SF’s Income Disparity Displayed in a Smile of Bad Teeth

Margaret Fisher addresses a group of community leaders and oral health professionals at the Mission Neighborhood Centers, Inc

Tooth decay paints a bleak picture of the Mission’s growing inequality. Even as incomes rise, the kindergartners at Mission Education Center claim the dubious distinction of having the worst teeth in the city – some 75 percent have had tooth decay, according to Department of Public Health statistics.

In the 94110 zip code, between 15 and 19 percent of white kindergarteners had experienced tooth decay, compared with 35 to 39 percent of Hispanic children.

Health workers are particularly troubled by disparities in tooth decay among demographic groups. In an annual survey of San Francisco kindergarteners performed by the public health department and the school district since 2007, rates of tooth decay in kindergarteners have dropped overall, but the gap between groups has only widened.

Children of color are more than twice as likely to develop untreated tooth decay as white children. The big divide, however, is income, and the challenge is changing behaviors among at risk groups.

“You never know what will make them change,” said Margaret Fisher, a Dental Hygienist in alternative practice (RDHAP) who works with the Department of Public Health and helps lead the San Francisco Children’s Oral Health Collaborative.

Not everyone has the means to sustain themselves and their family on fresh fruits and vegetables and water and milk. They might know that a liter of soda isn’t the best option, says public health dentist Lisa Chung, also a co-lead on the Children’s Oral Health Collaborative, “but maybe that’s all they can do at the moment.”

Chung also described access to care as a “chronic issue,” especially for low income communities that rely on DentiCal, the dental portion of MediCal. It’s difficult to find a dentist who will accept DentiCal, Chung said, and those that do are often overbooked.  The latter is a particular problem now because this year, DentiCal reinstated the adult coverage it dropped in 2009. Now affordable dentists are flooded with adult clients.

“Frankly, adult dentistry is a lot easier” (and doesn’t involve crying children), said Carson Bentley, a dentist at the Native American Health Center.

But dentistry early on is critical. Bentley and the Oral Health Collaborative recommended at least one dental visit for children before they turn one, topical fluoride application through tap water, toothpaste, and dentist-applied varnishes, as well as resin sealants for molars to prevent cavities.

Irene Hilton, a public health dentist and a board member of the San Francisco Dental Society,

said she runs into misunderstandings about the seriousness of allowing children’s primary teeth to rot, under the assumption that they’ll fall out anyway. Kids whose baby teeth were neglected and developed cavities tend to suffer from tooth problems well after their adult teeth come in because the harmful bacteria have already settled and flourished in their mouths. In the worst untreated cases, children have died from complications of tooth decay.

Serious tooth decay in young children can also manifest as “failure to thrive,” a lack of growth and weight gain as a result of not being able to transition to solid and healthy foods. All as the result of an entirely preventable affliction.

Education on any number of issues is important.

Sugar is, of course, another target of preventive dental care, and both the city’s dentists and its legislators are taking aim.

Educational campaigns about the negative health effects of sugar sweetened beverages and sugary foods adorn MUNI vehicles and government buildings as well as many nonprofits. San Francisco General Hospital announced recently it would stop selling sugar sweetened drinks on its campus and host a nutrition-conscious fair to celebrate.

“We feel that we have best practices, we have the knowledge … but it’s translating that into communities that are suffering from disease” that is the issue, according Chung.

“Knowledge doesn’t always equal behavior change,” said Chung. “We feel like we could be more effective.”

At a government level, after massive spending on the part of the American Beverage Association helped prevent a ballot measure for a soda tax from getting its required two-thirds majority, city Supervisors are apparently taking just such a top down approach.

They unanimously passed three regulations at a recent Board meeting that prevents advertising of sugar-sweetened beverages on city property and prohibits the city to spend any money on sugary drinks or include their sale in any city contracts and grants.

More dramatically, the health code now includes a mandate that any sugary drink advertising in the city include a health warning, similar to those for cigarettes, that takes up 20 percent of the ad space. The measure, if no action is taken against it, will go into effect this summer.

“This is a looming disaster for our healthcare system,” Wiener said at the Board of Supervisors meeting where he proposed the restrictions. “These are not just harmless products that taste good.”

The city has also allocated funding for an Oral Health Coordinator, who will help unify the efforts of dentists, the Department of Public Health, healthcare workers, and educators to prevent children from falling through the cracks of dental care.

A wide range of oral health stakeholders including the DPH, UCSF, Mission Head Start, and the San Francisco Dental Society have come together with educators and other city staff to create a Strategic Plan for oral health around the city. They hope to improve access to dental care for pregnant women, infants and young children. In part that means integrating dental health with general medical care, since many young low income children are seen by a doctor many times in their lives before they ever get near a dentist. But it also means elevating oral care to the same level of medical importance as other health concerns.

“A lot of times, oral health is considered an add-on, or some sort of luxury,” Supervisor Wiener told a meeting of community stakeholders and oral health professionals in the Mission last week. Health workers are hoping to change that, and want the community’s feedback about how to do it. And last Tuesday, part of the answer, as always, was winning hearts and minds.

“Families are struggling with choices,” said Estela García, Executive Director of the Instituto Familiar de la Raza. “This is a community problem.”

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