Should schools provide on-site oral care for children?
A fluorescent ceiling light flickers, and three pairs of young eyes dart nervously upward. The students shift uneasily in their seats, waiting for the Lord Stirling Community Elementary School nurse to call their names. One child crosses her arms, frowning deeply. Another tugs his teacher's hand until she lets him snuggle into the crook of her arm.
One curious little boy waiting for a Band-Aid stares across the nurse's office toward a mysterious, box-like room in the back. Inside that room is a low, reclining blue chair and a portable X-ray machine. Painted on a wall in the room is a multicolored mural of three happy little teeth running toward the school entrance, greeted by a smiling tube of toothpaste.
"What's in there?" the curious boy asks a dental hygienist standing in the nurse's office.
"That's our dental office," she replies, as the school nurse hands her boxes of toothpaste.
"You fix our teeth in there?" the boy asks.
"Yes, we sure do," she says, nodding.
For the students here, the school dental office, which opened in late fall, is still very much a curiosity. Dr. Ping Cai, one of two dentists who work part time at the 700-student elementary school, says pupils catch her in the hall all the time asking when they can visit the new clinic.
But Lord Stirling administrators say the dental office is much more than a curiosity. They say it is filling a huge void for a school in which roughly 70 percent of the students are living below the poverty line and many cannot afford the routine dental care that better-off families take for granted.
"[Dental care is] not something we can ignore," says Delfos Bruno, the school's vice principal "We need to teach a healthy child. The problem is we have been taught that dental care is a luxury, and it's not. It's a total necessity."
Lord Stirling Elementary is just one of many schools across the country that are responding to a need for better oral care for students. In many states, poverty, lack of oral health education, and shrinking numbers of dentists all limit regular access to basic dental services, especially for children from poor families.
The solution, many health-care advocates argue, is the school-based dental office.
They say that is especially true for districts like New Jersey's 7,000-student New Brunswick public schools. It is 65 percent Hispanic, and 70 percent of its students live at or below the poverty level.
School nurses and educators in the district had long seen a need for dental care after observing students who couldn't concentrate because of toothaches, or children who cried constantly because their teeth were literally rotting. But while parents were referred to outside clinics, few followed up with practitioners.
In November, the district opened two school-based dental offices with the help of a $105,000 grant from Delta Dental, a nonprofit organization based in Oak Brook, Ill., that offers nationwide dental insurance, along with support from the board of education and local donations.
One dental office for public school students is at the New Brunswick Health and Wellness Center, and the other is at Lord Stirling. The district will have built five new schools by the end of the 2003-04 school year, and each one is scheduled to have a dental suite.
The program—which targets students without dental insurance—offers screenings, X-rays, sealants, fillings, and oral education. Each facility contains a full dental suite and is staffed by a dental hygienist and two part-time dentists.
"This program has been a long time in coming," says Betty Whalen, the district's director of health. "My family was poor, and when there's a choice between a roof over your head and a child's teeth, it comes down to priorities. There's a real need for this here."
Although she's experienced the disadvantages of poor dental care, the severity of the problem didn't really hit home until she visited classrooms in the district.
"I used to dress up as the Cat in the Hat every year," Whalen says. "I'd ask the kids: How many of you have toothbrushes? And then I'd hand out toothbrushes to the ones who needed them.
"Well, I gave a toothbrush to this one little boy, and his eyes got really big and he said: 'Wow, now I won't have to share a toothbrush with my brother.'
"I'd never thought about sharing a toothbrush before. That really got me."
The U.S Department of Health and Human Services has described dental disease as a "silent epidemic." Tooth decay affects nearly 50 percent of 1st graders and about 80 percent of 17-year-olds, and an estimated 51 million school hours are lost to dental-related illnesses each year, according to a report released in 2000 by the U.S. surgeon general.
The report also estimated that children living in poverty are twice as likely as other youngsters to suffer from tooth decay, and that about 25 percent of poor children have never seen a dentist by the time they reach kindergarten.
Still, making dental care accessible to students is easier said than done. The major obstacle is funding.
"It is a financial problem to do this," says Whalen, who is working toward paying for the New Brunswick program through federal and state grants. The district also hopes to obtain a three-year, $500,000 grant from a health-care philanthropy.
But with equipment costs alone ranging from $30,000 to $50,000 for a one-chair dental suite, school-based programs can be a tough sell. Space is also hard to find at many schools.
Another big hurdle is hiring dentists that districts can afford to pay. At Lord Stirling, the dentists are paid about $45 an hour, but most dentists want much higher rates.
What's more, many are unwilling to work with children, according to Whalen. The United States has more than 175,000 dentists, but only 3,800 are practicing pediatric dentists, a low number compared with the 56,000 pediatric doctors, according to Dr. Burton L. Edelstein, a spokesman for the Chicago-based American Academy of Pediatric Dentistry.
To complicate matters, for every three dentists who retire each year, only two graduate to replace them.
Despite the struggle for financial and professional support, advocates staunchly defend the need for school-based dental programs, citing data from the federal Centers for Disease Control and Prevention and other health organizations that show oral disease is not taken as seriously by schools and communities as are other medical problems.
"There has always been a conception that oral health stands apart [from other medical fields], because the loss of a tooth is not life-threatening," says Dr. Leslie W. Seldin, a general dentist and consumer adviser for the Chicago-based American Dental Association.
Both dentists and proponents of school health care believe that better education can change such attitudes. And there is hope for school programs.
Several companies—including Johnson & Johnson and Colgate—donate toothbrushes, toothpaste, and other dental supplies to school programs. And dentists in private practice account for more than $1.5 billion in charity services per year for school and other programs.
Supporters argue that the advantages outweigh the costs. Many educators say that school- based programs help improve student achievement, bridge cultural gaps, and improve children's self-image.
But critics such as Lance Izumi, the director of the Center for School Reform at the Pacific Research Institute, a San Francisco-based think tank, contend that school-based dental care puts an unrealistic financial burden on schools and detracts from their true mission: educating students.
"I think there is validity to the argument that a child feeling pain will not do as well [in school]," acknowledges Izumi, "but while we need to ensure health care for our children, that doesn't mean that health care should be in schools."
He says that adding dental-care services could have a serious impact on schools that are already struggling to find enough money to buy textbooks and pay teachers.
"It seems absurd to me that you would add on a whole layer of services that schools need to administer when they can't administer what they need to now," Izumi says. "You're just setting up [the system] for failure."
Dental-health experts themselves point to different ways that schools can offer services to students. delete Dr. Ron Elliot, a dentist and the director of dental services with the Jefferson County, Ala., health department, says that his agency and the 40,000-student county school district have run a successful mobile dental program for schools since the early 1950s.
The district has three mobile dental vans that contain full dental suites. The suites are open five days a week, eight hours a day, and offer most services provided in a regular dental office, with the exception of major oral surgery. The program, which serves 30 schools and between 7,500 to 10,000 students a year, is financed with local tax dollars.
Yet even Dr. Elliot concedes that school-based dental care may not be a viable option for every community.
Dr. Edelstein of the American Academy of Pediatric Dentistry has worked with both school-based and school-linked programs in the Washington area. He says that school-linked services are probably a better option for most districts because programs based in schools themselves are often too small to be cost-effective. School-linked programs screen and refer students to off- site dental clinics and providers instead of offering in-house care.
The question can be one of demand, adds Jane Shapiro, the community-health coordinator with the Cheshire Medical Center in Keene, N.H.,which runs a free school-linked program financed by the Cheshire Health Foundation. The program, which has been running since 1997, offers cleanings, fluoride treatments, and oral education to pupils in kindergarten through grade 3. In 2001-02, the program screened more than 1,300 students.
But a school-based program would not be practical for the small community, Shapiro says, because there isn't enough demand.
Here in New Brunswick, however, Betty Whalen and her staff are convinced that a school-based program is the way to go.
"I think it's important that people see that you can do this," Whalen says. "You need a lot of commitment and support from parents, staff, and nurses. Maybe you even need to be a little bit crazy, but my goal is to keep this program going."
Eight- year-old Brittney Marmolejos will be happy to hear that. The Lord Stirling 3rd grader used to be terrified of going to the dentist.
When Brittney was an infant, her mother says, a dentist had to grind down her two front baby teeth to the gumline to save her primary teeth from succumbing to severe oral decay.
Now, Brittney is all smiles when it comes to her teeth, because her current dentist works right down the hall at the school dental office.
"Here is better," Brittney says, "because they do the work soft, not hard. You feel happy about seeing the dentist."
Vol. 22, Issue 16, Pages 27-29Published in Print: January 8, 2003, as Dental Dilemma