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Dental care called a health care crisis

Dr. Mark Hagele examines three-year-old Christopher Hernandez's teeth prior to his surgery, while his mother, Norma Tellez, looks on at the PDI Surgery Center in Windsor Wednesday.

CHRISTOPHER CHUNG/THE PRESS DEMOCRAT
Published: Friday, June 17, 2011 at 1:49 p.m.
Last Modified: Friday, June 17, 2011 at 1:49 p.m.

Even though she had 12 cavities, 3-year-old Vanessa Sepulveda never complained about pain.

Facts

Finding solutions

The Sonoma County Task Force on Oral Health, which met between January and May, seeks solutions that could be implemented within three years. Issues such as fluoridation of the county water system and augmenting dental insurance coverage were not considered because such efforts could not be achieved within that time frame or because it was beyond local control.

The following are among the recommendations that will go before the Board of Supervisors in July:

-- Expand access to care in Santa Rosa and other high-need communities by adding new clinical capacity. Examples are local community health centers, Women, Infant, Children (WIC) nutrition programs, private dental offices, Santa Rosa Junior College Dental Hygiene Clinic, and St. Joseph Health System's mobile dental clinic.

-- Strengthen oral health assessment, education and preventive care in primary care visits and fully integrate dental professionals within the medical home model.

-- Develop and integrate a comprehensive oral health promotion program, to include prevention, assessment, treatment, referral and case management, into the Comprehensive Perinatal Services Program (CPSP) for pregnant women at all CPSP service delivery sites.

-- Expand the use of Registered Dental Hygienists in Alternative Practice, or RDHAP, and other appropriate, trained personnel to deliver cost effective oral health education, assessment and preventive services in primary care, school, and community settings.

-- Develop and implement an ongoing oral health surveillance program, within the Sonoma County Department of Health Services.

-- Martin Espinoza

But on Wednesday, lying in a state-of-the-art dental operating room at PDI Surgery Center in Windsor, general anesthesia was used to help her deal with filling and crowning her caries — the likely result of drinking juice since she was 7 months old.

“We used to put it in her baby bottle with water so it wouldn't be so sweet,” said her father, Ignacio Sepulveda of St. Helena. “We now know that she should eat apples and other fruit, instead of drinking them,” he said in Spanish.

Sepulveda is part of what local officials are calling a growing North Coast health care crisis that only now is being assessed in Sonoma County. According to a study by the Sonoma County Task Force on Oral Health, yet to be formally released to the public:

-- In 2010, there were only 15 dentists for 109,000 low-income residents in Sonoma County — a fraction of the pool available to those with private insurance.

-- In 2009, 52 percent of the county's third-graders had a history of tooth decay, exceeding the state average.

-- The county's impoverished third-graders are more than twice as likely to suffer from untreated tooth decay as children from more affluent families.

The report is expected to be reviewed by the county Board of Supervisors next month.

Located adjacent to the Windsor Golf Club on 19th Hole Drive, the non-profit surgery center is the last line of defense for thousands of low-income children in the North Coast who have little access to routine dental care.

Though many of them have public dental insurance, almost no private practice dentists in the area will accept their coverage. At the same time, state budget cuts to dental programs and a recession that has left many local residents without private dental insurance has “pushed Sonoma County's fragile oral health ‘system' to the breaking point,” the report said.

“It's a disgrace. We have not given resources to dentistry and we've acted like it's a problem that doesn't exist,” said retired Kaiser Permanente pediatrician Kathy Foster.

Foster, one of the founding board members of PDI Surgery Center, is among two dozen health care professionals who participated in the task force, which sought to assess the state of oral health in Sonoma County.

The report highlights a number of factors that have led to the current troubles. Denti-Cal (Medi-Cal's dental program) no longer pays for adult dental treatment; Medicare does not cover routine dental care for the elderly; and most private practice dentists will not see children with Denti-Cal because of low reimbursement rates.

“It's alarming and it is very concerning,” said Mark Netherda, the county's interim public health officer. “It needs to be brought to everyone's attention and it needs to be changed.

Netherda said the task force was commissioned by the county Department of Health Services, First 5 Sonoma County and the Redwood Community Health Coalition. Its goal was to come up with solutions that could get at the problem within a three-year time frame.

These include expanding access through local health centers and programs like St. Joseph Health System's mobile dental clinic; integrating oral health care with perinatal programs; expanding the use of dental hygienists in the primary care setting; train primary care staff to make oral health assessments normally done in a dentist's office.

Netherda said the final recommendation would be for the county public health division to begin tracking oral health care issues as it would any other disease.

Foster, who is also the oral health educator for the Northern California Chapter of the American Academy of Pediatrics, said that at the core of the problem is the failure of the community at large to view poor oral health as a serious medical issue on par with such things as obesity.

“Tooth decay is rampant. One third of all kids in school have visible decay,” she said.

But she said that while cavities are “one hundred percent preventable,” treatment is expensive and “no one wants to pay for it.”

Pedro Toledo, a spokesman for the Redwood Community Health Coalition and a member of the task force, said two years ago, around the same time that the state cut Medi—Cal by 10 percent, the successful low-cost health insurance program known as Healthy Families was changed so that all Denti-Cal insured kids would be brought into managed care.

The result was that reimbursements rates for dental care under Healthy Families was brought down to Denti-Cal levels.

“It costs more to bill for Denti-Cal than what you get,” he said.

That change rocked PDI Surgery Center's once stable financial model, which relied on the 10 percent of patients who were covered by Healthy Families to offset Denti-Cal's low rates. PDI went from having 90 percent Medi-Cal to 99 percent.

“No one makes it on Medi-Cal,” said Viveka Rydell, CEO for PDI Surgery Center. “It's the second lowest reimbursement rate in the country.”

PDI, the only center of it's kind from Santa Cruz to the Oregon border, has treated 5,126 kids since it started in January 2008.

The county's oral health safety net is made up of dental clinics operated in the West County, Petaluma, Cloverdale, Healdsburg. Also, in Santa Rosa, the Indian Health Project and St. Joseph Health System operate dental clinics.

Christine Tomaszewski, a dentist with St. Joseph's mobile dental clinic, is in a different area of Sonoma County every day, treating those who cannot “pick up the phone and call a dentist” when they have a tooth ache.

Tomaszewski, a former military dentist who once ran the Naval Dental Center at Treasure Island, is also in private practice in Santa Rosa with her husband, Arthur Tomaszewski. She works only one day in private practice and spends most of her time in the mobile clinic, going from town to town.

“To me it's not all about making money,” she said. “It's being out there and helping people out.”

Tapping dentists in private care like Tomaszewskito do more to close the dental care gap is among the major goals of the task force report.

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