Children’s oral health is an important part of a child’s overall health [1-3]. Healthy teeth are essential for healthy eating, speaking, playing, and learning. Oral health in early childhood paves the way for oral health in adulthood and old age. The American Dental Association formally defines oral health to be a functional, structural, aesthetic, physiologic and psycho-social state of well-being that is essential to an individual’s general health and quality of life [4], and a window into the health of the body, which can show signs of nutritional deficiencies, general infection, or systemic diseases that affect the entire body and first become apparent because of mouth lesions or other oral problems [5]. Children’s oral health is a public health priority in San Francisco, where the vision is for “all San Francisco children to be cavity-free” (http://www.cavityfreesf.org/).
Tooth decay can be prevented by maintaining a low level of fluoride exposure on teeth [1, 6]. Prevention efforts must start before the age at which most of the population already has the disease. In California, prevention is recommended before 2 years of age [3].
To promote children’s oral health, the CDC recommends that parents and caregivers talk to their pediatrician, family doctor, nurse or dentist about putting fluoride varnish on their child’s teeth as soon as the first tooth appears in the mouth, and have the child visit a dentist for a first checkup by age 1 year [2]. Fluoride varnish is a type of gel that can be painted on children’s teeth with a soft brush. Fluoride varnish helps prevent tooth decay, a disease process also known as “caries”, in baby teeth [4]. Fluoridated drinking water, daily tooth brushing with fluoridated toothpaste, and a diet low in sugar and fermentable carbohydrates can also promote healthy teeth [1-2].
Oral health is a function of community-level factors, including local availability of medical and dental providers, insurance coverage, water supply, available food retail options, and child care provider resources and practices [7]. Child care providers can determine a child’s access to preventive oral health services, fluoridated drinking water, low sugar diet, and midday tooth brushing during the school/work day. Children can spend 30 to 50 hours per week in child care [8].
Tooth decay is a leading chronic disease of childhood [2, 9, 10]. Worldwide, 60–90 percent of school children have dental caries [1]. Nationally, in 2013-2014, 30 percent of children ages 3 to 5 years and 52 percent of children ages 6–9 years had experienced at least one cavity in their primary teeth [11, 12]. In 2004-2005, 71 percent of third grade students in California had caries experience and 29 percent had untreated caries [10]. Low-income and minority children have disproportionately higher tooth decay rates [2, 13]. Nationally, in 2011-2014, 21.7 percent of children in households with an income below 100 percent of the Federal Poverty Limit had untreated caries, compared to 8.0 percent of children in households with an income at or above 400 percent of the Federal Poverty Limit [14].
Caries prevention is a national health priority. Healthy People (HP) 2020 aims to increase the proportion of low-income children and adolescents who received preventive dental services during the past year from 30 to 33 percent, reduce the proportion of children aged 3 to 5 years with dental caries experience in primary teeth from 33.3 to 30 percent, and reduce the proportion of children aged 3 to 5 years with untreated dental decay in one or more primary teeth from 24 to 21 percent [15].
Poor oral health can cause pain, infections, school absences, difficulty concentrating, and poor appearance—problems that affect quality of life and ability to learn and interact with others [1-3, 16]. Children with untreated decay miss more school days and have lower academic achievement [13, 17, 18]. Caries in baby teeth can lead to chronic infection and deformation or damage of the permanent teeth under the baby teeth [19]. Chronic inflammation due to periodontal disease causes systemic responses that are similar to those triggered by chronic inflammation associated with cardiovascular diseases, diabetes, cancer and chronic respiratory diseases [20]. Some studies suggest that periodontal infection may magnify systemic inflammation [21].
Tooth decay remains a prevalent local health problem (see Figure 1). Between 2012-2017, there were no significant changes in caries experience among kindergarteners in San Francisco. Relative to 2013-2014, untreated decay has increased. In 2016–17, 33 percent of San Francisco Unified School District (SFUSD) kindergarteners screened had caries experience, 18 percent had untreated decay, and 126 children needed urgent dental care.
Caries experience varied by zip code (see Figure 3). Zip codes in Central and Western San Francisco met the national Healthy People 2020 target for caries experience of 30 percent. Zip codes in Southern and Eastern San Francisco did not. While 12 percent of kindergarteners living in zip code 94114 had caries experience in 2012-2017, over 40 percent of kindergarteners in Southern and Eastern San Francisco had caries experience.
Caries experience varied by zip code, independent of race-ethnicity . The pattern of higher risk in the Southern and Eastern zip codes was observed for all ethnic groups combined and for Asian and Latino groups, separately. Note that zip code-specific data are suppressed for certain zip codes and for Black/African American, Pacific Islander, and White children, due to small numbers.
In 2012-2017, rates of untreated dental decay did not meet the HP 2020 target of 21 percent in Southern and Eastern San Francisco zip codes. The highest rates of untreated decay were observed in zip code 94133, where 27 percent of kindergarteners had untreated decay. Zip code differences in untreated decay were primarily seen for Asian children. Among Asian children, depending on the zip code of residence, rates of untreated decay varied from 14 to 34 percent. Among Latino children, rates of untreated decay were below 21 percent across all zip codes.
Few children ages 1 to 2 years visit the dentist. Between 2013-2015, less than 20 percent of Denti-Cal eligible children ages 1-2 visited a dentist (see Figure 4a).
Limited availability of Denti-Cal providers. Citywide, in 2016, there were 42 Full-Time-Equivalent dentists for about 18,342 Denti-Cal eligible children ages 0 to 5 years. The estimated shortage of Full-Time-Equivalent dentists in San Francisco to serve 18,342 Denti-Cal eligible children ages 0 to 5 years is 34 dentists [22]. Only some zip codes in San Francisco had dental clinics that accept Denti-Cal eligible children. According to a 2018 survey of San Francisco Dental clinics serving Denti-Cal eligible patients, 9 out of 18 respondents reported a wait-time of 30 days or more for a third available dental appointment for a 0 to 2 year old child. Only one clinic reported offering treatment for pediatric dental patients with all types of special health care needs [22]. Figure 4b describes the distribution of Denti-Cal providers across San Francisco zip codes. Between 2012-2016, there were 3,015 SFUSD kindergarteners living in the 94112 zip code and only one clinic accepting patients with Denti-Cal insurance. In the 94124 zip code, the ratio of clinics accepting patients with Denti-Cal insurance to kindergartners was 2:1019. Local Head Start child care centers report lack of dentist availability or long wait-time for appointment as reason why children who were referred for treatment did not receive treatment during the school year.
Limited Denti-Cal reimbursement. California has had among the lowest Medicaid Fee-For-Service reimbursement rates for child dental care services, nationally, for many years [23]. In 2017, due to additional reimbursements from Proposition 56 Tobacco Tax measures, reimbursement for many Denti-Cal procedures increased temporarily by almost 40%. The increase was extended into 2018. In spite of this increase, Medi-Cal dental reimbursement remains less than half of what private dental insurers reimburse [24].
Limited child care center case management for children ages 3 to 4 years. Between 2012 and 2014, decreases in access to dental care for low income children, ages 3-4 years, coincided with a national transition in Head Start child care center administration (see Figure 4c). The data suggest that access to care for local children is dependent on national and statewide child care policy and practice. Access to dental care for children enrolled in Head Start decreased nationally and statewide between 2012 and 2014 [25, 26]. In San Francisco, the proportion of low income children enrolled in Head Start who needed dental services, who received dental services, decreased sharply from 93 percent in 2012 to 53 percent in 2014.
Few preventive dental services in medical clinics for children ages 0 to 5 years. The availability of preventive dental services, such as fluoride varnish application, in settings outside of dental clinics can buffer against limited access to dentists. In 2014, only 11.8 percent of San Francisco Health Network (SFHN) patients ages 0 to 5 years received a fluoride varnish application at a medical visit (see Figure 4d). Although this number increased by about 5-fold between 2014 and 2018, over 40 percent of SFHN patients ages 0 to 5 years remain to be reached.
Beginning in 2012, a citywide collaborative, now known as CavityFreeSF, formed to reduce children’s caries experience and disparities. CavityFreeSF developed the San Francisco Children’s Oral Health Strategic Plan 2014-2017, which aimed to “increase awareness and practice of optimal children’s oral health behaviors among diverse communities”, “increase access to oral health services”, and “integrate oral health with overall health.” [27]
Implementation of the strategic plan resulted in 16 additional medical clinics, in 3 large medical systems, providing fluoride varnish applications at pediatric well-child visits for children under age 6. In 2016, fluoride varnish applications were administered to 1,752 children through primary care clinics. [28]
With funding from California Department of Public Health (CDPH)-Oral Health Program, California Department of Health Care Services (DHCS) Prop 56, and Dental Transformation Initiative and in collaboration with Our Children Our Families, CavityFree SF aims to reduce caries experience from 39 to 27 percent; reduce untreated decay from 18 to 8 percent by 2020; reduce the difference in caries experience between Asian, Black, and Hispanic/Latino kindergarteners and White kindergarteners from 20 to 15 percentage points; reduce the race-ethnic disparity in untreated decay from 8 to 6 percentage points; and increase the percentage of Denti-Cal eligible children who have seen a dental provider by age 2 from 27 to 31 percent, all by 2020. San Francisco Dental Transformation Initiative Local Dental Pilot Program, working with CavityFreeSF, will implement 5 pilot projects to increase access to dental services, increase dental care coordination, develop health promotion messages, increase interprofessional collaboration, and incentivize FQHC dual-users. [29-32]
1. San Francisco Unified School District (SFUSD)-San Francisco Department of Public Health (SFDPH) Dental Services. Kindergarten Oral Health Screening Program.
2. California Department of Health Care Services (DHCS), Medi-Cal Management Information System/Decision Support System, 2012.
3. Head Start PIR (Program Information Report) data 2008 to 2016.
4. CHDP Children’s Dental Referral Directory available at https://www.sfhp.org/programs/medi-cal/benefits/dental-services/
5. San Francisco Department of Public Health, San Francisco Denti-Cal Clinic Capacity Survey.
6. San Francisco Health Network program data, Fluoride Varnish Applications for Children Age 0-5 Years, 2014-2018.
Caries experience is defined as having one or more untreated or treated (filled) cavity. Low income is defined at or below 200 percent of the Federal Poverty Level.
Between 2007–08 and 2016–17, the SFDPH Dental Services offered annual oral health screening to all children enrolled in kindergarten classes in the San Francisco Unified School District, excluding children in charter schools. Approximately 4,000 children were screened each year. Families were notified of the date of the oral health screening by flyer and a note sent home with each child. Children who were absent or who did not assent to screening on the date specified were not screened.
Forty to fifty licensed, volunteer dentists from the San Francisco Dental Society (SFDS) conducted the dental screenings. The program annually gave the dentists a written training module detailing the clinical data to collect and the diagnostic criteria to use. The oral health information collected for each child included the number of primary and permanent teeth with untreated or treated decay and treatment need. The diagnostic criteria defined treatment need in terms of Class I, Class II, and Class III categories:
Class I: No visible dental problems. Individuals apparently require no dental treatment.
Class II: Mild dental problems. Individuals require treatment, but not of an urgent nature. Class II problems include pinhead-size cavities that are not generalized or advanced, moderate plaque and calculus accumulation indicating the need for oral prophylaxis, or other oral conditions requiring corrective or preventive measures.
Class III: Severe or emergency dental problems. Individuals require treatment of cavities as large as a green pea, extensive pinhead cavities, chronic abscess(es), acute or chronic oral infection, heavy calculus accumulation, insufficient number of teeth for mastication, injuries, and/or painful conditions.
The San Francisco indicator may underestimate the prevalence of caries experience. To allow comparison of local data with national caries experience estimates, the San Francisco indicator does not include extracted teeth or count caries in permanent teeth. The HP 2020 target focuses on caries experience in primary teeth. The National Health and Nutrition Examination Survey does not capture data on extracted or missing primary teeth.
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[4] American Dental Association. ADA policy-Definition of oral health. https://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/ada-policy-definition-of-oral-health
[5] American Dental Association. Oral health. https://www.mouthhealthy.org/en/az-topics/o/oral-health
[6] Marinho VCC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews. 2013; Issue 7. Art. No.: CD002279. DOI: 10.1002/14651858.CD002279.pub2.
[7] Chazin Z, Glover J. A Community Framework for Addressing Social Determinants of Oral Health for Low-Income Populations. Center for Health Care Strategies. Technical Assistance Brief, January 2017. https://www.chcs.org/media/SDOH-OH-TA-Brief_012517.pdf
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[10] Oral Health Child Health and Disability Prevention Program, Health Assessment Guidelines
California Department of Health Care Services, Systems of Care Division. (2016,March).
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[12] Heathy People 2020. Oh-1.2 reduce the proportion of children aged 6 to 9 years with dental caries experience in their primary or permanent teeth. https://www.healthypeople.gov/2020/data/Chart/4993?category=1&by=Total&fips=-1
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[14] Gupta N, Vujicic M, Yarbrough C, Harrison B. Disparities in untreated caries among children and adults in the U.S., 2011–2014. BMC Oral Health. 2018; 18: 30. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840689/
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[16] https://www.cda.org/Portals/0/pdfs/untreated_disease.pdf
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[18] Seirawan, H., Faust, S and Mulligan, R.(2012, September). “The impact of oral health on the academic performance of disadvantaged children.” Am J Public Health.;102(9):1729-34. doi: 10.2105 /AJPH.2011. 300478. Epub 2012 Jul 19.5.
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[21] Giannopoulou C, Cionca N, Almaghlouth A, Cancela J, Courvoisier DS, Mombelli A. Systemic Biomarkers in 2-Phase Antibiotic Periodontal Treatment: A Randomized Clinical Trial. J Dent Res. 2016 Mar;95(3):349-55. doi: 10.1177/0022034515618949. Epub 2015 Nov 24.
[22] Cholera M, Fisher M, Stookey J, San Francisco Department of Public Health. Capacity of Dental Clinics in San Francisco to Serve Children Ages 0-5 years With Denti-Cal Insurance in Summer 2018: A Cross sectional survey. Slide presentation available at https://www.sfdph.org/dph/comupg/oprograms/MCH/Epi.asp
[23] Gupta N, Yarbrough C, Vujicic M, Blatz A, Harrison B. Medicaid fee-for-service reimbursement rates for child and adult dental care services for all states, 2016. Health Policy Institute Research Brief. American
[24] https://www.cda.org/news-events/rate-increases-and-benefit-restoration-for-denti-cal-program
[25] Head Start: Background and Funding. (2014, January 2) Retrieved from https://www.everycrsreport.com/files/20140102_RL30952_9de5df5a6c4debc9131eea76fb96ade27155c351.pdf
[26] “Head Start Timeline.” ECLKC. N.p., 01 Apr. 2018. https://eclkc.ohs.acf.hhs.gov/about-us/news/head-start-timeline
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[29] CDPH – Oral Health Program – Proposition 56 Local Oral Health Program OVERVIEW. (2017, July 26). Retrieved from http://cheac.org/wp-content/uploads/2017/07/LHJ-Informational-Webinar.pdf
[30] SF Dental Transformation Initiative – https://sfdti.weebly.com/
[31] “Home.” Our Children Our Families Council of San Francisco, Council San Francisco, https://www.ourchildrenourfamilies.org/
[32] CavityFree SF – San Francisco Children’s Oral Health Strategic Plan (2018, January). Retrieved from https://sfhip.org/content/sites/sanfrancisco/San_Francisco_Childrens_Oral_Health_Strategic_Plan_2014-2020.pdf
