Nine-year-old Dante Ladines clambered into the mobile dentist chair set up in the multipurpose room at Kalihi Elementary School, put on a pair of sunglasses under the bright light and opened his mouth.
His right leg jiggled nervously in his blue jeans as dental hygienist Gordean Kaluahine of Kokua Kalihi Valley used pumice to clean the tops of his molars and then applied clear plastic coatings known as sealants to protect them from cavities.
Dante may not have felt lucky at the time, but he is fortunate to get preventive care for his teeth through a free program offered by the nonprofit Kokua Kalihi Valley. While Hawaii has more dentists per capita than any state except Massachusetts, according to the Centers for Disease Control, its children have among the worst rates of tooth decay in the country.
"We have a lot of dentists, but we have a lot of caries, or dental decay, so they are busy," said Dr. David Sakamoto, the state Health Department’s deputy director for health resources administration. "What we are proposing to do is get sealants, fluoride and linkage to a dentist to as many needy children as we can."
A range of factors contribute to tooth decay in Hawaii, including the lack of fluoridation, a sweets-heavy diet and failure to make oral health a priority. Fluoridation of the water supply has long been controversial, and the Honolulu City Council passed a bill banning it in 2004, so only water on military bases in Hawaii is fluoridated.
The state Health Department’s dental hygiene branch was eliminated in 2009 due to budget cuts. Its staff had visited schools to teach students about oral health, screen their teeth, apply topical fluoride and refer them to dentists. More than a quarter of the students screened in fiscal year 2009 were referred for acute or urgent dental treatment, an indicator of widespread need.
Hawaii no longer participates in the National Oral Health Surveillance System, so it isn’t clear precisely how the state is faring on the dental front since it doesn’t appear in the state-to-state comparisons. But before the dental hygiene branch was disbanded, it reported that Hawaii’s children had one of the highest rates of tooth decay in the country.
New data from dental benefits provider Hawaii Dental Service also are sobering.
An analysis of 2012 dental claims submitted to the Delta Dental Plans Association, operating in all 50 states, found Hawaii’s kids at greatest risk of tooth decay, HDS President and CEO Faye Kurren told legislators at a recent briefing. The percentage of children ages 6 to 18 with "higher caries risk," meaning they had one or more cavities in the past three years, ranged from 15 percent to 48 percent among the plans, with Hawaii clocking the highest figure.
And those were children who had dental coverage through commercial plans and actually visited the dentist.
The Pew Center on the States gave Hawaii an F grade in its most recent report on how well the state is protecting children’s teeth from decay, the same grade the Aloha State got the previous two years.
"When I talk to people on the mainland, other dentists in public health, and I tell them the situation, they are all in disbelief," said David Breese, who directed Kokua Kalihi Valley’s dental program from 1987 to 2004 and continues to work with it. "They can’t believe that Hawaii would have poor oral health, because Hawaii is perceived as ‘the Healthy State.’"
There is hope on the horizon, however. The Department of Health just landed a $300,000 grant from the Centers for Disease Control to do a scientific, representative sampling of the population to assess oral health statewide and pinpoint the greatest needs. It is asking the Legislature to fund one employee to oversee that effort.
The department also hopes to launch a pilot prevention program for second-graders in two low-income schools, one on Oahu and one on a neighbor island. Bills that would require the pilot and fund it have foundered, but the issue could resurface in conference committee.
"I hope that we can move forward on the dental sealant program," said state Rep. Della Au Belatti, who introduced legislation on the pilot project among other dental initiatives. "I do know there is a bill still in conference, so I continue to be optimistic. There was such great community support around it, I hope the Senate will continue to work with us."
Tooth decay is the most common chronic disease of children, and sealants are a safe and effective way to prevent cavities, according to the Centers for Disease Control. The federal agency estimates that a third of school-age children have had the plastic coatings put on the chewing surfaces of their back teeth, where most decay occurs. Sealants last several years and can reduce cavities by 60 percent, it said.
The state Health Department envisions having the dental staff of community health centers, not state employees, perform dental outreach at schools. It will work to get a waiver from Medicaid to cover the cost of services in school settings to allow the program to eventually reach needy children across Hawaii.
"What we’re trying to do is create a low-cost, effective method of getting this kind of prevention to a lot of kids in our state," Sakamoto said. "This is not a substitute for dental care; this is a public health prevention program.
"In the pilot program we are going to provide fluoride varnish, we are going to put sealants on newly erupted molars, we are going to teach the kids dental hygiene and the most important thing is we are going to link them to a dentist."
Many children, especially in poor families, don’t get dental care until problems escalate.
"Low-income kids face a double challenge," Andrew Peters, an associate in children’s dental policy at the Pew Charitable Trusts, told legislators last month. "They are the least likely to get dental care. They are twice as likely to get cavities. School-based programs are great because you can target the schools with the highest needs."
In Colorado, officials found that every dollar spent on a sealant program yielded a $2 return in savings in the cost of treating cavities, Peters said. The lifetime cost of a cavity can range from $2,000 to $6,000, he said.
Kokua Kalihi Valley pioneered dental outreach in its neighborhood schools starting in 1995 and now screens nearly 3,000 students a year. David Pila, principal of Kalihi Elementary, said many of his students wouldn’t have contact with a dentist if not for KKV.
"They are reaching out to our families and providing a great service to the kids," Pila said. "Oral hygiene is very important."
Kaluahine received a Native Hawaiian scholarship to train as a dental hygienist and came to work at Kokua Kalihi Valley in 1996 to "give back" for two years. She stayed on and over the years has put sealants on thousands of children’s teeth, under the supervision of KKV dentists.
"The kids really need it," said Dr. Jennifer Hirota, who works with Kaluahine. "I don’t think they would get it if we weren’t here. We’re trying to save the molars for their adult years."
Dr. Jason Hiramoto, who directs KKV’s dental program, added, "I don’t think people realize that adult molars come out at age 6 or 7 and they are supposed to last you your entire life."
Kurren, Hawaii Dental Service’s CEO, endorsed the state’s proposed sealant pilot program for schools.
"We are doing our darndest to get children to the dental office, but nationally as well as in Hawaii, that is just not happening," Kurren said. "We need to develop sustainable models for our community. … I think it’s time. Our children deserve this."
