Photo: Angelic Mendoza Garcia, 18 months, receives a checkup from dental hygienist Jennifer Bidwell, center, while her mother, Maria Espinoza, observes as a part of the Every Smile Counts program at Walton Pediatrics and Medical Associates on Thursday, July 9, 2020. Every Smile Counts is a test program that places hygienists in schools – currently closed because of coronavirus concerns – and pediatricians’ offices to make it easier for Medi-Cal patients to receive dental education and services. Alie Skowronski ASKOWRONSKI@SACBEE.COM
Editor’s note: This story was first published in the The Sacramento Bee on July 13, 2020 and written by Ariane Lange.
Lanessa Pinkney has always struggled to bring her four kids to the dentist. She would have to take time off work, yank her kids out of school, and juggle appointments on multiple days.
Pinkney, of Sacramento, wanted them to have the regular oral healthcare they were entitled to on Medi-Cal, but usually she only visited the dentist in an emergency. And even then, like when her daughter fell and knocked out a tooth, she and her toddler had to spend hours in the waiting room.
Pinkney found out that Northwood Elementary School was offering on-site cleanings and immediately enrolled her eligible children.
“It’s just extremely convenient,” she said.
She had no hoops to jump through except signing a permission slip, and in 2020, her 11-year-old son Lamarr and her 7-year-old daughter Alyssa both had cleanings. The young students were set to have their teeth cleaned at school every six months, as recommended by healthcare professionals. This dental care at school was made possible through the county program Virtual Dental Home.
“The dentist is just something you kind of don’t think about until something’s wrong, so they just weren’t getting those regular screenings,” Pinkney said. “That’s what made it so great that they could be seen regularly.”
Around February, a dental hygienist at Northwood looked at Pinkney’s youngest son, 5-year-old Anthony, during an oral health kindergarten screening and referred him to a dental practice to address decay in his front tooth.
Then the coronavirus pandemic shut down schools across the state.
With schools closed and no plan, as yet, for reopening them, Pinkney’s children and hundreds of others participating in several promising Sacramento County dental pilot projects for low-income families had their oral healthcare left in a lurch.
“It sucks,” Pinkney said.
How to Remedy Low Rates of Care
Sacramento County has one of the state’s worst records for availing young low-income children of dental care. According to the state’s most recent data from 2018, only 18 percent of the county’s 1- and 2-year-old Medi-Cal beneficiaries had seen a dentist. Healthcare guidelines say children should have a dental appointment by their first birthday at the latest.
In the same year, less than half of the county’s low-income 3- to 5-year-olds — 42 percent — visited a dentist for routine care, according to the California Department of Health Care Services. By contrast, in two other urban counties – Los Angeles and San Diego –more than half of their 3- to 5-year olds had an annual exam that year; and San Francisco succeeded in serving 61 percent of that age group.
According to a Sacramento County needs assessment published in 2018, in a survey of 117 dentists in the county who treat children, 40 percent wouldn’t see them until they’re at least 3.
All told, nearly 60,000 Sacramento children 5 and under on Medi-Cal did not go to a dentist for an annual visit in 2018. Of those kids, 24,000 were between 3 and 5, either in kindergarten or near it. In addition to going through the pain of tooth decay, children are increasingly likely as they grow older to miss school days and fall behind academically because of ongoing oral health problems.
Aware of the dental access gap, county officials have been working to change these numbers. In 2017, the state Department of Health Care Services awarded the county $9.2 million to fund several innovative three-year local pilot projects from 2018 to the end of 2020 through the state’s Dental Transformation Initiative.
Implementing ‘Every Smile Counts’
The county debuted a suite of projects dubbed “Every Smile Counts” Sacramento County dental hygienists set up semi-permanent offices in 12 elementary schools and preschools as well as one high school and one middle school in the Twin Rivers Unified School District so children like Pinkney’s would have easier access to preventative care, including X-rays and cleanings, through Virtual Dental Home. It is one of several programs providing dental care for young low-income children.
In another prong of the initiative, pediatricians’ staff were doing basic oral health assessments and fluoride varnishes on very young children. Children with dental emergencies were fast-tracked into same- or next-day dental appointments by Medi-Cal-savvy care coordinators in each prong of the pilot.
The guiding principle was simple: make getting dental care easier for kids of low-income parents. Parents wouldn’t have to go out of their way to get their kids’ oral health attended to because the pilot projects were bringing dental care to the places families already were – at school and in pediatricians’ offices.
Robyn Alongi, the health program planner for the county’s Department of Health Services, said care coordination is the cornerstone of the projects. Many Medi-Cal-enrolled families didn’t know they were entitled to transportation and translation services, Alongi said, and care coordinators were helping them access their benefits.
The outcomes were encouraging: More low-income young children were getting preventative care. More families were being expertly shepherded through a sometimes over-complicated state public healthcare system. Without coordination, a parent might struggle to find a dentist who accepted Medi-Cal; if a child needed anything more complex than a cleaning, they might have to wade through an approvals process. Care coordinators would advocate for the kids’ needs.
The projects were being evaluated quarterly, and enthusiasm about their success was growing. So much so that in March, the school-based programs were about to expand to several more locations where hygienists would set up their compact workstations and bring their mobile X-ray machines right into the schools.
Pilot Projects at Coronavirus Standstill
Data showed they were making significant inroads: Of the 828 elementary school children who received care at their school campus through a Virtual Dental Home site in 2019, 207 of them – one in four – had not been to the dentist at all the previous year.
Because of the pilot projects, now they all had. But the projects have all but come to a standstill. Several of the employees working for them were furloughed.
“It’s so frustrating to make that much progress and then all of a sudden, halt,” said Debra Payne, Sacramento County’s program planner for the Dental Transformation Initiative Local Dental Pilot Project.
At a kindergarten screening conducted by one pilot in the fall, results showed about 20 percent of the children already had emergency-level tooth decay. These issues, Payne said, won’t be caught while those kids aren’t in school, and in the meantime, their decay will worsen.
Significant numbers of kids, like 5-year-old Anthony, had decay that wasn’t an emergency. Pinkney said when her son had his oral health screening at Northwood Elementary, a hygienist said a decaying tooth had to be treated in a dental office. But she couldn’t get an appointment until a few months later – an appointment that was canceled because of the pandemic.
Because it wasn’t causing him pain, it didn’t meet state guidelines for a dentist to treat him during the full shutdown, so she and Anthony were left in limbo as Pinkney tried to keep his oral health stable through brushing, flossing, and feeding him lots of vegetables.
As of May, Sacramento County allowed some urgent but non-emergency dental care to resume.
In June, increasingly concerned about Anthony’s teeth, Pinkney finally secured him an appointment at a clinic; he’s scheduled for an extraction later this month.
Meanwhile, pilot program administrators are scrambling. They banded together in March to counter an immediate threat to the programs’ viability, when the state Department of Health Care Services tried to repossess equipment such as portable X-ray machines and computers purchased by the state. Ultimately, DHCS relented.
In mid-March, Sacramento County’s pilot administrators asked DHCS to extend the evaluation period for one year, to account for the months that county and statewide stay-at-home orders effectively stopped all but emergency oral healthcare. On June 18, more than three months later, DHCS told the pilot programs in an email that no decision had been made on an extension. The department was still in talks with the federal agency Centers for Medicare and Medicaid Services, the message said.
Need for These Medi-Cal Services
The county has a dire need for the kind of Medi-Cal dental care coordination of these pilot projects, as parent Twanjai Blanks explained.
In 2015, her daughter Roselle was 5. Blanks could hardly believe the state of her little girl’s four front teeth.
She had been doing everything right: She brushed her daughter’s teeth twice a day and she didn’t let her have bottles. She’d also been diligently taking her to the dentist near their home in South Sacramento.
Blanks noticed dark yellow and brown spots on her daughter’s front teeth. “It didn’t look right to me,” she said. “I took her in immediately, and the dentist kept on saying, ‘Okay, there’s nothing to worry about.’”
But Blanks did worry. If Roselle had been a participant in a Local Dental Pilot Project, a care coordinator could have advocated for her and her mother. The care coordinator would have had expertise in the kind of care Roselle was entitled to. But in 2015, there was no program. Blanks was on her own.
After multiple appointments spanning months, the dentist finally told Blanks that her daughter needed surgery to remove her teeth. She got a second opinion, and recalled that dentist telling her, “It should’ve been handled a year and a half ago.”
Her daughter, by then almost 5, was in near-constant pain. She was only eating soft foods slowly, and sometimes she refused to eat at all. Her mother and grandmother had to feed Roselle at least five times a day because she would only eat tiny amounts of food, slowly. Still, approval for the surgery took months.
The experience was so shocking and disheartening to Blanks’ mother, Robin Blanks-Guster, that she joined the Medi-Cal Dental Advisory Committee. Dental services for Medi-Cal recipients have “gotten much better in the last few years,” Blanks-Guster said.
But with the setbacks to local pilot projects, the county’s low-income children will have to wait that much longer for the policy changes they so desperately need.
“There’s a lot of kids not being served. This was a critical time, because we finally cleared out all the barriers to being fully operational,” Payne said. “I’m nervous.”
Sacramento County Schools with ‘Every Smile Counts’ Onsite Dental Care
- Babcock Elementary
- Castori Elementary
- Del Paso Elementary
- Fairbanks Elementary
- Garden Valley Elementary
- Hagginwood Elementary
- Harmon Jonson Elementary
- Martin Luther King Jr High
- Noralto Elementary
- Northwood Elementary
- Rio Tierra Junior High
- Smythe Elementary
- Strauch Elementary
- Woodlake Elementary
Ariane Lange reports for The Center for Health Reporting at USC’s Schaeffer Center for Health Policy and Economics. This story was supported by a grant from First 5 LA.