Bay Area pediatricians focus on oral health

Nine-month-old Xochil Gonzalez squirmed and fussed as medical assistant Hilda Romero Gomez daubed a yellowish white mixture onto her baby teeth.

“Swipe and swipe,” Romero Gomez said as she quickly painted the fluoride varnish onto Xochil’s bottom two teeth with a miniscule brush. “One more, baby. On the top, ok? Thank you. That’s it.”

Medical assistant Hilda Romero Gomez paints fluoride varnish onto the teeth of 9-month-old Xochil Gonzalez. Photo by Nicole A. West.

Xochil wailed, but once her father scooped her up, she ceased crying and appeared to consider the strange substance in her mouth. “It has a mint taste to it,” Romero Gomez explained.

For the past two years, medical assistants in the pediatric center at Highland Hospital in Oakland have been applying fluoride varnish to the tiny teeth of babies as young as 6 months old at their regularly-scheduled checkups. The hospital sees about 1,000 children a month, and its practice helps prevent cavities and keep teeth healthy, Chief of Pediatrics Robert Savio said.

“I wish our kids had it years ago,” Savio said of the fluoride treatments. “It’s an amazing, easy preventive intervention.”

Pediatricians at Highland also teach parents about the importance of oral health and connect families to a permanent dental home—most often the dental clinic embedded within Eastmont Wellness Center in Oakland.

Fabian Gonzalez holds his daughter Xochil during a pediatric checkup at Highland Hospital in Oakland. During the appointment, Xochil received fluoride varnish and was placed on a waiting list for a dental appointment at Eastmont Wellness Center in Oakland. Photo by Nicole A. West.

Tooth decay is the most common chronic disease of childhood, according to Dr. Susan Fisher-Owens, associate professor of pediatrics at the UCSF School of Medicine and associate professor of preventive dental sciences at the UCSF School of Dentistry. Children are five times more likely to have oral health problems than asthma and four times more likely to have oral health problems than early childhood obesity.

Savio estimated that about a third of the children under the age of 5 seen at Highland have cavities. “I think that’s improving already in the last few years since the tide has kind of changed,” he said.

Most parents take their infants to a doctor, but fewer take their children to the dentist. According to Fisher-Owens, 89 percent of one-year-olds have been to a doctor or pediatrician, but only 1.5 percent have been to a dentist. Between 6 and 8 percent of one-year-olds already have cavities.

Highland Hospital is one of several Bay Area establishments that provide infants with fluoride varnish and dental appointments and their parents with knowledge about dental care. At San Francisco General Hospital, pediatricians also counsel families about oral health and auxiliaries paint fluoride varnish on infant teeth, Fisher-Owens said.

At four Alameda County Women, Infant and Children locations—including two Oakland locations—parents of infants are recruited to attend short informational sessions where they are taught about oral hygiene and shown how to clean their children’s teeth. At the same visit, their children receive fluoride varnish, according to Jared Fine, interim dental director for Alameda County Public Health Department. “They love it. They sign up in droves,” Fine said of the sessions.

Kungsang Lhanze, Xochil’s mother, said she didn’t know that preventive fluoride was put on children’s teeth at such an early age. “I think it’s great,” she said.

Lhanze had planned to ask her pediatrician when to start taking Xochil to the dentist. She said she’d wondered whether to find a dentist now or wait until Xochil’s permanent teeth came in. “My parents never educated me in these things, you know? They barely took us to the dentist,” she said.

Before the fluoride procedure, Savio explained to Xochil’s parents the importance of cleaning Xochil’s teeth, especially before she goes to sleep. “We know that dental caries [cavities], or problems with teeth, start really early, and we know it’s from lack of fluoride or lack of dental care,” he told them.

When Savio first started working at Highland in 1998, educating parents about oral health wasn’t a top priority, he said. “Education around dental care was on the list, but it was way down the list,” he said.

Romero Gomez told Xochil’s parents that normally the baby would be immediately scheduled for a dentist appointment at Eastmont, but instead she’d be placed on a three-month waiting list, which is a “real problem,” said Dr. Pamela Alston, a dentist at Eastmont Wellness Center in Oakland. “We need more staffing to handle demand for this,” Alston added.

Alston was inspired to collaborate with Highland by a presentation Fisher-Owens of UCSF gave several years ago. “She gave me so many ideas of what a physician can be doing to support oral health,” Alston said.

Alston starts seeing infants at 6 months of age. “The earlier parents take kids to the dentist the more likely they won’t get dental caries,” she said.

The dental clinic, embedded within Eastmont Wellness Center, is part of the Alameda Health System and Health Pac, a network of clinics that provides services on a sliding scale. Patients must prove their income level at an eligibility office. The program covers the same dental services covered by Medi-Cal, she said.

Alston said oral health affects children’s overall health, adding she’s seen children who have suffered from toothaches for years. Sometimes she sees kids with a tooth that’s rotted to the gum line. “It does affect school performance and days out of school,” she said. “When they are in school, they’re not able to concentrate.”

Neither Fisher-Owens nor Savio were taught about oral health in medical school. However, medical schools across the country, including UCSF, have started integrating oral health into the curriculum, Fisher-Owens said.

Fine, former dental health administrator for the Alameda County Health Department, helped create a program to teach physicians and dentists best practices to combat cavities in 2004.

The training was taken around the state to medical, dental and head start organizations, including Oakland Children’s Hospital and Kaiser Permanente. Fine also worked with the State Department of Health Services to get the state to reimburse physicians for fluoride varnish.

The curriculum was “kind of a wake up call” to something that had been overlooked, Fine said. There was an attitude that oral issues were something that dentists should deal with, he said, but added the trend today favors collaborating to create better health outcomes.

Savio said that medical trends go in and out of vogue, but the importance of dental health is “definitely here to stay.”

Applying fluoride varnish is “easier than painting your nails,” Fisher-Owens said, adding that the pediatricians’ oral health counseling that goes with it “is frankly the more important part.”