Community Dental Health with Dr. Vacharee Peterson and Pa Nhia Her

Author: A Public Health Journal

Oral health is an essential component of health throughout life. No one can be truly healthy unless he or she is free from the burden of oral diseases and conditions. This is especially true for children, where dental caries, periodontal disease and other dental problems can result in difficulty with chewing and speaking, loss of self-esteem, lost school time and much needless pain and suffering.

Despite it's importance, dental hygiene and dental care have not been a priority in our society. In fact, some of our routine activities, like increasing the use of sugar-sweetened beverages, and the lack of dental benefits in most insurance plans, are making dental problems worse. On today's episode of "A Public Health Journal," we'll be looking at the problems of oral health in our state and discussing what can be done to make it better. Please stay tuned.

(man) Welcome to "A Public Health Journal," a program that explores the public health issues facing our society today and tomorrow. The host of our show is Dr. Ed Ehlinger, Commissioner of Health for the State of Minnesota. "A Public Health Journal" is sponsored by the Minnesota Department of Health, the Hennepin County Human Services and Public Health Department, and the Minnesota Public Health Association, all working together towards the goal of healthy people living and thriving in healthy communities.

Welcome to "A Public Health Journal." Today we're going to look at the status of oral health in Minnesota. We'll be looking at the importance of oral health, the status of oral health among Minnesotans, and what's being done to address the oral health needs in Minnesota. In particular, we'll be focusing on how to improve the oral health and well-being of underserved communities, especially among children. Joining us in our discussion are 2 people who are dedicated to that mission. Dr. Vacharee Peterson, founder and CEO of Community Dental Clinics, and Pa Nhia Her, Program Manager for Minnesota Cavity Free Kids. Welcome to our program, both of you.

Community Dental Health with Dr. Vacharee Peterson and Pa Nhia Her

Thanks for having us. It's an important issue that doesn't get enough attention, so I'm hoping that in our half hour here, we can really draw attention to that and have people get a better understanding. So Dr. Vacharee, what's the Community Dental Clinic that you're the head of, give us a little perspective on where you're coming from, what you've been working on for the last several years. [with slight Southeast Asian accent] Well, actually, Community Dental Care started up about 35 years ago. We intended to treat the underserved patients and then we grow so much into now 5 clinics throughout, in the Twin Cities and we also have one now in Rochester. Basically, we have successfully increased access to the population who couldn't find access to dental care.

And the most exciting event that we are doing right now is that we have created a program named Minnesota Cavity Free Kids. We work in collaboration with the Minnesota Department of Health, the Healthy Teeth, Healthy Baby. It is a very exciting program. We intend to help our recent immigrants or those who don't have literacy to understand fancy languages and reaching out in the language in which they can understand so they can help us taking care of their baby's teeth or even their own teeth themselves.

Alright, so when you started this program 35 years ago, what was it that brought you into dealing with oral health in that way and what has changed over those 35 years? I think that the pay rate to dental and oral health has decreased quite a bit. When I first started, I think that they were paying at 60 cent to 70 cent to a dollar without any critical access. But right now they are paying about 20 cent to a dollar, it makes it very difficult to treat these populations. So we have to be creative in our own clinic. We lean on the economic of scale, so you have a fixed cost. So Pa Nhia, Dr.

Peterson talked about Minnesota Cavity Free Kids and you're running that program. Tell us a little bit about that program. Yeah, so Community Dental Care helped to write a bill called The Early Dental Disease Prevention Initiative Bill. It was passed in 2015 and we decided to take the matter into our own hands and start a pilot project.

So the pilot project is called the Minnesota Cavity Free Kids Program. And what we do is, we provide preventative education, and then also the clinical services to families with children under 2 years old. And we keep them in the program until they're 3 or until they're cavity free. And our goal is to really hone in on specific habits or talking to parents to see how we can help them so that their child is healthy and they're ready to learn when they go to preschool or start school.

And everything that we're doing, we don't charge parents out-of-pocket costs, so if they have insurance, we'll charge their insurance, but if they don't, we cover everything through grants and through private donors. So it's really just providing access to children zero to 2. So why is oral health so important? Having a healthy mouth also leads to healthy lifestyle, you're more successful. Not just that, but I think a lot of people realize that we live in a society driven by beauty and so if you have healthy-looking teeth, you're more likely to get a job, you're more likely to feel confident and that relates to all sorts of things in life.

So oral health is very, very important. But why start with kids? You've got baby teeth and they fall out and you get permanent teeth, why not just wait until the permanent teeth come in and then start to work on it. [Pa Nhia laughs] I'm being facetious-- why start at birth with oral health? I think Dr. Peterson could speak to that, Dr. Peterson. Actually you start even before birth because the pregnant mother can actually, if she has dental disease in her mouth, the bacteria can be transmitted to the little baby, so it's contagious.

So even at say, between zero to 6 months, the child does not have teeth yet, you start to clean that mouth. And so when the child drink milk, burp out or spew out the acid milk in the mouth, that is dirty actually, so if you help the child clean those, you eliminate the bacteria in the mouth, and that's one thing. But the other very important thing is that you are actually training that little baby to accept the cleaning device in the mouth. So these babies who you help clean at zero to 6 months, when the teeth start to come up, and now when you start brushing, the baby will not fuss as much. And further more, we also, parents have been reporting that when they clean the baby's mouth, the baby, when the other teeth erupt, then they seem to be more comfortable, they don't fuss as much. I want to talk in a little bit more detail about some of the activities that you're doing, but first we need to take a little break.

Well be back right after this message. [electric piano & strings play in bright rhythm] (woman) With a small bank loan and one dental chair, Dr. Vacharee Peterson set out on a mission to heal the aching teeth of Minnesota's low-income communities. Today, Community Dental Care is recognized as in of the state's most successful models for providing quality care to people disproportionately affected by preventable dental disease.

Realizing that access to care is not enough to ensure a healthy future for Minnesota's children, we created the Program to Improve Community Oral Health, or PICOH, delivering preventative care, risk assessment and education. PICOH is based on the belief that medical professionals, children and parents, all play a critical role in oral health. Our student training program provides clinical and cultural competency training to future health professionals. Our school-based sealant program provides direct care and education to children at school. Our Minnesota Cavity Free Kids Program teaches parents of infants and toddlers to be effective partners in oral health. We believe that every person, no matter their background, deserves access to quality dental care and empowering parents and children to build healthy habits, gives every child the chance to grow up cavity free. Nice video, explaining what you're doing and some of the programs you're doing. I'm really impressed on that.

I want to start by asking actually over the 35 years that you've been doing the dental clinics, the population has changed dramatically. We're much more diverse; we have many more cultures and different races-- is that changing how you approach oral health care? Is that changing your approach? Not really, because the facts still remain the same thing. We have, we all eat food, the food or the milk stick on our teeth, and it excretes acid, and these acid then damage the teeth. If you don't clean it out by our own 2 hands, if we don't help our children to clean their mouth, these acids continue to attack those teeth, especially if they continue to feed the baby with the bottle and sleep with that all night, actually the bacteria will have a party in the mouth, excrete acid. But my very common term with my language problem patient, I would just say the bacteria poop and pee on your teeth, and they have the party all night, and that's why your children have cavities. So it's the same, but yes, you are right. So there's no difference in racial groups on oral health, it's all about the same stuff-- it's the same bacteria doing the same bad things.

Yes sir, the same thing, and you're right, in the beginning I would say that we have recent immigrant, usually from the Southeast Asian, but now we have all across the world. Among our staff we speak 24 languages and so the disease itself is the same. And I'd like to add a little bit to that too. The disease process, yes, is the same, but there are social determinants of health that contribute to oral diseases. And I think our program does a really good job about honing in on different groups. And through the program, we've figured out that different communities require different intervention.

Like for example, the Hmong community would require a different intervention than say, the HIspanic community. And so what we've been trying to do is create focus groups where we have parents involved in the discussions as to how we can promote oral health in those communities. Dr. Ehlinger, very interestingly, Pa Nhia had put on Facebook, on the platform Cavity Free Hmong Baby-- within one night she get 50,000 hits. And now she's already a guest speaker, invited to be speaking in Fresno, so over 100,000 by now. (Pa Nhia) Yeah.

So specifically gearing toward the cultural competency, I think, that would help in the future. Pa Nhia, you talked about the fact that you're teaching families a whole bunch of things, and I know that the Health Department with the Healthy Teeth Healthy Baby Initiative has a little packet here that they've been handing out, or you'll be handing out. Maybe you can go through some of the things that are in that packet and then use that as a way of talking about what you're educating families about. Yeah, most definitely, first we've got a little toothbrush here for babies. We don't want children to be playing with toothbrushes, but this little thing is good for them to hold and it's just for them to start practicing oral hygiene and this is really convenient for parents and children alike. The bristles are very soft because we don't want children to be brushing, or anyone really, to be brushing with hard bristles. That would wear away the enamel, so there's that. And toothbrushing starts whenever teeth start to emerge? (Pa Nhia) Right.

(Ed) You don't have to wait for a certain age? (Pa Nhia) Exactly, you want to start brushing right away when teeth come in with fluoridated toothpaste. And just a smear, because little babies, they can't spit yet, so we want to teach parents to go in there and wipe the baby's gums or wipe away the excess fluoridated toothpaste. And then here we've got a timer, so a 2-minute timer, because we should be brushing our teeth for 2 minutes.

(Ed) And I'm sure all of us brush for 2 minutes. We should all have a timer, not just for kids. (Pa Nhia) I think so, yes, or you can sing the alphabet twice, that's what they generally say, about 2 minutes, and kids love these things. And then we've got little floss plaquers.

This is just to introduce flossing to kids. A lot of people, I'd say, don't floss on a regular basis, but this helps kids get used to the flossing in their mouth, in between their teeth. So a lot of it is just orienting kids to this is something that you do routinely, and it's normal, and if you get indoctrinated into it early on, it'll just carry on through the rest of your life. (Pa Nhia) Most definitely. (Ed) What about this other toothbrush here with the big red handle? I'll let Dr. Peterson explain this a little bit, but this is called the Baby's First Brush, and she created it, so Dr.

Peterson, you could talk a little bit about this-- this is amazing. Well actually, a lot of time the baby like to stick the toothbrush in their mouth and I thought if that happen, there have been stories about children falling onto the toothbrush and it penetrate into the pharynx. And this little device would have a little bit blockage right here, it's almost like a bottle design. So this one, I think is a little bit safer for the children.

So I created it, and if you would like to have these, the audience want to have one of these, we do give them out in Minnesota Cavity Free Kids for children zero to 2. So who are you targeting with Minnesota Cavity Free Kids? (Pa Nhia) So our main target audience is children zero to 2, of course, specifically from families that are underserved or low-income families. And really we're not discriminate of racial background or anything like that, so we're really open. We want to target the underserved communities because there is data showing that the underserved communities have higher rates of caries disease. So how do you get to these various communities? Do you go to community centers, do you go to schools, do you go to health fairs, do you go to the state fair, where do you go for all of your activities? Yeah, we've been at a few health fairs, we've been in the ECFEs. (Ed) Early Childhood Family Education. Yup, and then rec centers as well.

And we're trying to reach out to different community members. Our program is fairly new, we've only been around for about a year-and-a-half, and so we're still trying to get our name out there and also our services out there. But really, any community organization that serves families, we want to be there. What kind of response have you been getting? A lot of organizations have been very receptive and very open to having us there in their space doing outreach education, and the families love it. And this is information that a lot of oral health professionals they think this is repetitive information, we do this every day, but then parents, they don't really know this, and so when we go into those spaces and we give them the education, they are very, very interested and even some of the moms say, how come I didn't get this information when I was at the hospital with my baby? And that's the response that we like to hear.

Yeah, they've been very, very responsive. Good. I want to talk about some of the prevention activities in addition to what you've been doing, more on the clinical side, but first we need to take another little break. So we'll be back right after this message. Okay, everybody, it's time to brush your teeth! Go get your toothbrush! ♪ Brush, brushy-brush, brushy-brush, brush.

♪ ♪ Brush, brushy-brush, ♪ ♪ Brushy-brush, brush. ♪ ♪ Brushy-brush, you're looking good. ♪ ♪ Brush, brushy-brush. ♪ ♪ Brushy brush them round and round.

♪ ♪ Brush, brushy-brush. ♪ ♪ To keep teeth happy, here's the truth. Brush, brushy-brush. ♪ ♪ You gotta brush each and every tooth. ♪ ♪ The teeth in the front get a lot of care. ♪ ♪ But don't forget the ones back there. ♪ ♪ Brush your teeth, ♪ ♪ Keep them looking clean and bright.

♪ ♪ Brush, brushy-brush. B-b-brush, brush. ♪ ♪ Brush your teeth, ♪ ♪ Every day and every night. ♪ ♪ Brush, brushy-brush, b-b-brush, brush. ♪ ♪ Now your toothpaste might taste good ♪ ♪ When you got it in your mouth. Brush, brushy-brush. ♪ ♪ But you should never swallow it. ♪ ♪ You've got, got, got to spit it out.

♪ Go on and spit. We'll wait for it. ♪ Brush your teeth, ♪ ♪ Keep them looking clean and bright. ♪ ♪ Brush, brushy-brush, b-b-brush, brush. ♪ ♪ Brush your teeth, ♪ ♪ Every day and every night. ♪ ♪ Brush, brushy-brush, b-b-brush, brush. ♪ ♪ Now if your parents heard, here's what you've gotta do ♪ ♪ Let them have your toothbrush ♪ ♪ So that they can brushy-brush your teeth. ♪ ♪ Great job, you're almost done.

♪ ♪ 5, 4, 3, 2, 1. ♪ Now spit! [all laugh] I can't sing as well, but ♪ Brush, brush, brush. ♪ [all laugh] That was a catchy song and it's probably going to stick with folks for the rest of the day, so very nice. And it highlights-- first of all, welcome back. So we're talking with Dr. Vacharee Peterson from the Community Dental Clinics and Pa Nhia Her, the Minnesota Cavity Free Kids.

I want to talk about some of the preventive aspects. We talked about some of the educational thing and the tools that parents can have, but there's a lot of other things that go on. And one of the things-- varnish, fluoride varnish.

This is something that most people don't know about. Tell us a little bit about the importance of fluoride varnish and who can do it, and where should it be done? Yes, fluoride varnish, research has shown that it is an effective way to do preventive dentistry on children. Who should do this? It would be, right now the law already has passed... [clears throat] Excuse me. Physicians can do it, the healthcare worker can do it, but also please keep in mind that at the dental clinic, definitely they can do it. It's a very effective tool in delivering prevention to everybody. Then you also have water fluoridation. Actually, the lower dosage of the fluoride is better to protect the teeth, so drinking fluoridated water is very good.

Actually, we've just lowered the limit of fluoride in the water so recognizing you don't need very much to really protect teeth. Yes, and then you can also use a fluoride toothpaste. And when you use a fluoride toothpaste in children, please make sure that they spit it out. There is no need to ingest, to swallow that. The mechanism of the way the fluoride prevent teeth is that it just, every day, when the bacteria, eat the food, spit out acid or excrete acid, and it make little hole. This is a microscopic hole, but when you have the fluoride in the the saliva, and your teeth have the availability, your saliva and your body has the ability to make a little cement that will fill in those little holes, it's called a repairment process. So you have a destruction and repairment. If the repairment exceed or overcome the damaging of the teeth, then you don't have cavities.

So that's why fluoride would strengthen the surface of your tooth. How about dental sealants? How do they differ from the fluoride varnish? Dental sealant is a mechanism, or the product in which you put on little crack and crevices on the teeth; it's a plastic. So when you bond onto the tooth, the crack and crevices, then it prevent the bacteria to dislodge into those little holes in the mouth. That's how it keeps the bacterias out.

And Pa Nhia are you working with providers? Like traditionally we go to the dentist every 6 months, but oftentimes when we were kids, they go to the physician, to the medical clinic much more often than that. Do you talk to the providers about you should talk about oral health more frequently than they do now, and the fluoride varnish, doesn't have to be done in a dental office, it can be done in the medical clinic, and that's where they go more often. It can be done really by trained people who don't have to be physicians or even nurses. They can be the community health workers, for example. Do you do that kind of outreach in your talking? Yeah, so right now we do have a component of the Minnesota Cavity Free Kids that has a medical-dental integration. And Keith, who is our collaborative hygienist, does most of the coordinating of this with providers.

We already have an agreement with HealthEast Roselawn Clinic, and we are there 2 Mondays a month for about 2, 3 hours. And what we do is, we'll have the kids see the dentist first, or see our team first before they go into their well-child checks. And so this is just another way for us to increase access. I think it is a process, trying to bring medical providers into the conversation and getting them onboard with us and with our team and having the dentist being in that space. But we are in conversation with them about it. I know that the providers can actually charge for doing the varnish, but not everybody's doing it.

And it brings back Dr. Peterson, what you talked about early on-- we don't pay very much for oral health care. What's being done to try to address that, because we have a very low rate of Medicaid enrollment, providers accepting, dentists accepting Medicaid patients, which is really a big gap. What are you doing to try to address that? Well, we address it at the Capitol. We are trying to educate our legislators. The suffering actually, my colleague, the dentist, Minnesota Dental Association has been a big fan in trying to promote how to help the legislator understand that it is very difficult to treat patients when you are losing money left and right.

So I think that in the future we were hoping that the legislators would understand that treating our patients is expensive. Well, and I understand some of the oral health problems that actually lead to emergency room visits, which are very expensive, and pain and loss of teeth-- prevention is a lot easier and early intervention is much cheaper than letting things go. It is, that is very true. Now when you talk about emergency, our clinic, all together 5 clinics, we treated 134,000 patients, and count there are about 43,000 head count patients.

And about 20% of those were actually emergency patients, so can you imagine, if we can prevent to put the patient into an emergency room but sent to the dental clinics, those are a lot less cost at the dental clinic than at the hospital. It's obvious that the two of you are great advocates for early intervention and for oral health. Pa Nhia, what else needs to be done? What do we need to advocate for? Oh my gosh, I feel like we do, there's so many different things. I mentioned something earlier about bringing parents to the table, and I think having or including parents in the conversations to really know what they need from us. Right? And then also, what you had said earlier was, medical providers and dental providers, we need to come together and collaborate and see how we can tag team this disease together. Not just that, but I think one of the other things we need to do is, because oral health is so integrated into many aspects of a child's life, I think what oral health professionals really need to start doing is being a part of different coalitions. So say, for example, we've got the Early Childhood Learning Coalition. Why are oral health professionals not a part of that coalition? And being in that conversation and reminding others that okay, oral health is very, very important, it contributes to learning, so how can you guys help the child and parents recognize the importance of oral health? Dr.

Peterson, in the last 15 seconds, you get the last word. What else needs to be done? Number 1: we'd like to encourage the parents, do not allow the children to go to bed with dirty teeth. It's the parents' responsibility to brush those teeth-- and 365 days a year. And teeth are like dishes; they are dirty after each use. Thank you. Thank you for being with us-- very educational, very important. I'll be back with a closing comment right after this message. (woman) Today your child may receive a fluoride varnish treatment.

Maybe you're wondering, what is fluoride varnish? In this video, we'll explain what it is, how it works, and why it is so important to your child's long-term health. Fluoride varnish is an easy, safe, and effective way to fight tooth decay. It works by entering the tooth enamel and making the tooth hard. It prevents new cavities and slows down or even stops existing decay from getting worse. Dental health is an important part of your child's overall health.

Very young children usually do not see a dentist until there's a problem, yet they will likely see a doctor 11 times for checkups and vaccinations by age 3. Applying fluoride varnish is another important way to keep your child healthy. Fluoride varnish is easily applied, usually in less than 2 minutes. First, a small piece of gauze is used to clean and dry the teeth. Then the varnish is painted onto 2 surfaces with a tiny brush, forming a sticky covering that becomes hard as soon as saliva in the mouth touches it.

After the varnish is applied, your child does not have to wait to eat and drink, however, food should be soft and not crunchy the rest of the day, and your child should wait to brush or floss the teeth until the next morning. Fluoride varnish is safe, and it works. It should be used from the time babies get their first tooth. Studies show that children who have fluoride varnish applied every 3 months have fewer cavities than those that get it less often or not at all. Fluoride varnish has been clinically proven to be the most effective professional fluoride treatment for cavities.

Congratulations on taking this important step towards establishing a good dental health care routine, ensuring your child's healthy smile for years and years to come. The first surgeon general's report on oral health noted that oral health means much more than just healthy teeth. It means being free of chronic oral and facial pain, oral and throat cancers, birth defects such as cleft lip and palate and scores of other diseases and disorders that affect the mouth and surrounding areas. This broader definition emphasizes that oral health is core to the enjoyment of the very essence of our humanity-- the ability to speak and smile, sigh and kiss, smell, taste, touch, chew, and swallow, and convey a world of feelings and emotions through facial expressions. The report also noted that oral health is integral and essential to general health. Oral health and general health should not be viewed as separate entities. Children need to learn that oral health is a critical component of health, and we as adults must assure that dental health is included in the provision of general health care and the design of community and public health programs.

The surgeon general's report also identified what we can do to maintain and improve the oral health of ourselves and our children. Individually we need to include daily oral hygiene activities like brushing and flossing, and make some lifestyle behavior changes like limiting pop and sweets and eliminating the use of tobacco. On a community level, we need to support programs such as community water fluoridation, tobacco cessation, and providing healthy food and beverage alternatives for our children. We also need to ensure access to regular dental screening examinations and the use of appropriate dental advances like dental sealants and fluoride varnish.

Oral health is as important as any other part of our health. If we are to be balanced and healthy people, we need to work to be sure everyone gets good oral health care. The importance of oral health should be evident to each of us every time we see someone smile. That's all for today, Thanks for watching.

I hope you can join us again next time on "A Public Health Journal.".

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