Dental Care for the Underserved Children of Monterey County: Meeting the Challenge

By Ray E. Stewart, DDS, MS

With its expansive area, and the special needs of agricultural workers, Monterey County held significant challenges for setting up a children's health clinic. Part of the solution to addressing the county's unmet dental needs was the establishment of the Children's Miracle Network Dental Center in 1995. But working in the fields leaves little time for travel to appointments, so the Dental Center expanded to a mobile unit that can go where the need is. Understanding the special needs of one's community is crucial to establishing programs that can successfully address the state's needs for children's dental care.

Article copyright 1998 Journal of the California Dental Association.
Photographs copyright of the authors.

Monterey County is on the central coast of California and is, arguably, one of the most beautiful and desirable places to live in the entire United States. It contains communities that have among the highest per capita incomes in the nation (e.g., Pebble Beach, Carmel, Monterey, and Pacific Grove). Monterey County is also one of the country's most prolific agricultural regions. The Salinas Valley is often referred to as "The Salad Bowl of the Nation," and as such, is dependent upon a large population of seasonal agricultural employees who, by and large, have little, if any, health care insurance as a benefit of their employment.

A survey conducted for the Maternal, Child and Adolescent Health advisory board in Monterey County in 1991, found that by far the greatest unmet health need in Monterey County was children's dental health. Dental infections and accompanying pain were acknowledged to be one of the leading causes of school absence and impairments to classroom performance in the public schools. The following statistics were sobering:

* In 1991, there were approximately 34,000 Medi-Cal eligible children ages 0 to 16 years. Five years later, in January 1996, those numbers had increased to 44,000.

* Only 20 to 25 percent of Medi-Cal children saw a dentist during the year 1990-91. Less than 5 percent of children under age 6 visited a dentist. Of the children who had been to a dentist, many were seen only once -- for an emergency.

Only two pediatric dentists in the county were seeing Medi-Cal children under age 6 at that time, of which there were 18,000. In addition to this large number of Medi-Cal children, there were thousands of other children who were considered medically indigent and had limited access to dental care.

* Fifty-eight percent of Head Start preschool children screened in 1991 had dental decay, with an average of three decayed teeth per child.

Sixteen percent had baby bottle tooth decay; 12 percent required urgent or emergency care.

With these alarming statistics and given that there were but a handful of dentists in Monterey County seeing Medi-Cal patients in 1991, and with virtually no ability to expand services to this population, my partners, Roger Sanger, DDS, and Peter Chiang, DDS, and I developed a plan for a facility to provide comprehensive dental services to this large population of patients.

The Department of Health Services in Monterey County recognized the unmet need for dental care; however, they did not have the resources nor the capital available to build and staff dental facilities to provide the needed services. They did, however, enthusiastically participate in an effort to mobilize a collaborative effort among public and private entities to develop the necessary dental care facility. It was through these joint efforts and a commitment from the Children's Miracle Network at Salinas Valley Memorial Hospital, that the Children's Miracle Network Dental Center was opened in July of 1995. The dental center is a 2,500-square-foot facility, staffed by two full-time dentists and eight auxiliary personnel. It serves 45 to 50 patients per day, providing comprehensive preventive and restorative needs to children and adolescents up to age 18.

The geography of Monterey County is such that it is nearly 100 miles long from the northern line to the southern boundary. The population in need of pediatric dental service is broadly distributed from one end of the county to the other. This creates a significant logistical and transportation problem in delivering health care services from a single stationary or fixed site clinic facility such as the dental center. The additional fact that a large segment of our target population is from families whose parents are employed as field workers or in packing sheds makes it difficult to schedule dental appointments during working hours and leads to large numbers of missed or canceled appointments. These barriers, especially in remote areas of the county, prompted requests from several communities dotting the southern part of the county to establish treatment facilities similar to the dental center in those locations.

The $300,000 that would be required to capitalize the building and equipping of multiple facilities was prohibitive.

An effort to address these logistical problems eventually led to the proposal to build a mobile facility capable of delivering comprehensive preventive and restorative services to several communities on a rotating basis. It was further determined that, where possible, the unit would best be located at school sites to minimize the need for transportation to and from appointments or the need for parents to take off work to accompany the child, except for the attending appointment to provide health histories and informed consent.

The proposal was, again, a broadly based collaborative effort among numerous public and private agencies. The initial start-up funding for the project came from a $200,000 grant from the Children's Miracle Network at Salinas Valley Memorial Hospital.

The Charitable Council of Monterey County undertook the grant-writing responsibilities to raise the balance of the necessary capital to purchase, equip, and operate the unit. Their efforts were extraordinarily successful in raising an additional $300,000 from the California Endowment and the David and Lucille Packard Foundation.

The Children's Miracle Network Mobile Dental Center, dubbed "Smiles on Wheels" began operation in March 1998 in Greenfield and will eventually move to other school sites throughout the southern part of the county.

The target population to be served by the Children's Mobile Dental Center consists of children of uninsured, low-income families who reside in the target service area. The projected ethnic classification of the children served by the Children's Mobile Dental Center is characterized as 78 percent Hispanic, 18 percent Caucasian, 2 percent Portuguese, 1.5 percent Asian/Pacific Islander, and the final 0.5 percent distributed among the African and Native American population, respectively.

The overall goal of the Children's Mobile Dental Center program is to improve the oral health of uninsured, low-income children who reside in Monterey County by reducing the prevalence of dental caries and untreated diseases. The estimated impact is as follows:

* To expand prevention and comprehensive treatment of dental disease for uninsured, low-income children who reside in south Monterey County by offering 8,000 outpatient dental visits during the first 12 months of operation.

* To provide training to local primary care providers and school nurses on classifying Child Health and Disability Prevention Program oral health needs to help improve oral health screening and follow-up services.

* To educate parents about good oral health practices and train parents as teachers for other families.

* To reduce untreated dental caries to no more than the national average among children aged 6 through 8, within five years.

Dental services provided in the Children's Mobile Dental Center will be comprehensive in nature. A full range of restorative, surgical and preventative services will be available using state-of-the-art techniques and equipment. Children who need more complex treatment under sedation or general anesthesia will be referred to the Salinas Children's Miracle Network Dental Center.

One cannot overemphasize the importance of developing a grass-roots network of participating organizations and interested parties who come together to achieve a common cause and goal. Without a careful cultivation and building of a solid foundation, based on trust and cooperation, the best made plans for the most worthy of causes will fight an uphill battle to achieve access. The ultimate success of this project rests with the enthusiasm and support engendered by the solid cooperation among no less than 14 agencies, boards and governing bodies.

Author

Ray E. Stewart, DMD, MS, is the president of California Society of Pediatric Dentists.

To request a printed copy of this article, please contact/Ray E. Stewart, DMD, MS, 1117 Los Palos Drive, Salinas, CA 93901-3853.