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Growing up on Military Bases and The No. 1 Health Issue in Hawai’i

August 5, 2012 - Ray Tsuchiyama

Facts and Stats on Dental Health

No Hawai’i resident wakens each morning and states: “Although I do all the right things, like eating right, exercise, take tests as prescribed by my physician, and rarely go to the hospital, I look forward to paying more health insurance and increased out-of-pocket costs.”

But the lack of engagement with oral health in Hawai’i society is making this absurd statement true for Hawai’i residents.

That is because the No. 1 Health Issue throughout the State of Hawai’i is oral health. It’s not diabetes. Not gout. Not hypertension. It is oral health.

Poor oral health impacts the most vulnerable groups in Hawai’i’s society: children, working single parents with no dental insurance, the handicapped, the elderly, pregnant women, diabetics.

While some Hawai’i leaders bask in PR accolades about Hawai’i’s healthy image, national think-tanks and local state public health agencies alike take a critical, sobering look at the oral health of Hawai’i residents.

In spring 2012 the Washington D.C. think-tank Pew Center completed an analysis “The Cost of Delay -- State Dental Policies Fail One in Five Children” (27 U.S. States earned grades of an A or B) was blunt and stark in its “F” assessment of Hawai’i and dental health.

The 2010 report’s failing grade reviewed the state of Hawai’i’s children and oral health: “Contributing to a high demand for accessible dental care is the fact that children in Hawai’i continue to exhibit among the highest rates of dental caries in the nation. Dental caries or “tooth decay” is the most prevalent chronic disease affecting children nationally. Caries is an insidious and progressive disease process which can put children and adults at risk for potentially life-threatening infection. The health impact of tooth decay, periodontal (gum) disease and other oral diseases is apparent to most people. The social impact, including the high rates of missed school and work days due to chronic oral disease, the stigma associated with poor dental condition, the general wellness and health risks associated with chronic oral infection and the public and private expense of dental disease, is less so.”

According to the Pew Report’s national perspective, tooth decay is the most common disease of childhood— five times more common than asthma. In the U.S., for every child without medical insurance, there are nearly three children without dental insurance. Moreover, the Report pointed out: “Dental health has a major affect on children's health, education and well being. Research shows that kids who do not receive dental care miss a significant number of school days, use expensive emergency room services more often and face worsened job prospects as adults, compared with their peers who do receive care.”

Locally speaking, the Hawai’i Dental Agency conducts dental screenings for public school students. In 2010, more than 9,108 public school students in grades K-12 statewide were screened for dental problems. Hawai’i Dental Agency referrals for “urgent or acute dental treatment” were made for 2,477 students – or nearly 30%, a third of all students.

Another vulnerable group regarding oral health is pregnant women. Studies have indicated a possible linkage between dental problems and premature birth, and premature babies require complex, expensive medical care (incubators, close monitoring, possible physical and mental issues – leading to a lifetime of medical and even psychological support). Although the research findings are not yet definitive, dental disease may induce changes in the womb that may induce labor earlier and affect the baby’s health. In fact, the American Academy of Periodontology recommends that pregnant women have a periodontal evaluation because of the potential risk for premature birth.

Diabetes is linked to oral health: According to the American Diabetes Association: “The Surgeon General's Report on Oral Health states that good oral health is integral to general health. Emerging research also suggests that the relationship between serious gum disease and diabetes is two-way. Not only are people with diabetes more susceptible to serious gum disease, but serious gum disease may have the potential to affect blood glucose control and contribute to the progression of diabetes. Research suggests that people with diabetes are at higher risk for oral health problems, such as gingivitis (an early stage of gum disease) and periodontitis (serious gum disease). People with diabetes are at an increased risk for serious gum disease because they are generally more susceptible to bacterial infection, and have a decreased ability to fight bacteria that invade the gums.”

Aside from these priority groups -- children, pregnant women, and diabetics -- needing oral health resources, there is another group “under the safety net” for oral health treatment – and this situation has become worse. In the 2010 Hawai’i Dental Health Division (under the Department of Health) Report to the State Legislature pointed out: . . . we continue to have limited access to basic dental care for persons with disabilities and adults dependent upon Medicaid and Medicare for assistance with health care expenses. This problem is most acute for medically fragile individuals, including residents of long-term care facilities and persons with behavioral problems related to chronic mental illness or developmental disabilities. While the problem may be most obvious on the Neighbor islands, all islands have limited resources for dealing with the dental care needs of special needs populations. In addition, access to basic dental care has been further restricted with the elimination of all but a limited panel of emergency dental services for Medicaid eligible adults which went into effect August, 2009.”

What happened after August, 2009? The Dental Health Division report sadly explained that “Medicaid recipients, other low income residents and medically compromised individuals have limited access to dental care through private sector dental care providers. As of August, 2009 Medicaid recipients have dental benefits limited to emergencies only. Patients with acute access barriers are referred to the Dental Health Division by State and federal government, public health, and social service agencies, and private sector health care providers for treatment services.”

This above section translates to severe oral health cases on the Neighbor Islands are flown to Oahu for emergency treatment, but these extreme, expensive actions are a drop in the bucket in the impacted population requiring treatment, and moreover, prevention and oral health care and maintenance.

Sadly, many individuals on Maui – your neighbors -- without dental insurance cannot but allow for infections to destroy their teeth, resulting in emergency tooth-pulling. One old rhyme that best highlights how tiny actions can result in terrible large-scale consequences is: “For want of a nail, a shoe was lost. For want of a shoe the horse was lost . . .” which leads to a battle lost, and the kingdom lost.

In the case of oral health, the beautiful and pro-people “kingdom” won or lost is based by how many children annually in Lihue or Kalihi or Kahului or Hilo whose teeth have deteriorated so badly only a few can be saved. Simply, oral health is at the core of children’s health.

In conducting dental health outreach to schools, the Hawai’i Dental Health Agency uses topical fluoride to “reduce the incidence and severity of tooth decay”. Also, fluoride mouth rinse programs have been implemented in selected schools on Kauai, Lanai, and Maui through a “partnership of personnel from the Dental Hygiene Branch and volunteers from the school community, including school administrators, teachers and parents”. But much more is needed.

The Hawaiian Islands Oral Health Task Force report stated that “contributing to the problem of dental disease is the lack of community water fluoridation. Hawai`i has the lowest proportion of residents with access to the benefits of fluoridated drinking water. Only Hawai`i’s military bases have fluoridated drinking water.”

In 2007 a proposed Hawai’i Legislature bill (it failed) for a fluoridation pilot program in selected Hawai’i communities in oral health crisis (Waianae, Kalihi-Palama*, Waimanalo – all lower-income communities with proportionately more Native Hawaiian families, a group disproportionately affected by poor oral health -- compared to better overall dental health in Kahala and Hawai'i-Kai communities) contained a passage on the emphatic linkage between fluoride and dental health:

There is a dramatic documented variance in Hawai’i between children attending military base schools whose water is fluoridated and children in non-military base schools. While many factors affect dental health, the fact that Hawai’i’s military base water systems are optimally fluoridated is considered the major factor contributing to the superior oral health found among military base elementary school children. When dental health statistics from Hawai’i’s military bases are not used in the calculations, Hawai’i ranks last in oral health in the United States.

Again, that’s last. Not first. Not second. Not third. Last. One would have thought that becoming U.S. citizens in 1959, the Year of Statehood, brought many advantages to Hawai’i’s residents, not continuation of second-class status, and frighteningly, a decline in living standards, spiraling downwards, not year-on-year state-wide health care improvement, like many Third World nations during the past several decades.

However, and this is the point of this blog -- fluoridation on Hawai’i military bases is nothing new: water supplies on ALL Hawai’i military bases have been fluoridated since the mid-1950s – so there is nearly 60 years of data.

In a 1999 study that examined more than 24,000 Hawai’i children ages 5 to 9 statewide, the average number of decayed baby teeth per Hawai’i public school student was 3.9. On the other hand, students who lived on Hawai’i military bases averaged 1.5 decayed baby teeth. The U.S. national average, according to an earlier study, is 1.9 decayed baby teeth per child. In terms of numbers, that is 3.9 versus 1.5.*

Having lived at Schofield military base as a child, I can attest that child consumption of candy and soft drinks at Schofield was equivalent to the off-base community (unfortunately). Nor were there dentists standing on every street corner to treat children. Nor was there a significant military base campaign on oral health. The point is that fluoride was the only “other” factor on Hawai’i military bases that led to a fantastic low number: 1.5 decayed baby teeth per child.

The costs are not overwhelming. In fact, fluoride saves money that would be used for later expensive treatment: the Hawaiian Islands Oral Health Task Force report stated: “The United States Centers for Disease Control and Prevention estimates that the lifetime cost: benefit ratio of community water fluoridation is 1:80; every dollar spent on fluoridation will save eighty dollars in health care costs. The average annual cost of community water fluoridation is estimated to be about one dollar per person per year. The lifetime cost per person is less than a single dental filling.” Ultimately, the tiny investment has profound long-term results.

In 2005 a Honolulu Star-Advertiser editorial declared that “the U.S. Centers for Disease Control has called fluoridation one of the 10 great public health achievements of the 20th century. It has the endorsement of the World Health Organization, the American Dental Association, the American Medical Association, their Hawai’i chapters and virtually every medical or dental organization of any repute.” So, the message from Medical Doctors, Dentists, Ph.D.’s, and top Public Health officials is unanimous.

Oral health should be part of Hawai’i’s societal engagement on health and medical care for all residents, especially for pregnant women, diabetics, and citizens without access to dental insurance. Oral health starts with babies, with infant children.

As an American State with compassionate citizens who pride themselves on health and commitment to children (plus addressing imbalances in health care for ethnic minorities), Hawai’i parents will never declare that their keiki deserve nearly 4 decayed baby teeth and that diabetes and other debilitating illnesses are acceptable.

In adulthood the loss of teeth or severe periodontal disease and other oral health problems leads to life-threatening problems (premature births, diabetes, jaw issues, et al). These health issues lead to longer-term hospital treatment, and increased use of doctors, nurses, medicines, facilities, and ultimately, skyrocketing health care costs – payments and more payments.

Poor oral health and its ripple-effects throughout society affects everyone who pays for health insurance and health care.

Monthly insurance deductions and higher hospital costs are linked to smaller paychecks – Hawai’i families huddle about this issue around the dinner table every night. Just $200 more cash a month can pay for the electricity bill or gasoline, instead of another hospital bill. $300 could be fantastic, a spree at Macy’s for the children, for new school clothes instead of hand-me downs. Instead, there are medical bills for illnesses or conditions resulting from oral health issues. And so monthly a parent tearfully writes a check to cover the ballooning Visa minimum balance.

Lack of take-home pay is impacting family budgets from Lahaina to Kahului to Pukulani to Hana, cutting into spending for toys, pet food for new pets, school supplies, Disneyland vacations . . . so many things that can make a child’s life happier. Like the loss of a nail that can lead to the decline of a glorious, happy childhood in the most beautiful state in the nation – a magical kingdom – that is the connection.

*Few readers will be surprised to know that some military families lobby to live in on-base housing.

**Kalihi-Palama is my old neighborhood, ancient compared to today’s Kihei. Yet Farrington High School was established in 1936 – Maui High School was then already 23 years old, and Lahainaluna opened its doors in 1831 – only 19 schools in the entire United States are older than the home of the vibrant Lunas (interestingly, David Malo, a prominent 19th century historian active in promoting Christianity and Hawaiian performing arts star Keali’i Reichel are both Lahainaluna graduates).


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