Oral Health of California’s Children: A Commentary on the Status and Future Directions

Jayanth Kumar, DDS, MPH, is the state dental director, Office of Oral Health and the Center for Healthy Communities, California Department of Public Health. Conflict of Interest Disclosure: None reported.

Jared Fine, DDS, MPH, became dental health administrator for the Alameda County Department of Public Health in 1975, a position he held until his retirement in 2014. Conflict of Interest Disclosure: None reported.

Assessment that identifies key health needs and issues through systematic, comprehensive data collection and analysis is a key function in public health. It gives health departments, dental organizations and their partners the information to help with developing plans to achieve a community’s objective. Tooth decay is the most common chronic disease in children and often the greatest unmet need with profound disparities in the population.[1] Therefore, maintaining an ongoing understanding of tooth decay prevalence, distribution in the population and the factors that influence the development of the disease is paramount to its prevention and control and in achieving the fullest potential of health for individuals. However, dentistry lacks a mechanism for routinely gathering data on disease and on oral health outcomes, constituting a major challenge for performing the key assessment function in public health. To address this, the 2012 California Dental Association Access Report recommended the establishment of a system for surveillance and oral health reporting and followed up with advocacy that resulted in significant support for oral health in the 2016 Tobacco Tax initiative.[2] This among others provided the support for implementing the Association of State and Territorial Dental Directors Basic Screening Survey protocol.

In this issue of the Journal, Darsie et al. report a noticeable reduction in tooth decay experience and untreated decay and an increase in dental sealant prevalence among third grade children in public schools.[3] Historically, California has had high prevalence of tooth decay. A survey of third grade children conducted in 2004–05 showed that only Arkansas had a higher prevalence of tooth decay experience than California.[4]

Many initiatives undertaken since the last survey may have contributed to this improvement in oral health. Since 2007, several water systems including the Metropolitan Water District of Southern California began providing fluoridated water, resulting in 59.3% of the population receiving fluoridated water, up from 27.1%.[5] The percentage of children under age 21 who were enrolled in the Medi-Cal Dental Program and received a dental service increased to 46% in 2019 from 28% in 2006.6 In addition, the following policies and system-level changes also occurred during this timeframe:

■ Implementation of the Affordable Care Act (ACA), which increased dental insurance benefit coverage, affordability and integration.

■ Implementation of the kindergarten oral health assessment as part of school entrance requirements.

■ Promotion of screening, fluoride varnish and anticipatory guidance during well-child visits by the American Academy of Pediatrics and the age 1 dental visit.

■ The California Dental Association Foundation’s 2010 Oral Health During Pregnancy and Early Childhood: Evidence-Based Guidelines for Health Professionals and training of dental professionals to provide dental care for children under 6 years old.

■ The restoration of adult dental benefits, which may have increased utilization for children and youths as well as adults.

■ The Medi-Cal Dental Program’s implementation of the recommendations of the Little Hoover Commission, including the 2015 Medicaid Dental Transformation Initiative and supplemental payments to increase preventive dental visits.

■ The Medi-Cal Dental Program’s “Smile, California” campaign to increase members’ use of Medi-Cal’s dental benefit.

Darsie et al. also report that the prevalence of tooth decay remains high, and there are profound disparities with respect to race/ethnicity, socioeconomic status, languages spoken and geography. While there is no noticeable racial/ ethnicity or socioeconomic disparities with respect to sealants, the prevalence varied from a low of 29% in the Sacramento region to a high of 47% on the Central Coast. Overall, the prevalence remains low when compared to national data observed among children aged 9–11 years examined in the National Health and Nutrition Examination 2011–2016 Survey (37.0% versus 50.7%).[1] This observation, together with the profound disparities of tooth decay, suggests missed opportunities for prevention in younger children. Therefore, more efforts are needed to improve daily mouth care at home, provide community-level interventions and facilitate early dental visits. A concerted effort is required to promote healthy habits such as toothbrushing with a fluoride toothpaste and reducing sugar intake, timely dental visits starting early in a child’s life, access to professionally applied topical fluoride applications (e.g., in dental and nondental settings), community-level interventions such as water fluoridation and community-clinical linkages and improving oral health literacy.

California is poised to make significant improvements by implementing the strategies identified in the California Oral Health Plan 2018–2028.[7] First, California has set an ambitious target for third grade children to reduce the prevalence of caries from 70.6% in 2004–05 to 56.5% by 2025. Second, using the funding provided through the 2016 California Healthcare, Research and Prevention Tobacco Tax Act, the California Department of Public Health (CDPH) has established a statewide program with a focus on preventing tooth decay in children. It is providing $18 million annually across 59 local health jurisdictions to conduct local level, county-specific needs assessments, develop a community oral health improvement plan and implement interventions. Third, the Medi-Cal Dental Program is working collaboratively with public health programs and stakeholders to increase access to dental care. Fourth, CDPH is working to increase access to community water fluoridation (CWF) through maintaining and expanding state, local and tribal community water fluoridation programs. CDPH is encouraging compliance with proper water fluoridation practices through the promotion of CDC training and technical assistance resources. Fifth, CDPH is working with local oral health programs (LOHPs) to develop communitybased programs such as school-based/ linked programs to connect children in community settings to a source of dental care. Sixth, the kindergarten oral health assessment, required in California, helps identify children suffering from dental disease and assists them in finding a dental home. LOHPs are offering assistance in implementing kindergarten dental assessment protocols, track progress and improve the performance of and compliance with the kindergarten dental assessment. Finally, the Office of Oral Health has contracted with the Health Research for Action Center, University of California, Berkeley, to create materials for an oral health literacy toolkit and conduct trainings for dental teams and practices to improve the uptake of information about oral health literacy. The toolkit will include information on specific communication strategies, including plain language communication, the use of visuals and drawings, the teach-back method and creating a friendly and welcoming clinical environment. In addition, the California Oral Health Technical Assistance Center at the University of California, San Francisco, has created resources for local health departments and dental practitioners to promote the kindergarten oral health assessment, water fluoridation, school-based/linked programs and tobacco cessation counseling.[8]

At the local level, there are many opportunities for individual practitioners and component dental societies to advance the partnerships that increase awareness about oral health, provide early strategies to prevent dental caries and expand access to care. The annual “Give Kids a Smile” program can serve as a focal point for components focused on an educational campaign with local schools. An example could be reducing sugar sweetened beverage (SSB) consumption and increasing water choices through the “Rethink Your Drink” or “Soda-Free Summer” campaigns.[9] Partnering with schools is also an opportunity to foster their participation in the Kindergarten Oral Health Assessment (KOHA) in which practitioners can develop partnerships with schools to offer screening and encourage fluoride, sealants and early dental visits for those who have not done so. To fulfill the federal mandate that every eligible child have a complete “well-child visit,” which includes a dental examination, every county has a Child Health and Disability Prevention Program (CHDP) required to maintain an adequate dental provider referral resource list. Each component could easily include in their bulletins reminders encouraging members to participate in these annual surveys. In addition, each LOHP is required to maintain an advisory committee, offering another opportunity for individual practitioners to participate in guiding oral health improvement efforts at the local level.

LOHPs have a responsibility to develop the plans and linkage to care systems, implement programs and services that are prevention focused and promote improved oral health outcomes. By partnering with the CHDP program in each county and with First 5 organizations, LOHPs can play a pivotal role in the training and education of medical providers (e.g., pediatricians and family practitioners) who perform wellchild and periodic health assessments as well as educate and inform the public. Because the majority of the CHDP service population is under age 5, fluoride varnish applications are appropriate and should be promoted. The CHDP program is perfectly situated to provide oral health educational materials in offices encouraging health-promoting diets, increased tap water consumption over SSBs, dental visits by age 1 and KOHAs and facilitating presentations of early childhood caries and fluoride varnish at pediatric grand rounds at local hospitals and at CHDP provider meetings. The CHDP program requires that every child be referred for a dental examination and has the capacity to provide care coordination either directly or with partners to ensure that children are not only referred but also able to successfully access dental care. The LOHPs can also identify gaps in service based on distance, language or capacity to provide services and foster recruitment efforts with the Medi-Cal Dental Program and through partnership with the local dental society.

Many local-level stakeholders embrace the importance of assuring the oral health of children and are natural partners: notably, Head Start, the Women, Infants and Children Nutrition Supplementation Program (WIC) and elementary schools. Both Head Start and Early Head Start require that a participating child have a dental examination, creating an opportunity to offer both education and preventive services. Head Start parent advocates can serve the natural role of education and care coordination as well. The WIC program is designed to provide not only food vouchers, but also dietary education and counseling. Because caregivers are in attendance with young children, the opportunity to influence mouth-healthy practices is particularly rich. For example, many WIC programs have welcomed the LOHP’s assistance in offering staff training on early childhood caries (ECC), individual and group education, individual oral health assessments, one-on-one oral hygiene instruction, fluoride varnish application, caries risk assessment and referral to a dentist in the community. Unlike WIC, schools do not have the advantage of caregivers in attendance. However, schools are where most children are congregated. Schools are the gatekeeper to screenings, the KOHA, sealant application or fluoride varnish programs. As such, schools should be promoting healthy eating policies and practices and increased water consumption and discouraging soda consumption through enactment of policies and educational campaigns.[10] Churches, boys and girls clubs and community health centers are additional examples of natural partners that share the goal of optimal oral health for children and represent a significant opportunity to intervene with educational campaigns, care coordination and the promotion and delivery of early preventive interventions.

In spite of noticeable improvements in the oral health of children in California, tooth decay remains a major public health problem. The COVID-19 pandemic has affected the delivery of dental services and disproportionately impacted certain disadvantaged groups. The state governmental programs, local health jurisdictions, professional organizations and advocacy groups have affirmed their commitment to improving the oral health of Californians. We encourage you to review the data and share your expertise and perspective to move forward the state’s oral health agenda.

REFERENCES

1. Centers for Disease Control and Prevention. Oral Health Surveillance Report: Trends in Dental Caries and Sealants, Tooth Retention and Edentulism, United States, 1999–2004 to 2011–2016. www.cdc.gov/oralhealth/publications/OHSR2019-index.html.

2. California Dental Association. Phased Strategies for Reducing the Barriers to Dental Care in California, California Dental Association Access Report. www.cda.org/Portals/0/ pdfs/access_to_care/access-report.pdf.

3. Darsie B, Conroy S, Kumar J. California Smile Report. J Calif Dent Assoc 2021 May;49(5):331–336.

4. Dental Health Foundation. Mommy It Hurts to Chew: The California Smile Survey. www.centerfororalhealth.org/ wp-content/uploads/2018/11/Mommy-It-Hurts-To-Chew. compressed.pdf.

5. Centers for Disease Control and Prevention. Water Fluoridation Data and Statistics. www.cdc.gov/fluoridation/ statistics/index.htm.

6. Centers for Medicare and Medicaid Services. Early and Periodic Screening, Diagnostic and Treatment. www.medicaid. gov/medicaid/benefits/early-and-periodic-screeningdiagnostic-and-treatment/index.html.

7. California Department of Public Health. California Oral Health Plan 2018–2028.

8. California Oral Health Technical Assistance Center. University of California San Francisco. oralhealthsupport.ucsf. edu.

9. California Department of Public Health. Nutrition Education and Obesity Prevention Branch: Rethink Your Drink. www. cdph.ca.gov/Programs/CCDPHP/DCDIC/NEOPB/Pages/RethinkYourDrink.asp.

10. California Oral Health Technical Assistance Center. School Oral Health Programs. oralhealthsupport.ucsf.edu/ our-programs/school-programs.

THE CORRESPONDING AUTHOR, Jayanth Kumar, DDS, MPH, can be reached at Jayanth.Kumar@cdph.ca.gov.