Viewpoint

America, We Need to Invest in Dental Care for all of our Children

William J. Maloney, D.D.S.

Poor oral/dental care for children sets the stage for a lifetime of costly and painful dental issues and has a deleterious effect on the individual’s systemic health and overall quality of life. The oralsystemic health connection has been well-documented in the scientific literature in the past few decades. It is now known that deficient oral/dental health can set off a cascade of poor health throughout one’s life, with the resultant negative socioeconomic issues that are all too often associated with poor health.

In the United States, there are a large number of state and federally funded children’s dental health programs. However, many children cannot access care for a variety of reasons. It is imperative that all children receive a high standard of dental care by eliminating barriers, such as social inequality, familial economic status, separation of dentistry and medicine, and lack of public education about the impact of good oral and dental health on the overall development of children.

The United States cannot afford to provide anything less than top-quality healthcare to its children, as they are our nation’s future. This country must invest in premium dental care for youth and work to integrate pediatric medicine and dentistry in order to reduce the negative socioeconomic impact of poor oral health in later life. It is of utmost importance that we increase access to care and to that end, there must be a dramatic increase in dentists’ participation in publicly funded preventive dental services, which, in turn, would result in significant financial savings for the various government agencies. [1]

A Tragic Short-term Consequence

Untreated dental decay can lead to many deleterious health conditions. A tragic and well-publicized example is that of Deamonte Driver, a 12-year-old black boy living outside of Baltimore, MD. Deamonte had a badly decayed maxillary left first molar, which is one of the first permanent teeth to erupt into the oral cavity, at around 6 years of age. [2] Deamonte started complaining of a terrible headache to his mother, Alyce. Alyce had difficulty navigating the bureaucratic system, attempting to find dental care for her son. Deamonte eventually received dental and medical attention but, unfortunately, it was not in time. Deamonte died and became a horrific example of the defects in our nation’s ability to provide quality dental care to each and every one of our children.

His mother’s difficulties finding a dentist to treat Deamonte included inability to find a participating Medicaid dentist and trouble completing the burdensome paperwork of the Medicaid system. [2] Deamonte developed meningitis, was hospitalized and had two brain surgeries as the infection from his tooth spread to his brain. It seems almost incomprehensible that a child living within a short distance of our nation’s capital could die of a decayed tooth because access to care for youths dependent on Medicaid is limited. The tragic example of Deamonte Driver illustrates the most severe short-term consequence of a lack of access to dental care. Throughout my career I have also witnessed many long-term consequences which are wholly unacceptable in 21st century America. These long-term consequences have a deleterious effect on the individual’s health and education, as well as on the nation’s financial well-being.

The Oral-systemic Health Connection

The oral-systemic health connection is a prime example of another long-term impact of lacking pediatric dental services. It refers to oral/dental conditions that can affect an individual’s systemic health. This connection is well-documented in the scientific literature and is an integral aspect of my assertion about the importance of providing top-quality oral/dental care to America’s children.

It is imperative that we evaluate the significance of this link in assessing the importance of providing proper preventive services and necessary dental treatments to children in an effort to avoid a lifetime of devastating medical ailments. Many oral infections, such as periodontal disease, have been linked to the development of medical issues such as diabetes, [3] low birth weight infants, and respiratory [4] and cardiovascular diseases. [3-10] Therefore, it is of paramount importance to instill, at a very young age, good oral care habits, such as proper brushing and flossing techniques.

An example of the importance of the oral-systemic health connection to an individual’s overall health is the harmful changes Porphyromonas gingivitis, a bacterium found in the periodontal sulcus, causes in the human vasculature. This bacterium can result in potentially life-threatening conditions. [11] The evidence is clear that good oral hygiene can aid in avoiding these cardiovascular issues in many individuals. Obviously, it would be prudent for American society to make a concerted effort to decrease the impact oral/dental conditions have on systemic morbidities. This would not only decrease untold suffering and pain but eliminate an incalculable financial cost from the nation’s healthcare expenditure.

Inadequate Dental Care in Childhood Causes and Consequences

The true tragedy of the death of Deamonte Driver and the suffering of many of America’s youth is that they are preventable. The poor oral health of many youngsters is not entirely due to a lack of funding. Numerous states have dental programs that are meant to ensure good oral health in children. Unfortunately, many children miss out on these well-intentioned programs because their poor dental/oral health is caused by multiple factors. These include no awareness of available dental services, transportation issues and lack of parental engagement in their children’s oral health.

A report from the Department of Health and Human Services Office of Inspector General analyzed the utilization of dental services in four states by children from low-income families who had Medicaid dental coverage. Seventy-five percent of these children did not receive all of the dental procedures required by

law, and 25% did not see a dentist at all. [12] We must, as a nation, examine the causes of poor access to care. Various data point to the limited utilization of dental services by children from poor socioeconomic backgrounds, [12-20] with the oral health disparity being greatest when the children are from non-white families. [15]

While a study by Jihong et al. [13] found that 26.9% of American children did not see a dentist at all in the previous year for preventive treatment. This cannot be viewed as acceptable.

Lack of access to dental care is a major impediment to good dental health for children. The causes of poor access must be addressed. They include lack of awareness of no-cost dental programs, limited ability to travel to a dental clinic and a small number of dental providers due to low reimbursement rates. Disparities in the dental care of children based on socioeconomic status has led to poorer oral health outcomes for disadvantaged children. This results, for many of these children, in a lifetime of dental pain and the need for costly dental procedures which they may not have access to even as adults.

An undesirable cycle of poor systemic health and subpar attendance and performance in the workplace may result from medical issues linked to poor oral health. Hall et al. [3] studied a population in the United States with disparities and Medicaid benefits. This population found it difficult to perform their duties at their place of employment due to dental issues at a rate five-times greater than what was found in the general population. Among those individuals who are most likely to have substandard dental health are immigrants, those lacking insurance coverage, minorities and those living in rural areas where access to dental care is not adequate. [14]

A study by Guarnizo-Herreno et al. [16] found that socioeconomic status was the main cause of the difference in dental preventive care between black, Hispanic and white children, along with other factors, including maternal health and neighborhood safety. [17] It has also been found that untreated dental needs, including carious lesions, were higher in communities with a lower socioeconomic status. [18]

The impact of untreated dental disease extends far beyond already devastating oral problems. Children who suffer from dental pain do not perform up to their natural abilities in their academic endeavors. [19] A study by Seirawan, Faust and Mulligan [10] showed that disadvantaged youths are four-times more likely to receive low grades in school. This is probably due to their inability to concentrate and the many lost hours of school attendance caused by their dental pain.

A study by S.L Jackson et al. [20] shows that 17% of children’s absences from school are due to pain and/or infection. Among these children there was a correlation with poor school performances not seen in youths who were absent merely to receive routine preventive dental care. The authors [20] say this suggests that dental disease adversely affects a child’s performance at school independently of being absent from school. I strongly agree with the authors’ statement, as children often suffer, unfortunately, in silence. This is very difficult to measure in a quantitative manner. However, the result is obvious: the children are unable to concentrate and focus on their academic endeavors as their dental pain and discomfort are omnipresent in their lives.

The poor academic performance of these children directly correlates with future difficulty escaping the socioeconomic constraints to which they were born. The effects of children’s dental suffering are certainly not limited to the children themselves. Parents of these children lost, on average, 2.5 days at work each year because of their children’s dental pain. [20] It can be argued that the poor oral health of the children may jeopardize the employment status of the parents, leading to more financial upheaval and turmoil in the family. In order to avoid losing time at work, the parents may avoid taking their children to preventive appointments, which they may deem unnecessary.

Separation of Medicine and Dentistry

Medicine and dentistry have traditionally been separate and distinct professions yet dedicated to the same ultimate goal: the betterment of the health of the communities they serve. The separation of the two professions is a contributing problem in the overall health of children. Dentistry has, until recent decades, been almost completely limited to the oral cavity. While the oral and dental structures will always be the main purview of dentistry, the acceptance of the oral-systemic link has made collaborative research and patient care slightly more common. Unfortunately, pediatricians still lack the dental knowledge that would enable them to effectively counsel their patients about proper preventive dental modalities.

Many times, the first manifestations of a systemic disease are oral, and a professional interaction between the patient’s physician and dentist may lead to earlier diagnoses and more efficient and effective treatments, along with valuable education as to the vital role dentistry plays in one’s overall health. A more dynamic interaction between medicine and dentistry would aid in the fight against certain preventable childhood comorbidities, such as diabetes and obesity. [21]

A Paradox

An interaction between dentistry and medicine is critical as the debate rages in the United States over the financial costs of healthcare. I believe that educating the public about the many benefits of providing a national children’s dental health program, in which no child slips through the cracks, will bring both sides of the argument together. Paradoxically, providing increased funding and establishing a national system to ensure that all American youth receive top-quality dental care and nutritional counseling would decrease the future incidence of many dreaded systemic disorders and, therefore, decrease dramatically the nation’s healthcare expenditure.

The unnecessary cost of untreated dental disease is tremendous. More than 34 million school hours are lost annually on account of emergency dental treatment, [22] and untreated dental/oral disease costs the United States 45 billion dollars in lost productivity each year. [23] Certainly, putting children on the road to proper oral/dental health would be a wise financial decision for our nation. This could, potentially, result in a decrease in future national healthcare expenses, which would offset any initial increase in dental costs many times over. Also, those on the other side of the argument would see the intrinsic humanistic value in decreasing both the suffering of America’s youth from dental disease and the prevalence of systemic disorders later in life.

Conclusion An investment in the dental and oral health of American children can yield future dividends in terms of the overall systemic and dental health of the nation. Most childhood dental disease is preventable and if dental caries is detected early, it may be treated in a simple and predictable manner. However, the contrary is also true. Children who do not receive periodic examinations and preventive services such as fluoride treatments may develop complicated dental issues which, in turn, may lead to oral infections and loss of teeth. Suboptimal oral/dental health in disadvantaged children can lead to a lifetime of not only serious dental issues but, also, complex systemic medical and developmental issues. It is imperative that, as a nation, we focus on providing optimum dental care to all of our youth, especially children from impoverished socioeconomic backgrounds who suffer disproportionately with poor dental health.

I strongly suggest enacting either a state or federal mandate that all children receive oral examinations, as well as all necessary dental treatments, in order to address the dental issues that are diagnosed at a requisite annual oral examination. There must be mechanisms in place to ensure that this treatment is actually provided. There must be immediate direct referrals from the child’s school to dental public health clinics for any child who either misses school due to dental pain or who complains of a dental problem. These dental clinics could be staffed by seasoned den-tists and/or dental residents with the supervision of experienced licensed dentists. Because the data demonstrate that children living in lower socioeconomic communities experience a disproportionate amount of untreated dental needs, it is imperative that these clinics are most prevalent in the affected neighborhoods in order to provide quality dental care to children without regard for the family’s financial ability to pay for these dental services.

Dentistry and medicine must work collaboratively, with both dentists and physicians providing appropriate nutritional counseling that could, potentially, have a tremendous impact on decreasing systemic diseases often associated with extremely poor health outcomes and high financial costs. If children were to avoid high-sugar soft drinks and other such snacks, it would have a major impact on lessening childhood obesity and diabetes.

I feel that the professional interaction between medicine and dentistry should be integrated into medical and dental school educations. This would demonstrate the importance of working in an interdisciplinary manner and, it is hoped, these young physicians and dentists would continue to work in a collaborative manner with each other throughout their careers.

If our nation could decrease the prevalence of obesity, hypertension and diabetes through simple educational and preventive interventions that take into account the structural issues barring access to care, such as social inequality and the divide between dentistry and other forms of healthcare, a course would be set for a healthier and productive life for America’s children. p

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Dr. Maloney is in private practice in Westchester County and is a clinical associate professor at New York University. He is a fellow of the New York Academy of Medicine and holds a postgraduate certificate in Healthcare Writing from Harvard Medical School. Queries about his article can be sent to him at wjm10@nyu.edu.