by Leah Rosenbaum

Last April, Dr. Paul Reggiardo saw a patient who was referred to his dental office in Huntington Beach, California from the local emergency room. She was an eight-year-old girl with facial swelling, the soft tissue on her head puffy from infection. It was facial cellulitis, said Reggiardo, caused by an infected tooth. He sees multiple cases like this each year: an untreated cavity that progresses into a tooth infection, which can then spread to the face or, in extreme cases, the brain.

This was what happened to Deamonte Driver, a twelve-year-old boy from Maryland who died in early 2007 from a tooth infection that traveled to his brain. These cases raise an important question: in an age of medical advancements, why are millions of American children still suffering each year from tooth decay?

Dental decay, Reggiardo said, “is the most untreated and the most common problem that affects kids’ health.” According to the National Center for Health Statistics (NCHS), a 2011 survey found that more than 15 percent of American children aged 5-19 had untreated cavities. Tooth decay is four times more common in adolescents than asthma, according to the Centers for Disease Control and Prevention (CDC).

“Dental diseases are a silent epidemic,” said Josh Connolly, Interim Director of pediatric dental service at UCSF Benioff Children’s Hospital. And, especially for low-in-come children, the epidemic will only get worse without new dental policies.

Cavities, also known as dental caries, are  an infectious and chronic disease. They are infectious because the bacteria that cause cavities can be passed from person to person, often via kissing or sharing food. But they are also chronic, because once the cavity-causing bacteria have colonized the mouth, they are there to stay.

The two main culprits that cause cavities are Streptococcus mutans and lactobacilli, bacteria that feed off sugars left in the mouth and produce acid as a byproduct. This acid then begins to decay the teeth, first opening small holes in the enamel (the white part of the tooth that is visible above the gums), and then progressing to full tooth decay.

Cavities can cause more problems than a simple toothache. In addition to pain, children can also experience difficulty chewing, difficulty sleeping, and problems paying attention in class. One 2011 study published in the American Journal of Public Health found that children with poor oral health were almost three times more likely to miss school because of dental pain compared with their counterparts. Tooth decay “takes such a toll on people,” said Mary Otto, author of the book Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America. “It makes so many lives miserable.”

Unsurprisingly, minority children and children living in poverty are especially affected by poor dental health. According to the NCHS report, about one in four children living in poverty had untreated cavities.

There are many causes of tooth disease in children, one of which is diet. Cavity-causing bacteria feeds off of carbohydrates, so children who eat sugar- and carb-filled foods, more common in low-income areas without access to healthy food sources, are more likely to get cavities without proper brushing and flossing.

And there’s another preventable reason why children are getting tooth infections: lack of access to care. Many low-income families can’t afford dental care, which can be seen as an optional expense compared to car payments and other bills.

The fact that there are still serious disparities in the demographics of children affected by tooth decay is troubling said Otto. “A lot of people in the middle class don’t understand what a struggle it is to get good dental care,” she said.

Some low-income children are covered by dental insurance through Medicaid, which was expanded under the Affordable Care Act (ACA). Yet even with Medicaid coverage, it can still be hard to find a dentist. Many pediatric dentists don’t take Medicaid patients, said Reggiardo and Connolly, simply because they can’t afford it.

Medicaid only reimburses dentists a fraction of the cost for providing treatment, so some dentists opt out of seeing low-income patients all together. Seeing Medicaid patients “doesn’t cover the cost of my overhead,” said Reggiardo, who has been seeing low-income children for several decades. He understands why young dentists just starting their careers may not want to take the risk of treating low-income patients.

Now, the dubious future of the Affordable Care Act puts more children at risk. Dentists treating low-income patients hoped that reimbursements would go up, and more children would get access to care. Yet if the ACA is repealed, millions of children could lose the little coverage they do have. A roll back of the ACA, said Otto, ““could make dental care even harder to find.”

The tooth decay epidemic, said Otto, has been hiding in plain sight for decades. “There have been other deaths,” besides Driver’s Otto said. “There have been tremendous amounts of suffering.”

Maybe one day, children won’t have to worry about having to leave school or not eating lunch because of a toothache. But until the dental care system is reformed through legislation, children in America without dental care will continue to suffer.

This piece was written with guidance from Friends of Joe’s Big Idea.