With blond hair, blue eyes and a bright smile, Taylor Neely, 4, squirmed and giggled as she waited for a light sedative to make her relax before University of Florida pediatric dentist Dr. Michael Tarver put two crowns on her back teeth.
“I don’t feel it,” said Taylor, who in the past seven months has had one tooth pulled and two fillings put in at the UF College of Dentistry’s Pediatric Center. She also will have spacers put in soon. “I never feel it,” she said.
Experts from around the state say so much work on such a young patient is common in Florida, where many disadvantaged children have limited access or no access to a dentist.
The Gainesville Sun analyzed statistics from the State Oral Health Improvement Plan for Disadvantaged Floridians, findings from the Pew Center on the States’ 2010 “Children’s Dental Campaign” report and numbers from the Centers for Disease Control and Prevention, and found that Florida has one of the worst records in the country for providing dental care for its most vulnerable residents: children like Taylor who are on Medicaid and live in poor, rural communities.
According to data from the oral health improvement plan, Florida has:
32 counties that have no pediatric dentist who takes Medicaid.
15 counties that have neither a pediatric dentist who takes Medicaid nor a fluoridated water system.
One county – Walton – with one pediatric dentist who takes Medicaid, but no public or volunteer clinic and no fluoridated public water system.
48 out of 67 counties with less than 38 percent – the national average – of Medicaid children receiving dental services.
Five counties that provide dental services to children using professionals who work on a volunteer basis. These counties have no pediatric dentist who takes Medicaid.
The Pew Center on the States, a nonprofit organization dedicated to advancing state policies that serve the public interest, this year awarded Florida an “F” for the care of its disadvantaged children’s dental health – one of nine states to fail. Disadvantaged children are defined as those living at 200 percent of the federal poverty level, which is about $22,000 a year for a family of four. Florida was next to last when it came to access to dental care by children on Medicaid; 76 percent of Medicaid children did not visit a dentist in 2007. And Florida is last in the country when it comes to the amount reimbursed to doctors for treating Medicaid patients.
Compounding matters is the fact that Florida does not track cavity rates in children and does not have a statewide sealant program for disadvantaged children.
Oral health issues
Taylor is one of 10,705 pediatric patients seen at the pediatric clinic at UF in the past year. College officials said 98 percent of their pediatric patients are on Medicaid and that, for most of them, the college is their only access to dental treatment. Doctors say some parents drive for hours simply to have their children see a dentist. The clinic has a waiting list to treat new patients.
Without the clinic, Taylor’s mother, Tammy Neely, said, “Oh my goodness, I don’t know what I would do.” Her husband – Taylor’s father – died suddenly of a heart attack on Christmas Day at their home in Virginia. Afterward, Neely, 42, moved the family to Newberry to be close to her parents, but she is not working. Neely and her parents use the college’s adult clinic.
Experts say many factors affect pediatric dental health, including:
Bacterial levels in the mouth.
Parents’ education level.
Parents’ knowledge of dental hygiene.
Whether the children drink from a fluoridated water system.
When parents have high levels of tooth decay, their children tend to have high levels.
Newberry has a population of more than 3,300 people, about 13 percent of whom have a college degree. Nearly 10 percent of the area’s families live below the poverty line. And Newberry’s water is not fluoridated.
“It has not come up as an issue,” said Blaine Suggs, Newberry’s utilities director. “There’s been one or two people that have mentioned it in the last five years, but it hasn’t been a major concern. There just really has not been that much interest.”
When asked whether she brushes her teeth every day, Taylor starts to nod but then whispers, “no.”
Neely said she tells Taylor to brush her teeth every morning and every night and puts the toothpaste on the toothbrush for her.
“I’ve caught her in the bathroom washing the toothpaste off and telling me she brushed her teeth,” Neely said. “I have to stand right over her.”
Another culprit is the Sprite that Taylor loves to drink. Dentists have told her mom to switch to Sprite Zero, which has no sugar.
Advocates for change
Dr. Frank Catalanotto, chairman of the University of Florida’s department of community dentistry and behavioral science, is campaigning for better pediatric dental health care in Florida. He said Taylor’s case is common.
“I brought children to the operating room at 2 1/2 and 3 years of age, extracting several teeth and restoring seven, eight and nine teeth – and they only have 20 teeth at 3 years of age,” Catalanotto said. “It’s not uncommon in areas without fluoride – fluoride clearly cuts the overall numbers down.”
The Centers for Disease Control and Prevention has recognized water fluoridation as “one of 10 great public health achievements of the 20th century” because it has reduced cavity rates. Tooth decay, the CDC says, is the leading childhood disease – five times more prevalent than asthma – and the most preventable.
In 1951, the National Research Council found that water fluoridation was safe and effective and “recommended that any communities with a child population of sufficient size, and that obtained their water from sources free from or low in fluoride, should consider adjusting the concentration to optimum levels for oral health.”
Since then, water has been fluoridated for 69 percent of people in a public water system in the United States. About 70 percent of people in Florida drink fluoridated water. In 1949, Gainesville was the first city in the state to fluoridate its water to prevent tooth decay.
According to the U.S. Department of Health and Human Services, in the 1940s, cavities in areas that began fluoridating water dropped by 60 percent. Fluoride toothpaste and mouthwash have since been introduced and have been found to reduce tooth decay also, but the U.S. Department of Health and Human Services continues to recommend fluoridating water because “it provides the greatest benefit to those who can least afford preventative and restorative dentistry and reduces dental disease, loss of teeth, time away from work or school, and anesthesia-related risks associated with dental treatment.”
HHS studied the issue and found that appropriate levels of fluoridation are safe. And the American Dental Association continues to endorse water fluoridation to prevent cavities. However, officials with HHS warn that babies should not drink formula made with fluoridated water.
Every dentist who spoke with The Gainesville Sun said fluoridated water is vital to keep children’s teeth healthy.
Cavities – or caries, as they are called by dentists – mean more than just fillings or pulling teeth. They can lead to acute or chronic infections, abscesses, hospitalizations and, in some rare cases, even deaths. Catalanotto said toothaches are one of the top reasons for children to miss school.
“Parents don’t realize these are life-threatening problems. Since 2006, three children have died in the U.S. because of a dental infection that went untreated because the parents weren’t taking the kid to the dentist,” Catalanotto said. “In one case in Maryland, the parent couldn’t find a dentist who would take Medicaid. We estimate 200 or more children a year are actually admitted to the hospital for a life-threatening dental infection in the state of Florida.”
In April, 5-year-old Dylan Stewart died after being anesthetized for dental work. His death shocked and saddened the community, along with the dentist, Dr. Ronnie Grundset. She closed her practice for a short while. Grundset is one of eight dentists in Alachua County who serves the area’s most impoverished patients, taking Medicaid for pediatric patients while nearly 275 of her colleagues in the county do not.
The cause of Dylan’s death has not yet been determined as the medical examiner’s office awaits the results of several final toxicology studies. A 3 1/2-month wait is typical in these cases, medical examiner office personnel said.
Dylan went to Grundset to have four cavities filled and eight caps placed on his baby teeth. His parents and surviving siblings live in Rosewood, a rural community west of Gainesville with limited access to dental care and many people served by unfluoridated well water.
FAILING GRADE FOR THE STATE
The Pew Center on the States’ 2010 ‘Children’s Dental Campaign’ report awarded Florida an ‘F’ for the care of its disadvantaged children’s dental health. Florida received an ‘F’ because:
— Less than 25 percent of high-risk schools, in which a majority of children receive free or reduced lunches, have a sealant program.
— Only 24 percent of children ages 1-18 on Medicaid receive dental services. The national average is 38 percent.
— The state continues to require a dentist’s exam before a hygienist can put a sealant on children’s teeth, often a hindrance for participation for low-income children.
— Florida pays Medicaid dentists only 30 cents for every dollar the dentist would charge an insured patient, which often does not cover the cost of treatment and hinders many dentists from participating.
— Florida does not submit basic screening data to the National Oral Health Surveillance System.
— Florida has an alarming shortage of dentists, leaving 16 percent of the state’s population underserved. It would take 751 new dentists to close the gap, more than any other state.
— Florida is one of at least 10 states that do not require county health departments to track cavity statistics.
A Gainesville Sun review of data from the State Oral Health Improvement Plan for Disadvantaged Floridians shows Florida has:
— 32 counties that have no pediatric dentist who takes Medicaid.
— 15 counties that have neither a pediatric dentist who takes Medicaid nor a fluoridated water system.
— 1 county — Walton — with 1 pediatric dentist who takes Medicaid, but no public or volunteer clinic and no fluoridated public water system.
— 48 out of 67 counties with less than 38 percent — the national average — of Medicaid children receiving dental services.
— 5 counties that provide dental services to children using professionals who work on a volunteer basis.
— Out of Florida’s 9,804 active licensed dentists, only 118 pediatric dentists are active Medicaid providers.