The Dentist Comes To School

Tracey Oberg applied a mint-flavored fluoride to the surface of 9‑year-old Nashelley’s chompers, strengthening the hard enamel against the sticky layer of bacteria that causes tooth decay. She then swabbed a plastic protective sealant over the back molars. Nashelley said it tasted ​“kinda spicy.” Oberg sent the fourth-grader back to class in less than 20 minutes.

Compare that to average dental visit, which causes students to miss an estimated two hours of class.

Later on in the afternoon, as she continued seeing fourth-graders, Oberg taught a boy how to brush properly, and she caught a pus-filled infection in a girl’s gums.

Oberg’s work at Hill Central is part of New Haven’s push to bring medical services into the schools in the hopes of boosting attendance and teaching healthy habits, focusing in particular on dental services.

Last year, just over 1,300 students received cleanings, and 605 students were referred to outside providers for additional treatment. At Hill Central alone, 326 kids are enrolled, representing two-thirds of the student body — one of the highest participation rates in the district.

So far, the dental staff has found that the needs in New Haven are high. Last year, two-thirds of the students who were quickly screened with a mirror and a flashlight appeared to be at elevated risk for untreated cavities, with some students reporting that they had never been to a dentist or even used a toothbrush at home.

The district currently operates 17 school-based health centers, which extend the school’s medical capabilities beyond what can be pulled out of a first-aid kit.

“At the school health centers, we can provide all the services if a student isn’t feeling well,” said Will Clark, the district’s chief operating officer. ​“Rather than a cold compress, maybe that student can stay in school.”

At the school-based health centers, which are staffed by a nurse practitioner, a social worker and an office manager, students can receive their annual physical, flu shots and other immunizations, mental health counseling, or urgent medical treatment.

The school-based health centers don’t charge families anything. They bill Medicaid or private insurance for reimbursement when they can, but they won’t turn any students away for not being covered. Parents just need to fill out a permission slip to get access to the clinics’ services.

“There’s no questions asked,” said Sue Peters, the school health clinic coordinator.

Recently, with a $60,000 grant from the Connecticut Department of Public Health, the school-health centers began adding preventive dental services to the school health centers. Now, with permanent equipment in the clinics, unlike the ​“traveling roadshow” that Clark said used to go from school to school, a dental hygienist brings students into an office for routine check-ups and cleanings.

The expansion of dental services started at eight elementary schools: Barnard Environmental Studies Interdistrict Magnet School, Clinton Avenue School, Fair Haven School, King-Robinson Interdistrict Magnet School, Hill Central School, John S. Martinez Sea & Sky STEM Magnet School, Truman School and Augusta Lewis Troup School. The newest dental clinic just opened at Brennan-Rogers Magnet School.

Today, on scheduled visits, the hygienists are able to catch small cavities early before problems worsen. But they still regularly come across dangerous infections.

Last week, another fourth-grader came in for a routine visit. It had been about seven months since the girl had last been called down to the clinic, Oberg had been seeing her since May 2016, after noticing in state medical records that the student hadn’t had any dental appointments outside school for nearly three years.

The girl complained to Oberg that her tooth had been bothering her for about two months. She said she hadn’t told her parents, who both work and have a tough time getting to medical appointments.

Oberg peered inside her mouth and saw that the girl had what she described as ​“a major infection.” She saw an inflamed bump in the gum tissue (known as a fistula) from which pus was oozing out, reflecting a deeper infection underneath.

Oberg immediately sent her to the nurse practitioner, next door within the school health center, to receive antibiotics. The Spanish-speaking office manager called the parents and explained how the infection needed to be treated.

“The student will now receive the extra care she needs and not be in pain,” Oberg said. ​“Infection is huge as it can spread to the rest of the body if left untreated, so this was a win-win on all fronts in how are clinics collaborate on a daily basis in the best interest of the child in need.”

Tamiko Jackson-McArthur, a pediatrician who sits on the Board of Education, said that finding dental care for kids is difficult, both logistically and financially. That can prevent parents from seeking out the check-ups their children need.

The problems often begin when parents don’t know to seek out a pediatric dentist when their babies turn 1 year old. Instead, many try their family dentists, who often don’t start seeing children until 3 years old. Later on, parents are inhibited by ​“so many social and economic stressors,” she added.

But without catching cavities early on, students might develop more severe infections, which can leave them unable to eat or even talk, according to school administrators. When a toothache gets that bad, students might stop coming to class, they added.

Last school year, one in five students at Hill Central — 21.0 percent — missed at least 18 days of school. Even if it was for an excused absence, those students were marked chronically absent.

Citywide, New Haven’s chronic absenteeism rate is more than double the statewide average.

In the early grades, chronically absent students score lower on reading and math tests for years to come. By middle school, they are more likely to become high-school drop-outs, according to studies of Chicago and Baltimore schools.

Figuring out why students are missing class is a challenge for school districts nationwide. Locally, administrators are putting an emphasis on health, trying to track if diabetes, asthma, toothaches and other ailments are keeping kids away.

But outside of the excused absences, where students come back to school with a doctor’s note, it’s difficult to track exactly how many days of school students are missing for medical appointments.

Principal Jaime Ramos said the clinics help keep kids in school by establishing a trusting relationship with families. That’s especially true for undocumented parents, he added, who often can’t take their children to the dentist because they don’t have insurance, while working off-the-books gigs without benefits.

“You have an ally now,” Ramos said. ​“It’s now easier to call home. They know who’s calling.”

While that’s tough to measure, administrators said they do know they’re at least saving time on appointments. And they add that reinforcing oral healthcare within school is beneficial in itself, especially when so many families don’t know the basics themselves.

“It’s not just brushing and flossing, it’s eating from salad bars and exercising at recess. It’s all good health lessons,” said Clark. ​“It’s all part of their education, and it makes them more available to learn.”

Oberg said it’s especially important to communicate how much dietary choices matter in high-poverty areas, where cheap, sugar-laden snacks and soda line the shelves convenience-store shelves.

Oberg tried to do that with Hector, another 9‑year-old with four wiggly baby teeth, who came by her clinic for an appointment after lunch.

After she told him she’d ​“get his teeth all shined up,” Oberg asked him to demonstrate how he brushed his teeth on a stuffed animal with a set of plastic whites. Hector gave the teeth a once-over, brushing for just a few seconds — far short of what dentists recommended.

“Are you a speed racer?” Oberg asked.

“Yup,” Hector nodded.

Oberg pulled out an iPad to see if she could find another way to teach proper brushing. In one game, Hector scrubbed the plaque off yellowing teeth with his finger, taking his time until each was white again.

Later, as Oberg leaned back the chair and cleaned his teeth, pulling out food crumbs from one tooth, Hector said his father had lost several teeth on the side of his mouth. ​“My dad used to have a lot of candy every day, and a lot of his teeth fell out,” he said.

Did that mean Hector was going to limit his sweets? Oberg asked. Would an adult look at his Halloween candy before he dug in?

“No, I open it myself,” Hector said. ​“I do it all the time.”

“Are you sure? I don’t think your mom would let you,” Oberg asked. ​“You’re going to get a sick tummy.”

“On birthdays, I can eat a whole box,” Hector said. ​“It’s worth it.”

“Every once in a while is okay to have treats,” Oberg said. ​“But not every day, because you’ll have a mouth full of cavities.”

She sent him upstairs with a bag of toothbrushes and toothpaste, floss, and a two-minute timer to remind him how long he needed to keep scrubbing.

Jackson-McArthur said that it’s always difficult to instill the importance of dental healthcare in children when parents neglect their own teeth. She said she’s seen some middle-schoolers who need root canals for infections that have rotted all the way through to the pulp.

“If the child is getting seen by a pediatrician (which many are because the state requires health maintenance visits to enter certain grades) the parents are getting guidance and recommendations. But whether they adhere to the recommendations is another story,” she said. ​“Parents who don’t care about their detention will not raise children who care either. It is a vicious cycle of neglectful oral health maintenance.”

Jackson-McArthur added that the school-based dental services could ​“help break those habits.” She said New Haven sorely needs this care, and she’s happy to see it in the schools.