State of Decay

With Veronica’s front teeth blackened by decay and her molars a collection of jagged holes, Dr. Matthew Tognotti knew the only option was a “happy visit.�

That meant ignoring the 12 cavities and the disfigured teeth and letting the 5-year-old Oxnard kindergartner walk away with a quick examination and a rubber duck key chain.

“Sometimes with these kids, you just take a look in their mouth and give them a prize, just so we don’t traumatize them,� the dentist said. “She may be the worst we’ve seen.�

That is saying a lot.

In an empty classroom at Marina West Elementary School in Oxnard, the traveling dentist recently found children in need of root canals, multiple fillings and crowns. He fixed what he could, but the work required often was too much to do outside a dental office.

Yet it was all sadly routine.

In Ventura County, an average of 30% of children from birth through age 4 have untreated dental disease, local health officials say.

And it’s not just a matter of a cavity or two.

Children as young as 3 need root canals, those ages 6 or 7 are losing permanent teeth and others suffer speech defects, eating problems and malnutrition because of decayed or missing teeth.

“It’s a huge problem,� said Dr. Robert Levin, medical director for the Ventura County public health department. “It’s one of those areas that we look away from. There is a real shortage of services for kids because there is no money to pay for it.�

The situation is so severe that last year Ventura County formed the Infants and Children’s Oral Health Coalition, made up of local pediatric dentists and county health officials. The group is seeking $750,000 in Proposition 10 funding for dental treatment and $500,000 for education programs over the next three years. The money would come from increased tobacco taxes designed to aid child development programs.

“It sounds like a lot of money, but it will only make a dent in it,� said Martina Melero, a county public health nurse and chairwoman of the coalition. “For years, oral health wasn’t on anybody’s mind.�

Melero said the education money would target children through age 4 and pregnant women. The coalition also hopes to buy a van with a portable dental lab and hire a dentist and hygienist to treat children throughout the county. It also wants money to pay for a program in which children get a sealant on their teeth to help keep out bacteria.

Local grants already fund school site dentists such as Tognotti as well as anesthesia services for children whose teeth are in such bad condition that they need surgery.

Dr. Mark Lisagore, a pediatric dentist in Oxnard and member of the coalition, said that 80% of dental decay lies in 20% of the children, with lower-income families the most affected.

Many of the parents in those families have no dental insurance.

“They just go to the dentist when it hurts,� Lisagore said.

Then they must find a dentist who will either treat them for free or take Denti-Cal, the low-income dental insurance that pays dentists only about 40% of their usual fee, Lisagore said.

Lack of Care Is Statewide Problem

Statewide, the California Center for Health Improvement reports that 55% of children between the ages of 6 and 8 have untreated tooth decay--more than twice the national average. The center, a public health policy research group, also reports that 27% of children ages 2 to 4 had untreated decay and only one in four had dental insurance.

The state’s Dental Health Foundation said there were no county-by-county breakdowns of decay but that California as a whole is near the bottom nationally for oral health.

A major cause of decay is overuse of baby bottles.

“The natural sugar in milk sits in the mouth,� said Linda Young, coordinator of the Ventura County Women, Infants and Children program, which offers education and family health services. “During the day is not as bad as at night, when they take it to bed. Milk stays in the mouth and it’s like a banquet for bacteria.�

Caroline Turner, executive director of the Santa Barbara-Ventura County Dental Society, said that one-third of parents statewide put their preschoolers to bed each night with a bottle. This often leads to what dentists call “baby bottle tooth decay� or bottle mouth.

One of Tognotti’s patients, who had a dozen cavities, had been sucking on a bottle for all of his 6 years.

Along with bottle dependence, many parents don’t know that dental caries--the bacteria that cause tooth decay and gum disease--can be spread.

“Tooth decay is a transmittable disease,� Lisagore said. “A mother who has a history of tooth decay carries a strain of streptococcus and she can infect the baby. When they blow on food and kiss the child, they are sending the bugs.�

Breast-feeding mothers can also damage their babies’ teeth and gums by letting the baby sleep with them and nurse through the night, dentists say.

Compounding the problem is that only 30% of California’s population has access to fluoridated drinking water, compared with 62% of the rest of the nation, said David Nelson, water fluoridation consultant for the state Department of Health Services. In 1995, the state ordered cities with more than 10,000 water connections--or about 25,000 residents--to fluoridate. But it gave them no money or timetable to complete the $200-million project.

Three years ago, California ranked 48th out of the 50 states for water fluoridation, Nelson said. Since then, San Diego, Los Angeles and Sacramento have fluoridated their water, but California still lags behind the rest of the country in what dentists say is an easy, effective way to fight decay.

“Fluoride hardens the enamel so the tooth becomes impervious to acids that can cause decay,� said Nelson, a dentist. “And it helps rebuild damaged enamel.�

In Ventura County, only Port Hueneme is fluoridated at state-recommended levels. Nelson said his department hopes to help other cities in their fluoridation efforts.

Aside from the physiological causes of oral disease, there are often deep-seated social problems, many related to poverty.

“If you have to choose between eating and seeing the dentist, there really is no choice,� Turner said. “The children are at the mercy of whatever happens to their parents.�

Young, of the WIC program, said treatment is more popular than prevention.

“We have people with very severe problems in their life,� she said. “Nutrition and health are a low priority.�

The children Young sees are in such bad shape that they often can barely eat.

“We only see them when they are at the end of their rope,� she said. “This is just the tip of the iceberg.�

Visiting Dentist Does What He Can

Tognotti sits at the tip of that iceberg.

The 32-year-old dentist with a practice in Glendale visits three Oxnard elementary schools a month--Marina West, Norma Harrington and Cesar Chavez--to treat children who have been referred to him by teachers and school health care workers.

The day before he arrives, children with serious dental problems are X-rayed in a vacant classroom. Those in the worst shape are seen by Tognotti the next day. But even then, they each only get an hour, usually not long enough to make the numerous repairs needed.

The children sit in a big, red plastic chair. Tognotti lays his instruments out on a low table shared by the Play-Doh, finger paints and tiny scissors of the kindergarten class he is working in.

Some kids are understandably unhappy about the visit.

Tognotti cajoles them, lets them handle the drill and tries to lighten the mood. When he numbs a tooth, he tells them to shut their eyes while he injects them with “sleepy water.�

With the tooth now soundly “sleeping,� Tognotti drills and fills until the hour is up. What he can’t finish must wait until next time or be referred elsewhere.

Six-year-old Bobbie bounded in on his first dental visit ever. His open mouth revealed a slew of decay. Cavities abounded--10 of them. He pointed to two teeth he said hurt him.

“He is only 6, yet he is close to losing all four of his permanent molars,� Tognotti said.

Bobbie lay motionless as Tognotti drilled through the decay.

“This is the part where you close your eyes,� Tognotti said.

Bobbie never flinched or cried, instead peering intently at the tools rooting around in his mouth.

The dentist filled two teeth, gave the boy a fluoride rinse and let him go pick out a glow-in-the-dark rubber lizard. He called in the next child. A slightly built 5-year-old girl in a stained pink shirt struggled into the chair. Her father, who didn’t speak English, stood anxiously at her feet as the doctor worked. She wasn’t too bad--just four cavities. Tognotti filled two and sent her on her way.

Elizabeth Weeks, who coordinates the school site dentist project, said many children Tognotti sees are sons and daughters of migrant workers.

“Dental hygiene is often not a priority,� she said.

Tognotti knows the problem is too big for one dentist with a portable lab, too time-consuming for the hour he gets with each child and too complex for the vacant kindergarten class he must work in.

Still, he seems to enjoy it.

“It’s nice to get away from private practice,� he said. “You’re doing dentistry for the sake of dentistry itself. You are not selling it.�