Guest Editorial: Hope for a Cavity-Free Generation

Editor’s note: A colleague recently asked me, “Exactly what is it that the dental director does?” With that question, I knew it was time for the CDA Journal to more formally introduce the California Dental Director, Dr. Jay Kumar. CDA has worked closely with Dr. Kumar on several Journal issues since he took up his position in 2015, but also on oral health access projects and most recently on COVID-19 guidance. He has been a tireless advocate for improved oral health in our state and a wonderful partner and advocate for practicing dentists, especially in this pandemic. I have invited Dr. Kumar to introduce himself and give us a glimpse of his inspiration and his aspirations.

In this issue, we begin a recurring section entitled California Oral Health Briefings. The goal of this collaboration is to increase the understanding of the oral health of Californians and to help public health and private practice dentists realize the importance of working together to achieve a level of oral health in our state that is unmatched elsewhere.

We are grateful as residents of the state of California and as members of the California Dental Association that we have the benefit of a dental director like Dr. Kumar.

— Kerry K. Carney, DDS, CDE We need a commitment to find a better solution, which may require substantial investments in research and technology to find a cure within five years — something akin to a moonshot program.

In the late ‘90s, I listened to Rob Reiner giving a speech at the American Association of Public Health Dentistry annual meeting. He discussed a campaign to pass

Prop 10, the California Children and Families Initiative, which created First 5 California, a program of early childhood development services, funded by a tax on tobacco products.

Reiner’s ideas resonated with me and gave me the vision to free young children from cavities. I envisioned a “Free by 3” campaign composed of a series of milestones in three-year increments. First, all 3-year-old children should be cavity free; three years later, when children enter kindergarten, they should be cavity free; and three years after that, when we measure tooth decay in the third grade, we should see substantial progress in their overall oral health. This will put a generation of children on a lifelong trajectory to achieve good oral health, thereby eliminating oral health disparities.

I was looking for an opportunity to make this vision a reality and had read about the California Dental Association’s Access Report. It reflected the understanding that “there must be a realistic, comprehensive approach to solutions, focusing resources where they are most likely to have substantial impact and initially setting up a foundational structure that will contribute to the success of subsequent recommendations.” The report focused on building the infrastructure and capacity to establish a foundation for public oral health programs, optimizing early disease prevention and health promotion efforts through policies and system changes, promoting approaches to increase oral health literacy and expanding the capacity to provide care to at-risk populations. I saw the opportunities to achieve my vision in California because of initiatives such as First 5 and the Kindergarten Oral Health Assessment requirement as well as a commitment to improve access to dental care.

To translate that vision into a reality requires collective action. In the last five years, I have worked with our partners to create the structure to support it. The Office of Oral Health uses the collective action framework, which consists of five conditions — a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication and a backbone organization. The California Oral Health Plan 2018–2028 offers the structure for collective action to assess and monitor oral health status and disparities, prevent oral diseases, increase access to dental services, promote best practices and advance evidence- based policies. Funding for the Office of Oral Health to serve as the backbone organization comes from the California Healthcare, Research and Prevention Tobacco Tax Act of 2016. Publishing data and reports in the Journal of the California Dental Association establishes a means for continuous communication.

The California Smile Survey gives me hope that a cavity-free generation of 3-yearold children is a possibility. In this Journal issue, Darsie et al. report a 10 percentage point reduction in tooth decay prevalence since the previous survey in 2004–05. However, there are profound disparities with respect to the prevalence of tooth decay and untreated tooth decay. Over the last 20 years, the Alameda County Healthy Kids Healthy Teeth Program and the San Francisco Oral Health Collaborative have led the state in improving children’s oral health. Both local health jurisdictions created strategic plans, built partnerships and implemented interventions. In San Francisco, the prevalence of tooth decay in kindergarten children declined an impressive amount: from 60% in 2000–01 to 32% in 2017–18. However, the disparities in oral health are persistent, with tooth decay prevalence among children of color being three times higher compared to their Caucasian peers (greater than 35% versus 12%). What are the ongoing obstacles to achieving oral health equity? Is it because the impact of economic or community conditions prevents parents from complying with the recommendations to brush twice a day, feed kids a healthy diet and start dental visits early? Is it because of an overreliance on the clinical services? Is it because we don’t know the root causes of the disease?

As I reflect upon the COVID-19 pandemic, I am impressed with the remarkable scientific progress that has been made in a short amount of time. Within the space of a year, the complete genome sequences of the novel SARS-COV-2 virus have been identified, numerous tests have been developed, a new vaccine mRNA platform was used to develop innovative vaccines, clinical trials involving thousands of people were conducted, remarkable vaccines with 100% efficacy to prevent deaths were developed, a new monoclonal antibody therapy is available and several drugs are being tested. Yet there has been no such focus to address the age-old global problem of tooth decay. A researcher at the National Institute of Dental Research (NIDR) told our class at Johns Hopkins in 1979 that there would be a caries vaccine in five years! Forty-two years later, we still don’t have a vaccine. Is it because of disparate interests, lack of coordination or inadequate resources? Or is it because caries is not an “attractive” problem to solve that will lead to media attention and celebrity?

The only tool we have is fluoride, which is under intense attack. The best intervention to prevent and arrest tooth decay in young children is silver diamine fluoride (SDF), which I was using as a student 40 years ago. Silver nitrate was not popular back then because it stained teeth, and we still haven’t solved this staining problem! We do not have an objective test to identify children at high risk or a test to differentiate between active and arrested caries lesions. We need a commitment to find a better solution, which may require substantial investments in research and technology to find a cure within five years — something akin to a moonshot program. The last time such a commitment was made was in 1948 when the National Dental Research Act created the NIDR to address oral diseases.

In the meantime, we should use the tools we have to make progress toward achieving the vision of a cavityfree generation:

■ Introducing toothbrushing in early care and education programs.

■ Enforcing the kindergarten assessment law.

■ Supporting the implementation of the proposed California Advancing and Innovating Medi-Cal (Cal/ AIM) Dental initiative.

■ Implementing structured nutritional counseling.

■ Exploring dental and primary care integration by supporting an electronic platform to complete referrals and assist with care coordination.

■ Supporting dental teams’ clear communication capacity to enhance oral health literacy.

The second edition of the Surgeon General’s Report on Oral Health is expected to be released in 2021. I remain hopeful that the new report will articulate a vision for the future and call upon dentists and all Americans to take action against the burden of oral disease.

Jayanth Kumar, DDS, MPH, is the state dental director, Office of Oral Health and the Center for Healthy Communities, California Department of Public Health.