California

California Children and Oral Health: Trends and Challenges

James J. Crall, DDS, ScD
James J. Crall, DDS, ScD, is director of the Maternal Child and Health Bureau National Oral Health Policy Center at Columbia University, New York, NY.

Copyright 2003 Journal of the California Dental Association.

This paper highlights fundamental elements of the challenge of securing optimal oral health for California’s children, now and in the future, and underscores the need for new strategies to reduce the risk of dental disease and expand access to effective services. Developing effective strategies to gain optimal oral health for California children, especially those that are most vulnerable to dental disease and its consequences, requires an appreciation of key dynamic factors that define this challenge and the degree to which these factors are modifiable in the near and long term. Particular attention is directed toward three principal elements: population demographics, levels of dental disease in California children, and factors affecting access to services for vulnerable groups of children. The concluding section addresses the need for strategic action.

California is considered by many to be the nation’s trendsetter in health consciousness and health promotion. But beneath this popular image of healthy Californians are troubling trends and reports about the oral health of substantial and growing numbers of California children and their inability to access basic services that can help promote, restore, and preserve their oral health. Marked increases in the number of children living in poverty in California, dental disease rates that far exceed national averages, and fewer than one in three Medicaid-eligible children having access to dental services paint a picture that stands in sharp contrast to commonly held perceptions of health in this vast and diverse geosocial entity that is home to one in eight American children.^1-4

This paper highlights fundamental elements of the challenge of securing oral health for California’s children, now and in the future, and underscores the need for new strategies to reduce the risk of dental disease and expand access to effective services. Developing effective strategies to gain optimal oral health for California children, especially those that are most vulnerable to dental disease and its consequences, requires an appreciation of key dynamic factors that define this challenge and the degree to which these factors are modifiable in the near and long term. Particular attention is directed toward three principal elements: population demographics, levels of dental disease in California children, and factors affecting access to services for vulnerable groups of children. The concluding section addresses the need for strategic action.

Demographic Trends: A Major Underlying Force

n Increases in childhood poverty.

n Challenges of dealing with diverse cultures.

The demographic profile of California’s children has undergone dramatic changes during the past two decades. A recently released report by the National Center for Children in Poverty³ identified the following trends:

Ÿ The number of low-income children in California has increased by almost 1.6 million since the early 1980s, from 2.77 million to 4.36 million. The number of California children in poverty has increased by 850,000, from 1.27 to 2.12 million.^a

Ÿ One in six poor children in the United States currently lives in California compared to about one in 10 two decades ago.

Ÿ California alone has accounted for all of the net national increase of 800,000 in the number of children in poverty since the late 1970s.

Ÿ The child poverty rate in California increased from less than 20 percent during the period from 1979 to 1983 to 22 percent during the period from 1996 to 2000. During the same averaged time period, the national child poverty rate decreased from 19 percent to 18 percent.

The National Center for Children in Poverty report³ also points out that Hispanics have become a large and rapidly growing majority of the poor children in California. Hispanic children now account for 61 percent of all poor children in California (up from 41 percent two decades ago), while the proportion of poor children who are white has decreased from 30 percent to 21 percent. The share of poor children who are African American has fallen from 16 percent to 7 percent.³ Thirty-four percent of California’s Hispanic children live in poverty, a 14 percent increase from two decades ago. Poverty rates for African-American children declined from 32 to 24 percent during that same time frame, while the rate for white children remained nearly flat at about 11 percent. The poverty rate for Asian-American children was 19 percent during 1996-2000.^b

Immigration has had a major influence on the changing demographic profile of California’s low-income families. The National Center for Children in Poverty report³ notes that some 46 percent of all children in California are immigrants, and nearly 60 percent of the poor children in California are immigrants. At 29 percent, the poverty rate for immigrant children is significantly higher than the 17 percent rate for nonimmigrant children. These children present a challenge not only from the standpoint of their sheer numbers, but also by virtue of diverse cultures and linguistics.

The National Center for Children in Poverty analyses of U.S. Census Bureau data also point out that California children are much more likely to live in working and two-parent families than they were two decades ago.³ More than two-thirds of poor children in California now live in families with at least one employed parent; and 48 percent of poor children in California are in two-parent families. Immigrants in poverty are more likely to be in working families than native-born families in poverty.

Levels of Dental Disease: The Essence of the Problem

n Prevalence rates two times national averages.

n Even higher disease rates in rapidly emerging groups within the population.

Collecting state-level data on dental disease in children has not been a priority in California. In fact, a 1993-94 statewide oral health needs assessment of California children⁴ was reported to be the first such survey in California history, and it has not been repeated. Thus it represents the most recent comprehensive source of data for characterizing the dental status of California children.

Key findings from the 1993-94 California Oral Health Needs Assessment of Children⁴ include:

Ÿ More than 50 percent of all California school-age children were found to have untreated decayed teeth.

-- In 1993-94, the percentage of 6- to 8-year-old California children with untreated decay (55 percent) was more than twice the U.S. average for this age group in 1986-87. Comparisons with data from the Third National Health and Nutrition Examination Survey conducted from 1998 to 1994⁵ indicate that California children also were more than twice as likely to have untreated decay compared to national averages.

-- More than half (54 percent) of California 10th-graders were found to have untreated decayed teeth, and nearly 40 percent of 10th-graders in need of treatment had urgent dental care needs for extensive decay, pain, or infection.

-- Asian, black, and Latino children were found to have significantly higher rates of untreated decay compared to their white counterparts. Disparities were particularly pronounced for young (preschool and elementary school) children regardless of race or ethnicity and for Hispanic adolescents.

Ÿ Nearly one-third of California preschoolers, 69 percent of California children in grades K-3, and 78 percent of California 10th-graders had experienced tooth decay.

The striking levels of untreated tooth decay in large proportions of California children -- more than 40 percent of nonwhite preschoolers, 40 percent to 68 percent of all elementary school children, and 38 percent to 75 percent of all high school-age youths -- highlight two distinct dimensions of the challenge of providing oral health for California children: (1) finding effective ways to extend known effective preventive interventions to all California children and (2) ensuring access to quality dental care for the millions of California children in need of treatment as well as preventive services.

Access to Effective Services: A Key Component of the Solution

n Trends in numbers of dental service providers.

n Extent of provider participation in public programs.

n Workforce distribution issues.

n Public sector infrastructure.

Space limitations do not allow for extensive discussion of the complex factors affecting access to services that could improve the oral health of California children or related trends. However, observations and trends regarding several key areas are highlighted below.

State dental workforce -- According to data published by the Health Resources and Services Administration,⁶ California had the 10th-highest dentist-to-population ratio of all 50 states in 1998, but ranked 26th in dental hygienist-to-population ratio and eight in dental assistant-to-population ratio. During the period from 1991 to 1998, California’s dentist-to-population ratio declined by 8 percent. The number of dental hygiene graduates per 100,000 population declined by 4 percent from 1985-86 to 1995-96, while the number of dental assistant graduates per 100,000 population declined by 38 percent during that same period.

Dentist participation in Medicaid -- Data from the National Conference of State Legislatures⁷ indicate that 66 percent of practicing California dentists received at least one payment from Medicaid (Denti-Cal) in 2000 and that the percentage of dentists receiving at least one payment increased by 35 percent over the figure reported for 1998. The conference report also indicates that 29 percent of California dentists received payments of at least $10,000 from Medicaid in 2000. In 1998, Medi-Cal payment rates varied from 17 percent to 68 percent of average regional dental fees, depending on procedure.⁸ Low fees are the main reason cited by dentists for not participating in the Medi-Cal program.⁹

Dental workforce distribution -- In spite of relatively high dentist Medicaid participation rates in California, a recent report on the geographic distribution of California dentists¹⁰ found that:

Ÿ Of the 487 Medical Service Study Areas in California, 97 (20 percent) were at or below the federal Health Professional Shortage Area ratio of primary care dentists-to-population of 1:5000 in 1998;

Ÿ Sixty-six of the 97 shortage study areas (68 percent) were rural and contained 1.06 million people (3.1 percent of California’s population), while 31 of the shortage study areas (32 percent) were urban, containing 3.06 million people (8.9 percent of the state’s population); and

Ÿ Of the 32 study areas that had no dentists, 31 were rural.

Ÿ Related data also indicate that of the 487 study areas in California, 108 had no active Medicaid dentists and that half of the study areas in California had less than one Medicaid dentist per 1,000 Medicaid beneficiaries.¹¹

Public sector infrastructure -- Although the public oral health safety net infrastructure can include a broad array of entities and activities, attention is limited herein to care delivered in public community clinics. A recent report published by the University of California at San Francisco¹¹ noted that approximately 204 (30 percent) of the licensed community clinics in California offer some level of oral health care. Although the mission of most community health centers and other community clinics is to provide free or low-cost primary care to low-income and uninsured people, these centers generally face ongoing challenges of recruiting and retaining dental professionals and maintaining adequate financing. Without a mixture of federal, state, county, and private grants and reimbursement/payment, most clinics would not be sustainable.¹¹

Need for Strategic Planning and Action

Improving children’s oral health and ultimately the oral health of the population requires attention to two broad strategies:

Ÿ Reducing the burden of oral diseases in the population through proven preventive measures and

Ÿ Providing disease management and treatment services to individuals who demonstrate clinical manifestations of oral diseases and their sequellae.

The factors underlying attainment of these goals are complex and require strategic planning and action that emphasize outreach, education, prevention, early intervention, access to quality care, and program evaluation and management based on sound data.^c

Considerable information and recommendations related to these issues have been compiled by various groups throughout California of late; however, absent a sustained, adequately supported, unified public-private effort and strong leadership, advances are unlikely. Additional papers in this issue and the next provide a foundation for developing new approaches for major oral health challenges facing California. Developing strategic initiatives and programs to effectively translate this information within the emerging contextual environment will be the key to future oral health in California.

Notes

a. The National Center for Children in Poverty report defines a "low-income child or family" as living in a household with annual income less than 200 percent of the official poverty line ($35,048 in 2000 for a family of four). In looking at the larger population of low-income families, it also includes demographic analyses of poor children and families using the poverty line ($17,524 in 2000 for a family of four).

b. The Census Bureau did not collect information to determine the child poverty rate among Asian-Americans during the 1979–1983 period.

c. Additional background material on related oral health policy issues¹² and an example of using state-specific information to generate strategic planning and actions¹³ can be found at www.cthealth.org.

References

1. U.S. Census Bureau: State and County QuickFacts, Data derived from Population Estimates, 2000 Census of Population and Housing, 1990 Census of Population and Housing, Small Area Income and Poverty Estimates, County Business Patterns, 1997 Economic Census, Minority- and Women-Owned Business, Building Permits, Consolidated Federal Funds Report, 1997 Census of Governments Accessed on the Internet at http://quickfacts.census.gov/qfd/states/06000.html, October 1, 2002.

2. Center for Medicare and Medicaid Services, Form HCFA-416: Annual EPSDT participation report: California FY 2001. U.S. Department of Health and Human Services Center for Medicare and Medicaid Services.

3. Palmer JS, Song Y, Lu, H, The changing face of child poverty in California. National Center for Children in Poverty, New York, NY, August, 2002.

4. The Dental Health Foundation, The oral health of California’s children: a neglected epidemic, 1997. Accessed on the Internet at http://www.dentalhealthfoundation.org/documents/Pub2000complete.pdf, October 1, 2002.

5. Vargas C, Crall J, Schneider D, Sociodemographic distribution of pediatric dental caries: NHANES III, 1988-1994. J Am Dent Assoc 129:1229-38, 1998.

6. Health Resources and Services Administration, Bureau of Health Professions, HRSA State Health Workforce Profile: California, December 2000. Accessed on the Internet at ftp://ftp.hrsa.gov/bhpr/workforceprofiles/CA.pdf, Oct 1, 2002.

7. Gehshan S, Hauck P, Scales J, Increasing dentists’ participation in Medicaid and SCHIP. National Conference of State Legislatures Forum for State Health Policy Leadership Promising Practice Issue Brief, 2001.

8. U.S. General Accounting Office. Oral health: factors contributing to low use of dental services buy low-income populations. US General Accounting Office, (GAO/HEHS-00-149), Washington, DC, Sept 2000.

9. Mertz E, Manuel-Barkin C, et al, Improving oral health care systems in California: dental care delivery and financing. University of California at San Francisco Center for the Health Professions, San Francisco, December 2000.

10. Mertz E, Grumbach K, et al, Geographic distribution of dentists in California: dental shortage areas, 1998. University of California at San Francisco Center for California Workforce Studies, San Francisco, Jan 2000.

11. Manuel-Barkin C, Mertz E, Grumbach K, Distribution of Medicaid dental services in California. University of California at San Francisco Center for California Workforce Studies, San Francisco, December 2000.

12. Crall JJ, Edelstein BL, Elements of effective action to improve oral health and access to dental care for Connecticut's children and families -- Appendix I: background materials and Appendix II: strategic working documents. A report commissioned by the Connecticut Health Foundation and Children’s Fund of Connecticut. July 2001. Available on the Internet at www.cthealth.org.

13. Crall JJ, Edelstein BL, Elements of effective action to improve oral health and access to dental care for Connecticut's children and families. A report commissioned by the Connecticut Health Foundation and Children's Fund of Connecticut. July 2001. Available on the Internet at www.cthealth.org.

To request a printed copy of this article, please contact: James J. Crall, DDS, ScD, Columbia University School of Dental and Oral Surgery, 630 W. 168th St., 7th Floor, New York, NY 10032-3702 or at jjc233@columbia.edu.