You probably never would have guessed it, but one of the front lines of public health in New Hampshire is on the second floor of an elementary school in Claremont - in a storage closet. Here a dental hygienist meets with a second grade girl to talk teeth.
"I haven’t been really, um, brushing my teeth a lot. I keep on forgetting," the girl tells the hygienist.
"Oh dear. Who’s in charge of your teeth? Who takes care of your teeth?"
"Me," the girl says.
"Yeah. But you’re not."
Looking into a child’s mouth can tell you a lot about her health. In fact, oral hygiene is a sort of canary in a coal mine for not just a child’s health, but also the environment she grows up in. In New Hampshire, some are tackling oral hygiene through both caring for children’s teeth and the environment the child grows up in.
Consider this little girl as a case study: second grade, suspected cavities on at least five molars. Hygienist Kyle Messier last saw this second grader in this storage closet a few months ago. Then, the girl had pain on one side of her mouth. Now it’s spread to the other side.
Messier is the driving force behind a program that has dramatically improved oral hygiene in Sullivan County. Messier cleans teeth in schools. She refers kids with urgent needs to dentists, and hounds parents to go to appointments. In extreme cases, she’ll ask DCYF to step in.
"I can’t eat apples, or my teeth will start hurting," the girl says. "I can only eat like soft food and stuff."
Maple Avenue School in Claremont asked us not to use this girl’s name, but Messier has talked to her mother, who says she can’t afford dental insurance.
A Hidden Problem
So how big a deal is access to oral hygiene? And can it impact a child’s prospects down the line?
One California study found adults were twice as likely to get a job – and get off welfare – after their teeth were fixed. And there’s good evidence the environment kids grow up in impacts their teeth in the long term. Consider this: in 2005, more people visited the ER in New Hampshire because of an urgent dental problem than for the combined visits for asthma, diabetes, congestive heart failure, and high blood pressure.
And the county – and city – with the worst track record back then: Claremont, right in Sullivan County.
"A lot of times we’ll have kids who will be burying their heads, hands on their face, giving us indicators that something’s not right," says Dan Cherry is the principal at Maple Avenue. "We’re providing that first line of defense to investigate why is this child maybe not available for learning."
A 2014 survey of third graders conducted by the state found untreated tooth decay dropped 32 percent in the last five years – good news. But kids in the poorest school districts have more than twice as much decay history as kids in richer districts.
Sullivan County is a big bright spot in the data. Over the past ten years, Claremont’s rate of untreated decay dropped from 64 percent to 10 percent. In that time, Kyle Messier has seen nearly every kid in the district.
"It’s hidden," says Messier. "I think it’s a hidden problem. And when I changed from private practice to public health it became clear to me quickly there is a very small safety net for dental health. And it’s not just New Hampshire, it’s across the country."
"We are changing"
In the 1960s, the American Dental Association lobbied against including dental benefits for elderly Americans on Medicare, and it lobbied against dental coverage for poor adults through Medicaid. Medicaid provides full coverage for kids’ dental coverage in New Hampshire. But that’s if a parent can find a dentist that accepts Medicaid. Only about half of New Hampshire kids on Medicaid saw a dentist in 2013, and that’s in part because only a little more than half of New Hampshire's dentists accept Medicaid.
David Jordan runs a national effort to increase access to dental care. He says dentists want to have it both ways: they don’t want to accept low-paying patients, but they’ve resisted efforts to let others see them too.
"I think a lot of dentists are very well meaning," Jordan says. "They also aren’t seeing the high-need population."
Jordan points to a bill that has failed a couple times in New Hampshire – opposed each time by the New Hampshire Dental Society – that would create dental therapists, or midlevel practitioners who could operate in poor, rural areas with some, but not much, oversight from dentists. This bill has increased access in Alaska and Minnesota, and it recently passed in Maine and the Vermont Senate.
But Peter Welnack, the president of the New Hampshire Dental Society, says New Hampshire is saturated with providers.
"We are changing," Welnack say. "We’re not changing in the way that some people want us to change, and we like to think we’re pretty much experts in the dental arena. So we’re putting our resources into the areas that we think will help the most people."
That includes starting a program at the New Hampshire Technical Institute to train dental hygienists and dental assistants to do more advanced work under the direct supervision of a dentist.
Both the New Hampshire Dental Society and dental therapy advocates say their solution would increase access to care by lowering the cost - the number one obstacle for patients. Lack of awareness is also a barrier, as is transportation, especially in the North Country. The Dental Society has stated dental therapists would not have enough training, while dental therapy advocates point out therapists have been working internationally for 100 years.
Fix the neighborhood...fix the teeth?
Janet Valeri is the principal of Ledge Street Elementary School in Nashua's Tree Streets community. Ninety percent of the kids at Ledge Street are eligible for free or reduced lunch, and about one-third speak Spanish.
The same survey that found Sullivan County had made huge leaps in oral health also found Nashua schools like this one had as many as 5.5 percent of kids in need of urgent care – a.k.a. pain in their mouths. That’s the highest rate anywhere in the state.
"You know it’s easy to use the parent as a scapegoat to say the child is underweight, overweight, dental hygiene is an issue, because they don’t care," says Valeri. "When really when you dig deeper, they care just as much as any other parent, but their resources are limited."
And even though Nashua is struggling to meet this need, the city is also taking an innovative approach to fixing it.
Kerran Vigroux is the city’s public health director. She says the city is working with a couple dozen institutions - the police, banks, mechanics - to paint murals and build gardens on a walking trail, and promote healthy living in the Tree Streets neighborhood. Tree Streets is the low-income community where many children attend Ledge Street School.
"We actually know that about 20 percent of a person’s health outcomes are dictated by their genetics," says Vigrous, "but the 80 percent is where they live, what education level they have. So if we’re looking at how can we best help our residents, it’s by impacting their environment. And it’s not just for low income. When we talk public health, it’s about everyone who lives in our community."
Nashua is banking on this idea: that if you can make a neighborhood safer and help people feel better about where they live, then good health, including good oral hygiene, will follow. They’re using Tree Streets as a test lab before expanding the concept to other poor communities. And there’s a little evidence it’s working: a survey found optimism about the community rising in Tree Streets.
Still, Nashua will continue to meet kids where they are – in a dental chair right in school.
Corrections: An earlier version of this story included two errors. The story stated Vermont had passed a dental therapy law; in fact a dental therapy bill passed the Vermont Senate. Also the story stated the New Hampshire Technical Institute will be training midlevel dental providers, when in fact it will be training dental hygienists and dental assistants to do more advanced work.