Sacramento County’s toothache

Sacramento County children are literally taking it in the teeth (and gums) when it comes to oral health care. Due to the county’s unusual assistance program for low-income children, there is a huge, toothy gap between the dental haves and have-nots.

Known as Denti-Cal, the program helps only one in five, or 20 percent, of the children who are eligible for assistance. This translates to a little more than 23,000 children out of 117,000.

“There are barriers on both sides [that prevent successful dental care],” Debra Payne, a program planner for First 5 Sacramento—a commission that aims to improve children’s health—explained to SN&R.

Those barriers date back to the Sacramento County program’s launch in 1994. Designed as a pilot program to control costs, the program mandates that county patients use one of five pre-assigned health-care-management providers. (The state of California contracts this out to commercial health-care plans.) The more common system, used in other California counties, is one that pays dentists for each service provided. In Sacramento County, though, Denti-Cal dentists get paid regardless, and there are numerous hurdles to adequate dental care.

“For parents [of Denti-Cal-eligible children], they may not be able to get an appointment for two to three months and don’t remember or don’t show up,” Payne said. “Or they don’t have transportation, or there is a language barrier, or concerns about money or insurance or paperwork. For providers, there is no incentive to provide service. They are paid from the moment of a child’s birth, whether they see a patient or not,” she said.

As a result, chronic toothaches are going unaddressed and leading to a range of other problems.

“If your teeth are hurting, you’re less likely to be able learn in school,” Payne told SN&R. “Or it can affect your behavior, and you might be more likely to act out in class.”

The health concerns are also acute.

“We see child patients with poor oral care all the time,” said Eric Enriquez, who oversees development and outreach for the Sacramento Native American Health Center. “The linkages of poor early oral health to chronic diseases later in life are getting [clearer] all the time.”

For now, those linkages paint a grim picture of what is ahead. A survey by Smile Keepers, for instance, found that 27 percent of Sacramento County students had tooth decay and 9 percent needed emergency dental care during the 2006-2007 school year. In California, studies have found that two-thirds of third-graders in California have a dental disease and a quarter has dental decay, making it a top health issue for the state. Nationally, the Center for Disease Control and Prevention lists tooth decay as the most common infectious disease for young children.

“The sooner, the better, but that’s not happening,” First 5’s Payne said of the need for children, particularly young children, to receive regular dental care. Payne also noted that children with urgent toothaches often end up at hospital emergency rooms, costing California millions, since the hospitals are reimbursed by Medi-Cal.

There are efforts underway, however, to improve Sacramento County’s dental care for low-income children.

On a recent Tuesday morning at a north Sacramento elementary school, for example, students gathered for an assembly in the multipurpose room. Lucky students were happy to be out of class and instead watching an animated film featuring Gina the Giraffe brushing her teeth. The assembly was fun for the students, but there was also a larger purpose. The event—a blend of corporate sponsor and good cause—aimed to better educate the students about how to care for their teeth (“tongues have lots of germs, so brush them, too”), how to brush properly (use circular motions, brush five times a day) and for those with parental permission, to provide a dental screening.

“I am seeing more and more younger kids with problems,” a volunteer dentist at the assembly, Dr. Glenn Middleton, said as he checked students’ teeth with a mouth mirror. Nearby, students practiced brushing on a large plastic set of teeth beneath peppy school posters and material for the event’s corporate sponsor, ACS, which is an affiliate of Xerox and a wide-ranging company that also oversees Sacramento’s red-light cameras (and, full disclosure, this reporter’s student loans).

“I see a lot more need for education and more preventive care,” Dr. Middleton added.

At a neighboring table, students who lined up to see Dr. Dana Eric Berry had a range of problems. Some had holes in their teeth, others had inflammation. Dr. Berry told a few to go to a dentist for cleaning in the next six months, and gave others with urgent problems a referral to see a dentist immediately. At one point, four out of 10 students that he screened needed immediate dental care.

In response to such chronic teeth issues, the First 5 commission and other local partners, including the Sacramento Children’s Dental Task Force and the Sacramento District Dental Society, are attempting to improve outreach and education to parents and health-care providers.

One major campaign is a “first tooth, first birthday” effort that encourages parents to take their child to the dentist by one of those occasions. Statewide, Assembly Bill 1433 requires kindergarten students to have a dental checkup by their first year in school. (The SETA Head Start program also mandates dental checkups for preschoolers.)

Sacramento pediatric dental advocates also aim to boost the low numbers of area dentists who see Denti-Cal patients. In one survey by the SDDS, just 10 to 13 percent of the county’s approximately 900 dentists took Denti-Cal patients. Many dentist who are officially listed as taking Denti-Cal patients actually do not take new patients.

In addition, First 5, which is funded by a 1998 tax on tobacco products in California and aims to improve children’s health, has launched five community dental clinics to help make it easier for parents to get their children to a dentist. The $3 million pediatric clinics are all federally qualified health centers, meaning they receive 80 to 90 percent reimbursement from the federal government. So far, Midtown and Oak Park dental clinics have opened in the past year, with another scheduled for North Highlands in April, and two more set to open this year in Rancho Cordova and south Sacramento.

Midtown’s SNAHC, which treats both Native Americans and anyone in need, opened the first of the community clinics last September. The dental clinic is new and shiny, with brightly colored cartoon animals on the walls, highlighting the clinic’s target audience.

Enriquez said the number of visitors to the dental clinic keeps growing. “You really do have to get them before their first birthday to get the entire family focused on positive oral-health habits and hygiene,” he said.

More broadly, Payne hopes to get the state on board with improving Sacramento County’s unusual managed-care program. (Also on the table for both Head Start and for First 5, which centers on children younger than 6, are funding cuts. California is considering tapping into First 5’s accumulated 10-year savings reserve.)

“We’d like to start a conversation with the state to see if we can improve things, perhaps move more toward a [more traditional] system like they have in Los Angeles,” Payne said. “Right now providers are paid whether they see a patient or not, and we need better monitoring to ensure they don’t get paid if they don’t see a child.”

In the meantime, for children, SNAHC dentist Magnus Yang has one more simple piece of advice: “Floss is the boss!”