Interview with Dr. John Rossetti

Chief Dental Officer, Maternal and Child Health Bureau
Chief Dental Officer, Health Resources and Services Administration

1. Overall, what was your impression of the Forum? Did you find anything particularly exciting, unique, or innovative? If so, what?
     I was very excited about the Forum. We need more of this type of activity. I still find it refreshing to see the enthusiasm that Head Start programs and staff have for addressing critical issues. It brought back fond memories of the annual training meetings and workshops that Head Start and HRSA's Maternal and Child Health Bureau (MCHB) held for several years where training, data, and other information were shared between Head Start grantees and dental experts. But, based on comments from participants, I am not sure if appropriate oral health information is getting down to the grantee level as well as it did in the past when Head Start and MCHB worked together more closely. I think the understanding and dialog generated at the Forum–cavities as an infectious transmissible disease, innovative ways to prevent dental disease, and the critical role that diet and feeding practices play in dental disease–were very eye opening to many participants.

     Today, many Head Start programs are having greater difficulty accessing dental services and finding dentists to treat their children than in the past. The Forum provided participants a great overview of why this has happened. It's obvious there is a maldistribution of dental providers, and there may not be enough trained dentists to treat young children.

     Access to dental services for Head Start children is a problem confronted by grantees all over the country, and it seems to be getting worse in some communities. Dental disease among many Head Start children is not any better either. For example, a study done in Maryland found that 50 percent of Head Start children had decayed teeth and 90 percent of these children required fillings; 16 percent of these children were in pain. In a similar study conducted in California, 37 percent of Head Start children were found to have urgent dental needs. How can children learn, be well-behaved, and feel good about themselves when they are in constant pain?

2. While Head Start and Health Resources and Services Administration (HRSA) have worked together for many years on oral health (through the interagency agreement), this is the first time the partnership has been expanded to include Women, Infants and Children (WIC) and Health Care Financing Administration (HCFA). Do you have any thoughts on this expanded partnership? What do you think made it work?
     None of us can do it alone. I think the partnership worked because we recognized that oral health must be addressed comprehensively; each agency must be involved–each plays an essential role. It is critical to have WIC participate in prevention and early intervention efforts, not only for children but for pregnant women as well. Many children are seen by WIC before entering a Head Start classroom or being seen by a dentist. WIC has an important role to play in reinforcing dental health concepts taught and practiced in Head Start programs, but we need a mechanism to let WIC staff know what is happening in Head Start. By working with families, WIC is in a unique position. If a pregnant mother has active tooth decay and her children have decay, chances are pretty good that the next child born will also have tooth decay. Knowing this, WIC staff can be trained in prevention and early intervention that would have enormous benefit to both the mother and the child. HCFA's involvement is critical because of its role in financing dental services–services that can be provided by Head Start and WIC staff. HRSA also offers valuable expertise in providing information and training on oral health education, prevention, early intervention, and treatment.

     There are HCFA staff at the national and regional levels who are working very hard to overcome the access to care barriers and their efforts seem to be paying off. After several years of inertia, we are beginning to see some movement by states to increase dental fees and remove some of the paper work and administrative barriers that have kept dentists out of the program. But, we have only begun the process and have a long way to go to make Medicaid a program that the dental providers will readily accept. I strongly recommend that grantees and state level Head Start organizations work much more closely with Medicaid and SCHIP staff. If a state level Head Start organization has an advisory committee, Medicaid or SCHIP representatives should be asked to be members. If they say no, ask again.

3. You have worked with Head Start programs for over 25 years. Have the training and technical assistance issues related to oral health remained the same, or have they changed? If they have changed, what are the emerging issues?
     As I mentioned, for many years MCHB administered an agreement with Head Start to provide technical assistance to grantees on prevention, early intervention, and access to oral health care. We maintained over 200 dental consultants and experts to work with grantees on all aspects of oral health. The agreement no longer exists, but the issues are basically the same–with a few noteworthy changes. We have always had higher disease rates in Head Start than in the general population, and the need for prevention, early intervention, education, and access has been with us for a long time. But for some programs, the situation may have worsened.

     Today it is more difficult to access providers and there are fewer dentists willing to treat Head Start children than in the past. This may not be the case everywhere but the feedback that I get from many states reinforces this point. Nationally, we are seeing about 6,000 dentists retiring every year and only 4,000 graduating from dental school, and we also see fewer and fewer dentists practicing in underserved areas where our Head Start programs may be located. There is also a problem with the low numbers of pediatric dentists. Low Medicaid fees also have been a problem for some time. Until recently, there were very few states that raised their Medicaid rates to attract dentists to treat Head Start children.

     The distribution of oral health disease has also changed. Oral health problems are more concentrated in a smaller proportion of children than in the past. Currently, 80 percent of the dental decay is concentrated in 25 percent of the children. These children are usually from low-income families, families with low parental education, and recent immigrants–the same 25 percent that are Head Start children. The general public, many providers, and policy makers do not think oral health is a problem. They do not see it in their children so they think it no longer exists. But we all know they are wrong. We see it every day.

     Some people may not see or experience it, but dental decay is the most prevalent chronic disease in children in America today. The fact that the organisms that cause dental decay are transmitted from caregiver to child (and are also affected by nutrition and hygiene) is a new concept to many. This goes back to what I said about the need for greater involvement of WIC in prevention and early intervention programs. We know how to prevent it and intervene early in the disease process, but we have not been using the tools that we have. The right people have to be made aware of these tools and be trained to use them if we are to gain control of the problem.

     During my 25-year involvement with Head Start, I have provided direct dental care to Head Start children, taught in the Head Start classroom, conducted teacher training, managed regional technical consultants and been a national advisor/consultant to the Head Start Bureau. These have been very enjoyable and rewarding years for me. During this period I have observed much about the Head Start program, its children and families, and I have also developed several opinions and philosophies. Today Head Start puts greater emphasis on parents or caregivers getting the child to the dentist for needed care instead of having Head Start programs access care for the children. Unfortunately, we're finding that many children aren't always getting to the dentist. As we discussed earlier, it's much more difficult to get an appointment today for a Head Start child on Medicaid than it was 15 to 20 years ago. It's great to get parents involved, but if they fail to follow through or just can't get a dentist to see their child, it is the child that suffers–the child falls through the cracks. In the past, programs made the appointment and ensured that children received care. We can't have kids falling through the cracks. We may need to go back to having programs take a more active role in getting children to the dentist.

     Most of us tend to think of parents as the teachers of their children, but I have found that children can be teachers of their parents and siblings as well. When Head Start children learn proper and regular oral health habits in the Head Start classroom, they bring this information and healthy habits home to their families. I have had many Head Start parents come into my dental clinic after years of dental neglect because their child came home from Head Start and told them how important it was to take care of their teeth and that they shouldn't be afraid of going to the dentist.

     With respect to the emerging issues, we are now much more aware that children with a high level of decay in their baby teeth are probably going to have a lot of decayed adult teeth. We also recognize that the bacteria that cause tooth decay are transmissible–most likely from the mother or caregiver to the child. We also know that we can stop or slow down the decay process once it begins. This lends strong support for training and utilizing Head Start and WIC in dental screening and early intervention techniques. We are exploring the use of fluoride varnish application as one of the things that Head Start and WIC staff can do to address the problem.

4. In your opinion, what are the challenges that Head Start and Early Head Start programs face in implementing some of the preventive practices presented at the forum? What steps can programs take to overcome these challenges?
     Just getting things started will be tough. The challenge is to put more emphasis on early intervention. We need more training and technical assistance for local programs. We need more dental providers on health advisory boards to provide training and technical assistance to programs, and hopefully become providers of dental care for Head Start children.

     We need to get parents involved in getting their children to dentists, or if parents can't do it, find ways to get care for children through the Head start programs (by taking groups of children to the dentist, for example). The challenge is to get kids to leave Head Start with good oral health habits and attitudes toward oral health and ensure they continue healthy habits and routine dental care once they leave Head Start.

     We need to get WIC, the dental community, and the pediatric medical community involved. The pediatric community could help enormously. For example, they could provide oral health guidance to Head Start parents, they could better screen children for dental disease, and apply fluoride varnishes. In general, we need better utilization of the private sector medical and dental community.

5. Do you have any final thoughts on the Forum, the partnership, or the recommendations?
     We need more Forum-type meetings around the country. Over a decade ago, we routinely held regional workshops similar to this one. We should do that again. I'd also like to see a rejuvenation of the collaboration between HRSA and Head Start on a formal basis, maybe including WIC and HFCA.