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UMSL College of Nursing alumna Carol Berger led the creation of the documentary “Rural Children in Crisis: Access to Missouri Oral Care,” which highlights the dental health disparities faced by low-income children in rural Missouri. She started moving towards this with her DNP clinical grant project. (Video still)
The documentary opens with a laughing child. The camera zooms in to focus on the boy’s mouth, giving the viewer a close look at what should be his front teeth.
But instead he’s missing four from his top row, and three silver crowns peek out from the corners of his grin.
“His teeth had rotted away here in the front, down to the gums,” said Rachel Hakim, the boy’s foster mother. “…when I call my doctor, it’s very easy to get the help I need. But for the kids, it’s an extremely difficult time because of Medicaid. I have to set aside a whole, couple of hours to do the research and know that.
The scene is from “Rural Children in Crisis: Access to Missouri Oral Care,” which was created in part by the University of Missouri-St. Louis alumna Carol Berger, a three-time graduate – BSN, MSN and DNP – of the College of Nursing. She now works at Maryville University as an assistant professor of nursing.
It is Berger’s voice that accompanies the story throughout the 18-minute documentary as she interviews foster mothers, doctors, dentists and other experts. It was produced in conjunction with the Missouri Office of Dental Health, including State Dental Director John Dane; UMSL Professor Anne Fish and Assistant Professor Umit Tokac, who contributed to the research; Maryville Faculty Scott Angus and Lilli Kayes; and composer Carl Leta.
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<img width="300" height="420" src="https://blogs.umsl.edu/news/files/2021/07/Carol-Berger.jpg" class="attachment-full size-full" alt="Maryville University assistant professor of nursing Carol Berger" loading="lazy" aria-describedby="gallery-1-89822"/>
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Assistant Professor Carol Berger
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Professor Anne Fish
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Assistant Professor Umit Tokac
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The result is a story that Berger hopes will influence the way healthcare providers in Missouri care for children’s teeth before the age of five, when they typically receive dental care.
“We tolerate children who go through the earliest years of their lives with inflamed gums and rotten teeth,” she said. “I hope it raises awareness about what kids go through when they have missing teeth and how a simple $1.50 process can really make a difference.”
The problem the documentary highlights is multi-faceted, particularly affecting low-income children living in rural Missouri. Partly due to a lack of patient education and because typical dental care does not begin until later in life, children develop caries.
After eating, digestive acids and sugars from food sit against the tooth enamel, stripping away important minerals and making it too soft. This is especially true for babies who consume milk.
A common consequence is baby bottle tooth decay, where the front teeth can erode down to the gum line. But Berger has also seen other cavities and broken teeth in the mouth.
“Children live with this condition that no adult would live with,” Berger said. “They can’t eat, they can’t talk, they have trouble sleeping and they’re in pain. If we pull their teeth, they live like this for five or six years and have to learn to eat and speak without their first four upper or lower teeth.”
Children without those key teeth often develop speech problems and have to relearn how to eat once adult teeth come in.
But when low-income or foster children covered by Medicaid have eroded or cavity-filled teeth, getting them treated isn’t easy. That’s because in rural Missouri, not many providers accept Medicaid, and that number continues to decline over time.
Gregory Casalone, a physician of dental surgery and director of the Lincoln County Health Department Dental Clinic, states that for Medicaid patients, the state reimburses 30 percent of dental costs for most dentists or clinics, compared to 60 percent for a federally qualified health center .
As a result, the documentary argues, only 23 percent of Missouri dentists accept Medicaid patients. For children in rural areas, that may necessitate a trip to St. Louis or Kansas City to get cavities filled or teeth extracted.
“The biggest problem is dollars,” Berger said. ‘It’s not that the dentist isn’t willing. They volunteer their time. They serve the community with free clinics where they pull teeth all day for people who don’t have insurance. They are a giving profession, but no profession can operate and survive in the red.”
Berger’s answer to this problem is prevention, specifically through a fluoride varnish, a solution she first encountered while setting up her clinical grant project for her UMSL DNP. She worked at a rural health clinic in Elsberry, Missouri, and began to notice how “strikingly bad” the children’s teeth were.
She wanted to know if this was a statewide problem and, if so, could education or preventative care help. That became her 2012 project, “Establishment of an Oral Health Prevention Program, Including Fluoride Varnish, for Preschool Children from Birth to Five Years in a Rural Health Clinic: A Clinical Scholarship Project.”
Among her several findings, Berger found that applying a fluoride varnish to children as part of regular childhood examinations was a major contributor to caries prevention.
Fluoride, a mineral often added to the water supply, works by remineralizing teeth and can reverse tooth decay at an early stage. But in areas without potable tap water, spring water or for those who prefer bottled water, there is little or no protection for residents’ teeth.
Fluoride varnish could close that gap and is a quick and inexpensive treatment — costing about $1.50 with a $15 to 20 reimbursement from Medicaid.
“Missouri has a school oral health program, and they encourage health care providers, like myself, to apply a fluoride varnish annually and educate children who are under school age,” Berger said. “As healthcare providers, we could literally apply fluoride varnish to the very first tooth that erupts, at six months, at 12 months, at 18 months. They could get that protection, if we just added that to the regular visit to kids, and Medicaid pays for it.
She published her DNP research in The Nurse Practitioner, which was accepted for publication four weeks after graduating, and she has continued to work and publish in this area, marketing Fish, Tokac, and others.
“If you ever want to get something published, Anne is the person to make sure it’s on track and scientifically sound,” Berger said. “We worked with Umit to do the statistical modeling.”
Berger never imagined she’d be so focused on teeth when she first started her nursing career, but she’s glad she’s starting to see the effect of her efforts. She begins to hear from health care providers using fluoride applications and saw the growth of teledentistry bringing care to areas without health care providers. The numbers are also moving in the right direction, with a slight drop in caries rates in Missouri children.
But there is still much work to be done. She hopes that medical providers will watch the documentary, be inspired, get involved and start providing fluoride varnish.
“It’s going slowly, but we’re getting there,” Berger said. “I think it’s going in the right direction. But we have to make a lot of noise.”
St. Louis public radio
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