Jasmine, a first-generation immigrant from the Middle East, was one of the first patients I cared for when I transitioned from private practice to public health dentistry. She had only been in the States for a few years and was raising three children, including a 17-year-old son with developmental delays. She was computer savvy and her ability to navigate complex systems, including medical and dental care, was impressive. When I met Jasmine, it appeared that she had everything under control.

Yet, when she and her children stepped into my dental chair, I found signs of rampant decay and poor oral health. Despite their relatively uneventful medical histories, I noticed some underlying issues that needed attention.

Jasmine’s daughter appeared obese at only 14 years old. Jasmine had expressed that her daughter had been complaining about sporadic dizziness, which she attributed to pubertal changes. As a dentist, I recognized the interconnectedness between oral health and overall well-being. I took her blood pressure, which I was surprised to find was elevated and indicated early stage 1 hypertension.

This was a wake-up call for me. How many cases of childhood hypertension are going unnoticed? And more importantly, how many could be prevented if the underlying issues leading to childhood obesity and unhealthy eating were being addressed more proactively?

I spoke with Jasmine, and it soon became clear to me that her story was more than just a tale of dental struggles or deficient knowledge about healthy food and beverage choices. She understood that what goes in her mouth affects her overall health, but she also pointed out that eating healthy requires time, money, and access to healthy food options. Jasmine reminisced about her childhood, being raised in a family that prioritized fresh, non-processed, and predominantly vegetarian homemade meals. Despite her affinity for internet-sourced healthy and delicious recipes, the demanding reality of juggling two jobs, caring for three children, and sharing a single car with her husband left her with limited time and hindered access to the fresh produce these recipes often required. Jasmine mentioned that she lived nearly 20-25 minutes away from the nearest grocery store but there were plenty of fast-food options that were just down the street with convenient hours. Jasmine’s story shook me to my core and inspired me to champion policies that support better oral health and equitable access to healthy food and beverage choices.

Enhancing patient outcomes through comprehensive strategies and advocacy

Comprehensive oral health assessments are a valuable tool that can help dental providers identify risk factors that impact children’s oral health. Cal AIM is a statewide initiative that was initiated by the Department of Health Care Services that can support these assessments by rewarding increased use of preventive services for Medi-Cal-eligible children ages 0-6 years old. Dentists are encouraged to use a Caries Risk Assessment (CRA) form when evaluating children. This form includes questions to assess evidence of caries in a child’s oral cavity as well as questions related to frequency of beverage intake other than water, including sugary drinks (juice, flavored milks or soda) and the in-between-meal snacking of packaged or processed sugary foods. (1)  A recent study found that children with higher consumption of sugar-sweetened beverages (SSBs) had a two to nearly five-fold increased likelihood of experiencing early childhood caries in comparison to those who consumed minimal amounts of SSBs. (2) As a dentist, when using the caries risk assessment form, I spend extra time learning more about my patients’ habits when it comes to food and beverage choices. As a result, I often provide nutritional counseling around healthier food and beverage choices as well as close follow-up.

However, as Jasmine reminded me, education alone does not address the underlying oral and systemic health problems within many marginalized communities. To eat healthy food, one must have access to the resources to do so.

CalFresh, federally known as Supplemental Food Assistance Program (SNAP), is an important means of providing financial support for low-income families to access nutritious food. (3) Yet, identifying individuals and families that can benefit from these programs and ensuring sustained access is challenging. Although there is growing recognition that food insecurity--a lack of consistent access to enough food for every individual in a household to live an active and healthy life (4) --contributes to poor physical and overall health, screening for food insecurity is not routine in dental or medical practices. A recent U.S. study found that only 24% of hospitals and 16% of physician practices reported screening for food insecurity. (5) This creates a missed opportunity for identifying individuals and families that can benefit most from supplemental food assistance programs. For families who are identified as food insecure, enrolling for benefits can be a confusing and challenging process that presents additional barriers to accessing benefits. Although some health centers have Medi-Cal enrollment specialists, they are not routinely available. Even after navigating the application process, families like Jasmine’s who are getting by working part-time jobs with dynamic incomes, may find that they do not qualify for sustained benefits.

Learning strategies to better equip my patients to enroll in healthy food program options and providing them with local community resources and food banks that could provide supplemental healthy food is a current priority of mine as a Champion Provider Fellow. I am partnering with my local health department to incorporate screening and resource referrals for food insecurity in the dental clinic setting as well as foster collaboration with dentists to raise awareness of barriers to healthy food and beverage consumption.

I am learning to break free from the confines of the dental chair. In doing so, I am becoming an advocate for improving the health of my patients and building healthier communities.

1. California State Department of Health Care Services. Caries Risk Assessment. https://www.dhcs.ca.gov/services/Pages/caries-risk-assessment.aspx https://www.dhcs.ca.gov/provgovpart/denti-cal/Documents/DHCS-6212-CalAIM-CRA-Tool-Form.pdf

2. Evans, E. W., Hayes, C., Palmer, C. A., Bermudez, O. I., Cohen, S. A., & Must, A. (2013). Dietary intake and severe early childhood caries in low-income, young children. Journal of the Academy of Nutrition and Dietetics, 113(8), 1057–1061. https://doi.org/10.1016/j.jand.2013.03.014,

3. CalFresh Benefits and Eligibility. https://www.benefits.gov/benefit/1228 4. USDA Food Insecurity Definition. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-u-s/definitions-of-food-security/

5. Fraze, T. K., Brewster, A. L., Lewis, V. A., Beidler, L. B., Murray, G. F., & Colla, C. H. (2019). Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals. JAMA Network Open, 2(9), e1911514. https://doi.org/10.1001/jamanetworkopen.2019.11514

Dr. Arratoonian completed her DDS degree from Ostrow USC School of Dentistry in 2000. She is currently undertaking a Certification Program in Community Oral Health and a Master of Science in Health Care Delivery. Over the past decades, Dr. Arratoonian has provided essential care to underserved communities in various roles, including Dental and Program Director and clinician.