a New York-based private foundation.

Of the more than 400 students students screened at James Madison in the last two years, nearly three quarters of elementary school students and just over half of middle school students showed signs of tooth decay, Cannon said.

Another model is a mobile dental clinic that travels to schools. In the San Diego Unified School District, the La Maestra Mobile Health Clinic, which includes dental services, began operating in fall 2012 to provide fillings and restorative dentistry to students at the Hoover Cluster of schools: 10 elementary schools, two middle schools, and one high school in the City Heights neighborhood, an area of high need.

Students receive initial screenings and preventive care at dental clinics housed in school health centers in the Hoover Cluster. For treatment, they go to the mobile van, which includes two “operatories” – full stations with dental chairs, suction devices, drainage, drills and x-ray equipment – and a comfortable reception area.

“What we are trying to do is make it a positive experience,” said Dorothy Zirkle, a consultant for Price Charities, a nonprofit dedicated to improving the quality of life for children in City Heights. “Our kids have a high need for multiple fillings. We need to build trust.”

All services are no-cost, with providers seeking reimbursement from insurers when possible. Among the organizations funding the facilities and services at the mobile dental clinic are La Maestra Community Health Centers, private foundations including the City Heights Partnership for Children, and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

A third model is a partnership with a nearby dental college to offer expanded services for students. In the El Monte City School District, students receive comprehensive dental care at two dental clinics housed in elementary schools, as well as from a mobile dental unit.

The dental clinics, which opened in 2012, rely on the services of dentists and dental students from the Western University of Health Sciences College of Dental Medicine.

Advocates say these programs and others like them are key to helping solve the dental health crisis facing California students.

Data that show the connection between oral health and student achievement will help persuade districts to support school-based dental care, said Maryjane Puffer, executive director of the Los Angeles Trust for Children’s Health, a nonprofit founded to serve students in LA Unified.

“School districts are eager to find a way to help kids stay in school and achieve,” she said.

 

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