Gaping Cavity

She could see the black dots on her son Albert’s teeth. He would brush them and brush them, but they could not be rubbed out. They were cavities. Deep ones.

And Delia Holguin had no way to help.

Her other son, Ruben, told her his mouth hurt. Told her month after month. Then, one day, he came up to her. “Mommy,” he said. “My tooth broke.” He fished a chip of enamel out of his mouth. Then another. His tooth was crumbling.

And his mother could only tell him to brush.

It is one of the most pervasive problems that medically uninsured children face: They do not have access to dental care.

Preventive checkups are, for most, impossible luxuries. Families scraping to pay the rent simply cannot afford X-rays or cleanings. Even emergency treatment can be hard to come by.

The consequences are predictable: kids with cracked molars or infected gums, or cheeks so swollen they make them look like cartoon characters. Kids ashamed to smile.

School nurses see it all the time. They write notes to the parents, urging prompt treatment. But they know it’s a wasted exercise.

As Irene Mendes, a school nurse in Central California’s Kings County, put it: “If they don’t have food on the table, who am I to tell them they need to fill this cavity in a baby tooth?”

It’s not that parents don’t care. Holguin was so concerned about her sons, she had nightmares that her own teeth were falling out. But the network that supports uninsured children with physical problems breaks down when it comes to oral health.

In theory, the California Health, Disability and Prevention Act program, which offers low-income children free physicals, can be stretched to cover dental care as well. If an ailment--including a dental problem--is uncovered during an exam offered by the program, the child can usually get it treated for free. But the exams are conducted by physicians or nurses, not dentists. And oral X-rays are not included. So in most cases they catch only the most glaring dental decay.

For less obvious problems, uninsured parents have few places to turn.

The public health system in Los Angeles County has 151 clinics for primary medical care--but only five that deal with dental needs. Similarly, the nonprofit neighborhood clinics so willing to treat a child’s earache for free are usually not set up for dentistry. Neither are most hospital emergency rooms.

And although many California school districts sponsor campus medical clinics, only one--Fontana’s--has dental hygienists on staff.

In many communities, good-hearted dentists donate their services to a few kids a month. But they don’t advertise their charity in the Yellow Pages. Parents must connect with someone plugged into the health care system to even have a shot at finding them.

Otherwise, their children learn to live with pain.

Holguin’s sons did.

A full-time clerical worker, Holguin lost health coverage for her children two years ago when she and her husband divorced. Until then, she had taken them to the dentist for regular checkups. But with her house payment, her groceries and her utility bill to squeeze out of her modest salary, dental care had to go.

By this fall, her 9-year-old twin boys had visible decay. Her daughter, April, 12, had cavities too.

Finally, Holguin pulled together enough money to take them to a discount clinic in Los Angeles. For $75, a dentist evaluated all three children with X-rays. The verdict: They each needed at least $500 in dental work.

Holguin told her children she could not afford it.

Keep brushing, she told them. Keep brushing.

“I felt horrible,” she said. “Helpless and very frustrated.”

Then a savior arrived: Pasadena’s Young and Healthy program.

Founded in 1990, the plan matches uninsured children with community doctors willing to treat them for free. Twice a year, Young and Healthy also brings in a mobile dental clinic--a recreational vehicle smelling of mouthwash, staffed by USC dental students under supervision. To the beat of rock music, the budding dentists spend a week filling cavities, affixing sealants, building crowns and scrubbing plaque for 120 of Pasadena’s neediest students.

The three Holguin kids all qualified. They sat through a total of 10 appointments--and emerged with gleaming new smiles.

“It’s a big relief,” their mom said. “My children really, really, really needed it.”

*

Similar success stories fill the files at the Long Beach Children’s Dental Health Clinic. For 65 years, the facility has been providing care to uninsured children for an average fee of $14 a visit. Among its former patients: Long Beach Mayor Beverly O’Neill, who got her teeth fixed there as a child, after a school nurse identified decay. “It was a godsend to our family,” she recalled.

Fontana takes a different approach: Its school district hired two part-time hygienists and installed dental chairs at three schools.

The hygienists screen 1,000 preschoolers a year. They also take care of older pupils; any youngster in the district who needs a cleaning, a fluoride treatment or sealants can come by for free care. If a student requires more serious work, local dentists pitch in for reduced fees. In all, about 2,000 students take advantage of the program each year. And the school district plans to serve more children soon by enlisting volunteer hygienists.

“We have tons of students who just don’t have any way to access preventive dental services without us,” said Michelle Hurlbutt, one of the district’s staff hygienists.

For all their triumphs, however, the Pasadena, Long Beach and Fontana programs remain small and very local solutions to a problem of boggling magnitude.

Although there are no firm statistics, analysts say most of the 1.7 million California children without medical coverage also lack access to dental care. Even some who have health insurance may not have dental coverage.

Pasadena mother Tina Cisneros manages to pull together $150 a month to enroll her two young daughters in a health maintenance organization. But she can’t even think of dental coverage, not on her husband’s salary as a rental car manager and her part-time clerical wages. “Something else to worry about,” she said.

The result of such widespread lack of insurance showed up in a recent study by the Dental Health Foundation. California children ages 6 to 8 have twice as much untreated oral decay as the national average. And more than half the state’s school-age children need dental work, the study found.

Clearly, said the foundation’s chairman, Dr. Jared Fine, “the uninsured child is at the greatest risk.”

And at risk for much more than an occasional toothache.

Tooth pain is the No. 1 reason students miss school in Los Angeles, according to Helen DuPlessis, medical director of the Los Angeles Unified School District. And falling behind in class can compound the self-doubt that many children feel when their teeth turn brown or grow in crooked.

“They start thinking that something’s wrong with them, that they’re defective, that people will ridicule them. Then they start acting out,” said Harvey Buzin, an Arcadia therapist who counsels needy children through Young and Healthy. “Kids pay very steeply when they don’t have these [medical and dental problems] addressed at an early age. They pay with a lifetime of pain.”

They may also pay with their health.

Dentists warn that oral infections, if left untreated, can spread to the bloodstream and cause fever or swelling. If teeth fall out from rot, children can have trouble chewing and speaking. And decay in baby teeth can presage orthodontic problems later, because adult teeth may grow in malformed.

By failing to get them prompt dental care, Fine said, “you’re basically building more problems that these children will have to deal with as they grow older.” Unlike many childhood illnesses, which clear up after they have run their course, dental problems do not heal. Instead, Fine said, “they get progressively worse.”

But, as he acknowledged, educating parents about these perils will do little good as long as they lack dental insurance. Unless they can access subsidized care, parents will continue to rely on ice or clove oil to numb the pain of a toothache. And twice-a-day brushing will pass for the best in preventive care.

“People don’t realize,” said Eve Fazekas, an uninsured mother who runs a gift shop with her husband in Long Beach, “that the dentist is a real luxury.”