JENKINS — Dr. Nikki Stone received her patients in the gym. Her lap formed half the dental chair and an assistant's made the other half.
On this October morning, there was a 4-year-old whose two front teeth were rotting, a 3-year-old with six cavities, and another 4-year-old with 10. It's not unusual for Stone to see preschoolers with cavities in all 20 teeth.
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"These are the kids who haven't been to the dentist at all," Stone said.
Stone brings dental care to Head Start preschool programs in four Eastern Kentucky counties. Her work provides a snapshot of how early Kentuckians' dental problems start, how much they hurt the state and its children, and how much more needs to be done.
Last fall, almost 60 percent of the 418 children Stone saw at Head Start programs in Letcher, Perry, Leslie and Knott counties had cavities. Twenty percent had urgent needs — more than six cavities, pain or infection.
Even in a state with measurably bad teeth — Kentucky regularly tops the list of states with the most toothless adults — the high rates of decay are notable.
"We're finding lots of disease, little treatment," said Dr. Raynor Mullins of the Center for Oral Health Research at the University of Kentucky, which sponsors the program. "And we're beginning to understand the magnitude of the problem."
Treating kids with urgent needs isn't easy. It requires an operating room and anesthesia and costs $5,000 to $10,000.
But not treating them is worse. Kids with tooth decay have a hard time learning. They can't concentrate because of the pain, and they miss class often.
Decay in baby teeth can transfer to adult teeth when they come in. In the most severe cases, decay can lead to serious infections and even death.
Far too many urgent cases
As the children put their heads in her lap, Stone told them to open their mouths as big as an alligator. She promised the girls that she'd make their smiles sparkle like princesses'.
Her voice was high-pitched, a sing-song happy sound as she examined their teeth with a flashlight and then cleaned them with electric toothbrushes decorated with Elmo and Cookie Monster. The kids take those toothbrushes home.
Stone wants the experience to be fun for the children. She doesn't force the ones who are scared. She lets them watch their friends and see how painless a dental exam can be.
When Jacob Barnett, 4, put his head in her lap, Stone's voice dropped. "Urgent," she said to the dental hygienist and the dental assistant who helped her.
Jacob's two front teeth were brown with decay and one of them was half-gone.
Inside his mouth, she found five more obvious cavities and four teeth with white spots.
It's unlikely that Jacob's two front teeth can be saved, Stone said later. They'll have to be pulled, leaving him with a gap-toothed smile until his adult teeth grow in.
On this morning, there are several kids who already have had four front teeth pulled. Pulling teeth gets rid of the decay, but it's an imperfect fix.
Baby teeth hold space for the adult teeth, said Judy Skelton, a professor at the Center for Oral Health Research. Without them, it's more likely that the adult teeth will be crowded when they come in and the child will need orthodontic work, she said. In the meantime, the missing teeth make it hard for the children to speak clearly and eat.
Fluoride helps, but not enough
At the end of the exam, Stone applies a fluoride varnish that she tells the children tastes like a cherry Popsicle. The varnish coats the teeth, protecting them and re-mineralizing soft spots in the enamel.
It's the one treatment she can offer kids in the makeshift dental office she brings to the preschools.
The problems she finds are noted in reports sent out to parents. The Head Starts contact the parents in the most urgent cases to help them schedule appointments. But even with that help, many of the children don't get the treatment they need.
Last year, 78 kids had urgent needs, but only six had all of their problems taken care of, Stone said. Eleven other kids had one or two fillings done, but the majority did not have any work done at all.
The fluoride varnish helps some. Stone has seen white spots, precursors to decay, and even small cavities disappear between visits. She hopes that the fluoride, given often enough, will stave off future cavities.
But the kids with the worst teeth, those classified as urgent, grow cavities — an average of four per child in six months, Stone said. One child had 14.
Cavities can be contagious
Tooth decay can be prevented, but for children like Jacob, it's challenging.
The bacteria that cause decay can be passed from one person to another. Young children who have multiple cavities usually have a caregiver who has tooth decay.
The more active cavities the caregiver has, the more cavity-causing bacteria lives in their mouths, and the more opportunity there is to transfer it to the child, said Dr. Evlambia "Betty" Harokopakis-Hajishengallis, a professor at the University of Louisville School of Dentistry.
Diets high in sugar and carbohydrates, frequent snacks and a lack of dental care contribute to the problem, creating an environment where the bacteria thrive.
To prevent decay, these children have to be identified before their first teeth come in, said Harokopakis-Hajishengallis. And their parents have to have their problems treated as well.
But the children Stone sees are unlikely to visit the dentist. If they do, it's for an emergency — a painful tooth that has to be pulled — and they tend not to return to have other cavities addressed, Stone said.
Part of the problem is that many of the children don't have dental insurance, and their families can't afford to pay for a dental visit, Stone said.
In addition, their lives and those of their caregivers are focused on survival. They move often, their phones are disconnected, or they might not have a car to get to appointments, Stone said.
Dental care and baby teeth aren't seen as important.
In addition, traditional dentists are reluctant to treat very young children, making it hard to find a dentist in the first place. And there are only a few pediatric dentists in Eastern Kentucky.
Stone started going to the Head Starts three years ago as part of an outreach program at UK's Center for Excellence in Rural Health in Hazard.
At first, she was so overwhelmed by what she found that she wondered whether the fluoride treatments would work.
Now, having seen some improvement, she tries to give fluoride treatment to everyone, even the babies who cry.
"If we can even swipe a little fingerful in there, then we do it, because we know it's making a difference," Stone said. "It's at least holding it at bay."