Because of her developmental disability, Ava, now 15, requires general anesthesia for non-routine dental work. The dentist, like most of his peers, was not equipped to provide it.

The girl’s parents, schoolteachers who live in Huntington Beach, Calif., called other dental offices in the region. They were turned down dozens of times before finally finding a dentist prepared to work with an anesthesiologist to treat their daughter.

But there was a hitch: Insurance would not cover general anesthesia for root canals. So Ava’s parents decided to pay the $2,400 from their savings to ensure their daughter received prompt care.

“What about kids who don’t have parents who are professionals or who have no one to advocate for them?” wondered Donny Terranove, Ava’s father.

People with autism, cerebral palsy and other developmental disorders face enormous barriers to adequate and timely dental care — on top of their other challenges. Many dentists either avoid treating these patients or lack the skills needed to do so. Some patients with developmental disabilities are unable to endure even regular dental exams or cleanings without general anesthesia.

But most dentists don’t offer it and getting insurance to cover it for routine dental work is often a struggle.

Because it is difficult for them to get treatment, people with developmental disorders suffer “a high burden of dental disease,” according to a of over 4,700 patients published in the Journal of the American Dental Association. One-third of the patients studied suffered from untreated cavities, and 80% from serious gum infections.

“Many individuals with developmental disabilities cannot personally maintain their own dental hygiene,” according to by the California Legislative Analyst’s Office (LAO). “Often they need extra appointments or special accommodations that dentists are unable or unwilling to provide.”

In many cases, patients need these extra appointments to help them get accustomed to the environment of a dental office, including the equipment, procedures and personnel. This can help minimize their anxiety and reduce the need for deep sedation or general anesthesia.

But sometimes there is no alternative to anesthesia.

Mike Loughran, 54, of Tacoma, Wash., has a 14-year-old son with Down syndrome and autism. After years of failed attempts to complete a basic checkup, Loughran and a willing dentist concluded that the child should have general anesthesia for any and all dental work. That led to hefty charges.

For one routine, 45-minute exam that uncovered no problems, the anesthesia bill was $1,155. Loughran’s insurer, Tricare, adjusted it down to $912 — a sum he described as “very reasonable.” But the hospital charged nearly $21,000 for the operating suite. Tricare agreed to coverage and negotiated the price down to about $15,000. That left Loughran with a $2,500 out-of-pocket copayment. He later got the state’s Medicaid program to cover most of that amount as his son’s secondary insurer.

Still, Loughran was taken aback by the astronomical amount charged for his son’s care. “The whole idea of it costing that much to get a dental exam, and you’re supposed to do that a couple of times a year — it was just stunning when I got the bill,” he said. “I don’t think I would take him to the operating room anymore.”

Without access to regular cleanings and other preventive care, “you get to the point that you need anesthesia because you’ve had a little problem that’s gotten big,” said Eileen Crumm, executive director of Family Resource Navigators, an advocacy group in Alameda County.

To accommodate the many patients who do need general anesthesia, some hospitals and regional centers for the disabled allocate a limited amount of surgical time for dental care. But because of the strong demand for these services, it can take many months or even more than a year to reserve an available operating slot, patient advocates say.

Like the Terranoves, Mariana Murillo had trouble finding appropriate care a few years ago for son Oscar, 20, who has cerebral palsy and cannot communicate verbally. Oscar, a teenager at the time, was in pain from impacted wisdom teeth, and his regular dentist said an oral surgeon would have to extract them. But Murillo, who lives in Lompoc, Calif., had difficulty finding one who would accept Denti-Cal, the state’s Medicaid-funded dental coverage for low-income people.

Murillo ended up paying $1,600 out-of-pocket to an oral surgeon. The surgeon agreed to extract Oscar’s four wisdom teeth while the boy was already under general anesthesia for the removal of a benign growth on his tongue — a procedure covered by Oscar’s medical insurance.

“Our financial situation is not great, but it was not too bad,” said Murillo. “Knowing Oscar was going to be free of that pain, we decided to do it.”

In some states, officials and private-sector organizations are trying to address this large unmet need among patients who may suffer in silence, unable to articulate their distress.

New Mexico, for example, has a that entitles dentists who have completed a special training program to an extra fee of $90 each time they treat a patient with developmental disabilities. And New York University’s College of Dentistry recently opened a strictly for the care of people with disabilities.

In California, most patients with developmental disabilities are eligible for care under Denti-Cal, but only a fifth of dentists in the state accept it. And only a fifth of developmentally disabled patients with Denti-Cal received even one dental service in 2014, 2015 or 2016, according to the LAO report.

Last year, to increase payments to Denti-Cal providers for the 2018-19 fiscal year — up $70 million from the amount of tobacco tax money it had earmarked for that purpose the previous year. Federal matching dollars bring the total amount of new money for the program to as much as $600 million. The most recent boost will help pay for the additional time needed to treat patients with special needs, as well as for anesthesia.

A particularly difficult challenge for patients with developmental disabilities is the transition from pediatric to general dentists as they age, said Dr. Joseph Castellano, president of the American Academy of Pediatric Dentistry, who practices in Laredo, Texas. That’s because pediatric specialists generally receive some training in working with that population, whereas general dentists tend to have little or no such experience.

“A lot of times [patients] will just stay in the [pediatric] practice,” Castellano said. “We know the patients and are comfortable with them, and they and the families are comfortable with us.”

Dr. Wade Banner, a Southern California dentist, took the matter into his own hands in 2014, when he launched a mobile dental program and began making house calls to patients with developmental disabilities. Banner, who has a nephew with autism, said he wanted patients to receive basic care in an environment where they felt most comfortable and were less likely to require major sedation.

Noting the paucity of providers for patients who need general anesthesia, Banner said, “one of my main goals in starting house-call dentistry was to prevent them from having to be put to sleep, if at all possible.”

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Los Angeles Superior Court Judge Mary Strobel found last month that the state’s Department of Health Care Services failed to obtain permission from the federal government before it cut its rate for a special cleaning by 58 percent and created new preauthorization process for it and other dental procedures.

The department runs the publicly funded dental program for the poor known as Denti-Cal.

“After doing research, we realized that not only was it wrong for them to do what they did, but they didn’t seek federal approval, so they did it against the law,” said Darci Trill, a hygienist working in Alameda and Contra Costa counties. She is one of eight plaintiffs who against the department in 2016, shortly after the changes were made.

Larry Hall, the plaintiffs’ attorney, said department officials told him that they plan to appeal. The department declined to comment on the case.

The plaintiffs are among a specially trained class of dental hygienists who make house calls to patients living in nursing homes and board-and-care facilities.

These patients are particularly vulnerable to gum disease because they can’t care for their own teeth, the hygienists said.

When plaque and tartar build-up leads to inflammation and infections, hygienists perform a procedure called “,” which is a deep cleaning below the gumline. After they do that, the hygienists usually follow up with special cleanings every three months to keep the gums healthy.

The state reduced the reimbursement rate for those quarterly cleanings from $130 to $55. The hygienists say that’s inadequate, but the department has said the rate is similar to what other states pay.

The department also created a new preauthorization process that requires hygienists to obtain X-rays of their patients’ mouths. Capturing those images is not always possible, however, because some patients have involuntary head movements or refuse to open their mouths widely enough, Trill said.

The number of cleanings performed by independent hygienists plummeted 45 percent, from 70,671 in the 19 months before the new policy took effect to 38,915 in the 19 months that followed, according to department estimates in court documents. “That’s a huge impact. That’s a lot of people not getting the standard of care,” attorney Hall said.

The hygienists fear the issue will remain tied up in court for months or years to come. Meanwhile, they say, patients continue to suffer as the lower rate and preauthorization process remain in place.

Trill estimates that she has lost about 70 percent of her Denti-Cal clients because most of her requests to treat them have been rejected.

The lower rate of pay also makes it harder for hygienists to continue treating these patients because it doesn’t cover their costs, she said.

Trill worries that the damage to her patients’ teeth may be irreversible. “We’re going back to a bigger mess and bigger medical emergencies,” she said. “Some may not even have teeth.”

Gita Aminloo, one of the plaintiffs, will no longer see five patients in a Rancho Cucamonga board-and-care home that she has served for seven years, because none has received approval for continued dental work.

“It breaks my heart, but I’m doing what I can,” she said.

Aminloo is looking for private-pay clients in senior living homes and memory care centers to make up for the Denti-Cal patients she has lost.

“I just hope that by the time all of this is resolved, we’re still in business,” she said.

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Era 2009 y California estaba en medio de una crisis presupuestaria. Para reducir los costos, Medi-Cal, el programa de seguro de salud del estado para residentes de bajos ingresos, eliminó los beneficios dentales que no eran de emergencia para adultos.

Inglett, de 63 años, quien vive en San Diego, necesitaba una corona para ese diente vulnerable, pero el estado ya no iba a pagar. Por lo que se quedó sin el arreglo. Más adelante le sacaron otros tres dientes porque los servicios dentales que los habrían salvado ya no estaban cubiertos.

“Terminas tomando decisiones sobre lo que puedes y no puedes pagar”, dijo Inglett. “Si se necesita un procedimiento y simplemente no puedes pagarlo, y es más barato sacarte el diente, entonces te sacas el diente”.

Ahora, Inglett no tendrá que elegir entre arreglarse los dientes o hacer que los arranquen.

Muchos de los servicios dentales que se recortaron hace nueve años se restauraron el 1 de enero, para ella y aproximadamente 7,5 millones de otros adultos que tienen Medi-Cal.

Algunos beneficios se restauraron parcialmente en 2014, como los empastes y los rayos X, pero los tratamientos críticos siguieron sin cubrirse, incluidas las coronas procesadas en laboratorio, las endodoncias en los dientes posteriores, los tratamientos para las enfermedades de las encías y las dentaduras parciales.

Esos procedimientos ahora están cubiertos. Pero se avecina una pregunta crítica: ¿habrá suficientes dentistas dispuestos a aceptar las tarifas que paga el Denti-Cal, el programa dental de Medi-Cal?

“La gran mayoría de los dentistas no aceptan pacientes de Denti-Cal porque no pueden pagar”, dijo Sigmund Abelson, decano asociado de asuntos clínicos de la .

La escuela opera clínicas en San Francisco y Union City, en las que tratan a unos 2.500 pacientes de Denti-Cal por año, explicó. Los servicios son proporcionados por estudiantes bajo la supervisión de la facultad.

Abelson cree que la salud general de los beneficiarios de Medi-Cal mejorará ahora que se han restaurado los beneficios dentales completos, suponiendo que puedan encontrar dentistas que participen.

La salud oral y física están directamente relacionadas, y muchos beneficiarios de Denti-Cal padecían enfermedades prevenibles porque no podían recibir atención dental adecuada, expresó Abelson.

Algunos terminaron en salas de emergencia, “muchas veces con infecciones agudas que podrían haber sido tratadas por dentistas”, agregó.

Entre los tratamientos que se restauraron este mes, Abelson clasifica como dos de los más importantes a los conductos radiculares y a las limpiezas especiales para personas con enfermedades de las encías.

Según las reglas anteriores, los conductos radiculares en los dientes posteriores no estaban cubiertos. Las extracciones sí lo estaban.

Ahora, todos los dientes son elegibles para la cobertura del conducto radicular, dijo Abelson.

Para los pacientes con enfermedad de las encías, Denti-Cal también comenzó a cubrir el , que es una limpieza profunda debajo de la línea de las encías que puede ayudar a reducir las infecciones en la boca, agregó Abelson.

“Recuerda, tus encías te retienen los dientes”, agregó. “No tiene sentido arreglar un diente si tienes malas encías”. Al final, puedes perder el diente”.

, quien es el dentista de Inglett y atiende en National City, al sur de San Diego, dice que está encantada que sus pacientes ahora sean elegibles para dentaduras postizas parciales.

Después que los beneficios se restauraron parcialmente en 2014, los inscritos solo pudieron obtener dentaduras postizas completas. Eso significaba que cualquier diente restante tenía que ser extraído antes de que los pacientes pudieran calificar, dijo Hirota.

Tener dentaduras postizas “hace una enorme diferencia por la auto confianza y por la capacidad de conseguir un trabajo y presentarse en público”, explicó la odontóloga.

Sin embargo, los inscritos que no tengan un dentista que acepte Medi-Cal pueden tener dificultades para encontrar uno.

Un informe mordaz sobre Denti-Cal en 2016, realizado por la Little Hoover Commission, una agencia de supervisión estatal independiente, señaló que solo una cuarta parte de los dentistas de California participan en el programa “debido a sus bajas tasas de reembolso y barreras administrativas”.

Los funcionarios estatales dicen que están comprometidos en un esfuerzo de alcance estatal para reclutar más dentistas y han simplificado la documentación de inscripción para los proveedores.

Y el año pasado, Denti-Cal aumentó las tarifas que paga a los dentistas por cientos de procedimientos en un 40%, un impulso que fue financiado con el impuesto al tabaco, la Propuesta 56, que los votantes aprobaron en noviembre de 2016.

El cargo habitual de Hirota por un relleno que repara daños en dos superficies de un diente es $130. Antes del aumento de las tasas, Denti-Cal le pagaba $48, pero el año pasado aumentó a $67.20, dijo.

Para buscar dentistas que acepten tarifas de Denti-Cal por servicio, el modelo de atención para la mayor parte del estado, visita el sitio web de Denti-Cal en o llama al 800-322-6384. Si vives en Sacramento o en el condado de Los Ángeles y tienes Denti-Cal como atención administrada, envía un correo electrónico a dentalmanagedcare@dhcs.ca.gov o llama al 916-464-3888.

También puedes llamar a tu , que probablemente tenga una lista de dentistas en el área que aceptan Denti-Cal. Puedes encontrar tu sucursal visitando el sitio web de la Asociación Dental de California (www.cda.org) y haciendo clic en la pestaña “About CDA”.

Al igual que la Universidad del Pacífico, muchas escuelas de odontología aceptan pacientes con Denti-Cal, agregó Abelson. Sin embargo, en el Área de la Bahía y el Sur de California, por lo que no son accesibles para todos los californianos.

Esta historia fue producida por Kaiser Health News, que publica , un servicio de la .

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Gita Aminloo, his dental hygienist, tries to calm him by singing “Itsy Bitsy Spider,” the classic children’s song.

Rising, 42, is mentally disabled and blind. He has cerebral palsy and suffers from seizures. It’s hard for him to get to a dentist’s office, so Aminloo brought her dental picks, brushes and other tools to him at the residential care facility he shares with several other people who have developmental disabilities.

Rising is among a vulnerable class of patients who are poor and so frail they can’t leave the nursing home or, in his case, the board-and-care home to visit dentists. Instead, they rely on specially trained dental hygienists like Aminloo, who come to them.

But this may be the last time Aminloo cleans Rising’s teeth. And it’s not because of his resistance.

Hygienists say some of their patients are no longer getting the critical dental care they need because of recent policy changes: The state dramatically slashed payment to providers and created a preauthorization process they call cumbersome.

In 2016, Denti-Cal, the publicly funded dental program for the poor, cut the rate for a common cleaning procedure for these fragile patients from $130 to $55. Hygienists say they can’t afford to continue treating many of them for that kind of money. They also claim that half of their requests to perform the cleanings are rejected — an assertion not supported by state data.

The Department of Health Care Services, which runs Denti-Cal, said it made the changes to bring the program’s reimbursement policy in line with other states and to reduce “unnecessary dental treatment.”

But Aminloo insists the new state regulations victimize the most vulnerable people, who she said are losing their access to routine dental care.

“If these patients don’t get preventive oral care, their overall health is going to suffer,” she warned.

Dental hygienists are generally allowed to practice without the direct supervision of a dentist , including Nevada, Texas, Colorado, Michigan and Florida. But the type of patients they can see varies by state. So do reimbursement and preauthorization rules.

Washington state’s Medicaid program pays providers $46 for a similar cleaning procedure, said Anita Rodriguez, a member of the Washington State Dental Hygienists’ Association. Hygienists there don’t have to obtain preauthorization to perform cleanings, but they are required to explain why the cleaning was necessary when they bill Medicaid.

“Our state makes access for our independent hygienists relatively uncomplicated though, like other Medicaid providers, we make pennies on the dollar for our care,” she said.

Since California reduced payments for “maintenance” cleanings for these patients — usually performed every three months to treat gum disease — many hygienists have stopped seeing them. Eight hygienists, including Aminloo, filed a lawsuit in Los Angeles County Superior Court in 2016, arguing that the health care services department cut the reimbursement rate without first obtaining necessary federal approval.

At one point, it appeared as if the department had agreed to settle and cancel its rate change but then backed out, court documents show. The department said it will not comment on pending litigation.

At the time of the rate reduction, the state also started requiring dental hygienists to obtain prior authorization to treat gum disease in patients who live in special care facilities. Hygienists must submit X-rays along with their authorization requests. But they say it’s almost impossible to take decent X-rays of elderly or disabled patients who have a hard time controlling their head movements, or who refuse to open their mouths widely.

When hygienists do manage to get X-rays, their requests are often denied anyway, hygienists from across the state told California Healthline.

In a letter to the state legislature last year, the California Dental Hygienists’ Association wrote that more than half of their authorization requests had been denied since the change. “Denti-Cal’s sweeping new rules are destroying the lives of fragile patients and the women who own small businesses providing care at the bedside,” the letter said.

But state statistics show a much lower denial rate.

From the time the change took effect in July 2016 through June 2017, the health care services department approved 10,000 of nearly 13,000 deep cleanings requested by these dental hygienists to treat gum infections, according to the data. It also approved 31,300 of the nearly 33,000 requests for routine cleanings that follow a deep cleaning. The state said it paid more than $2.5 million to dental hygienists for these procedures.

Darla Dale, a hygienist in Eureka and a vice president of , said the department’s denial numbers don’t reflect what her organization is seeing.

“There’s no way that’s true,” Dale said. “We’re in contact with these hygienists. … Many have stopped working because we can’t spend our lives trying to get authorization.”

Darci Trill, a hygienist working in Alameda and Contra Costa counties, is among those who stopped seeing patients in nursing homes after denial letters piled up. “I lost about 70 percent of my Denti-Cal clients,” she said.

State health officials pointed to the American Academy of Periodontology, which considers the new authorization guidelines standard, including X-rays to diagnose gum disease.

An by the Little Hoover Commission, an independent state watchdog agency, said the state health services department found it “unusual” that nearly 88,000 out of 100,000 Denti-Cal-eligible patients in nursing homes had received deep cleanings during the 2013-14 fiscal year. This figure and other factors raised “questions about their necessity ­— and hence the new policy requiring X-ray documentation,” the report said.

In frail patients, advanced gum disease can cause not only tooth loss, but pneumonia and other respiratory issues, Trill said.

Maureen Titus, a hygienist in the San Luis Obispo area, said her clients rely entirely on caregivers for their dental hygiene, and that brushing and flossing is neither easy nor effective. “Most have bleeding gums, inflamed gums and tartar buildup,” she said.

Among patients who are attached to feeding tubes, tartar builds up quickly because they don’t chew their food, Aminloo said. “After two or three months, you can’t even see their teeth.”

The independent practice of dental hygienists in California dates to 1997, when the state legislature allowed them, with additional training and certification, to work without the direct supervision of dentists. Some started their own mobile businesses. This is the first time in the intervening 20 years that they’ve had to obtain preauthorization to perform dental cleanings, Trill said.

, which represents dentists, said dentists have long been required to get prior approval for cleanings for patients in special care facilities.

“We supported the department’s decision to equalize requirements for periodontal services, regardless of whether a dentist or hygienist provides the service,” said Alicia Malaby, the association’s spokeswoman.

Dr. Leon Assael, the director of community-based education and practice at the University of California-San Francisco’s School of Dentistry, said preauthorization requirements in other states, including Minnesota and Kentucky, where he used to work, have also delayed or limited care for homebound patients.

The requirements have driven providers out of the system, he said, leaving patients behind.

“If this were toes being lost, this would be a scandal,” Assael said, “but with teeth, it’s been accepted.”

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El llanto de Allen puede ser angustiante, pero su boca abierta permite que Calvo comience el examen. La residente cuenta sus dientes de leche y comprueba si tiene caries.

“Nada de lo que voy a hacer le hará daño”, le dice Calvo a la madre de Allen, Maritza Barron, quien está sosteniendo las manos de su hijo.

Para algunos, el niño de 20 meses puede parecer demasiado joven para un examen dental. Pero, de hecho, está un poco atrasado, según las principales .

Para evitar una vida de problemas dentales y asegurarse de que los padres aprendan a prevenir las caries en los niños, los bebés deben tener el primer examen cuando aparece su primer diente, o a más tardar en su primer cumpleaños, de acuerdo con las de la Academia Americana de Odontología Pediátrica.

Sin embargo, muchos dentistas se sienten incómodos tratando a bebés, y eso ha creado una brecha significativa en el cuidado dental para bebés y niños de todos los orígenes, dicen los expertos. El déficit es difícil de cuantificar porque las organizaciones profesionales, como la Asociación Dental Americana, no encuestan a sus miembros sobre la atención a bebés.

“La gente piensa que los niños tienen miedo de los dentistas, pero realmente es que los dentistas tienen miedo de los niños”, dijo Pamela Alston, quien es dentista y directora dental del Eastmont Wellness Center de Oakland, en California, una clínica financiada con fondos públicos que forma parte del sistema de salud administrado del condado de Alameda.

Con la esperanza de reducir la brecha en la atención, las agencias de salud pública de los condados de San Francisco y Alameda están lanzando programas piloto para capacitar a los dentistas para tratar a bebés. Aproximadamente 70 dentistas aprenderán durante los próximos tres años cómo convencer a los niños de cooperar durante el examen, y a ayudar a los padres a que los protejan de las caries. La primera sesión de entrenamiento en el condado de Alameda está programada para principios de noviembre; San Francisco comenzará su entrenamiento en enero. La Asociación Dental Americana no tenía conocimiento de programas similares en otros estados.

Las directrices que exigen visitas tempranas al dentista derivan de una conciencia creciente de que las bacterias causantes de , a través, por ejemplo, de compartir cubiertos. Darles a los bebés botellas de jugo de frutas o agua con azúcar también puede causar caries. La caries en los dientes de leche se ha relacionado con la caries dental en adultos.

“Al momento en que los niños tienen 3 años, a menudo los dientes están tan deteriorados que la prevención ya no es una opción”, dijo Ray Stewart, profesor de odontología pediátrica de UCSF, quien ha tratado a bebés por más de 15 años y está entre los profesionales reclutados por Alameda y San Francisco para entrenar a los dentistas.

Los niños de familias de bajos ingresos, que corren y tienen que las familias con dinero, presentan la mayor necesidad de exámenes orales tempranos, dicen los profesionales de la odontología.

Si tienen éxito, los programas de capacitación de Alameda y San Francisco, financiados por donaciones del Medi-Cal, podrían ser reproducidos en toda California, según el Departamento de Servicios de Salud.

Maritza Barron vino a UCSF después que su propio dentista -a pesar de las mejores intenciones- no pudo examinar la boca de su bebé. “Trató de decirle ‘abre la boca’, pero no lo hizo”, dijo Barron sobre el fracasado intento, que dejó a su hijo llorando.

Alston, el dentista de Oakland, enfrentó una vez problemas similares tratando a niños muy pequeños, pero desde entonces ha experimentado una transformación. Cuando se graduó de la escuela de odontología en 1982, dijo, no tenía ningún entrenamiento que la preparara para trabajar con niños menores de 6 años.

“No sentía que pudiera controlar su comportamiento”, dijo Alston.

Sin embargo, con el tiempo, se hizo cada vez más claro que no estaba viendo a los niños lo suficientemente temprano en la vida.

Casi todos los niños que iban a su primera consulta dental a los 6 años tenían las bocas llenas de caries, dijo Alston. Ella tuvo que remitirlos a especialistas para tratamiento que requería sedación. En su consultorio, Alston siguió bajando la edad mínima de la primera visita, hasta que la estableció a los 3 años durante mucho tiempo.

Pero incluso los niños de 3 años llegaban con caries. En última instancia, aprendió a tratar a bebés y niños pequeños a través de un programa dirigido por el departamento de salud pública del condado de Alameda, no muy diferente al entrenamiento que se ofrecerá en los nuevos programas piloto.

Hoy en día, Alston es una apasionada de la atención de niños muy pequeños, y ha logrado que los pediatras los refieran a ella. Y ha revisado su guía sobre cuándo los niños deben tener su primer examen oral, aconsejando a los padres que los lleven al dentista antes de que aparezca el primer diente.

También entrena a estudiantes de odontología para examinar a los bebés. Un truco importante que les enseña es cómo evitar que los muerdan: “¡Pon tu dedo detrás del último diente!”.

Comunicarse directamente con los niños durante los exámenes dentales puede ayudar a reducir su estrés, coinciden Alston y Stewart, el profesor de UCSF.

En una reciente visita a la Pediatric Dentistry Faculty Clinic de la UCSF, Sebastian King, de 18 meses, exploraba el espejo dental que le dio Stewart.

“¡Esto es lo que voy a poner en tu boca para mirarte los dientes!”, le dijo Stewart con tono gracioso.

Le pidió al pequeño que le mostrara dónde estaba su boca. Sebastian sonrió con deleite mientras Stewart le daba un guante de examen azul que infló como un globo, y así estuvo calmado durante todo el examen.

Ayudar a los padres a entender su papel también es crítico, dicen los dentistas.

Además de aconsejar a los padres que no compartan cubiertos con sus hijos, Stewart los insta a no dejar que sus hijos se queden dormidos con una botella de leche y a limitar su consumo de jugos de fruta. También dice que deben limpiar las encías y los dientes de sus bebés con un paño después de alimentarlos para eliminar los residuos que pueden causar caries.

Ese es el mensaje que Calvo, la residente dental, le dio a Barron, cuyo bebé se sentó felizmente en el regazo de su madre después de su examen. El niño tenía caries porque se quedaba dormido con su botella.

Barron dijo que ella reconoció que sacarle la botella de leche a Allen a la noche sería un desafío.

Pero “es realmente lógico”, le dijo a Calvo, agregando que estaba decidida a intentarlo.

Esta historia fue producida por Kaiser Health News, que publica , un servicio editorialmente independiente de la .

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Allen’s crying may be distressing, but his wide-open mouth allows Calvo to begin the exam. She counts his baby teeth and checks for dental decay.

“Nothing I am going to do will hurt him,” Calvo tells Allen’s mother, Maritza Barron, who is holding her son’s hands.

To some, the 20-month-old toddler may seem far too young for a dental exam. In fact, he’s on the late side, according to .

To stave off a lifetime of dental problems and make sure parents learn how to prevent children’s tooth decay, babies should have their first exam when they get their first tooth, or no later than their 1st birthday, according to from the American Academy of Pediatric Dentistry.

“By the time children are age 3, they are often so far down the road that prevention is no longer an option,” said Ray Stewart, a pediatric dental professor at UCSF, who has treated infants for more than 15 years and is among the professionals enlisted by Alameda and San Francisco to train the dentists.

Dentists don’t regard exams of very young children as a means of boosting their income, said Alicia Malaby, spokeswoman for the California Dental Association. “Denti-Cal reimbursements are below actual costs for many procedures,” she said. Rather, they want to help “improve community health outcomes.”

Low-income children, who are and have to care than their affluent peers, present the greatest need for early oral exams, dental professionals say.

A portion of the revenue from California’s new tobacco tax will be earmarked to help very young children from low-income families get the dental care they need. The money will be used to give dentists a 40 percent increase on top of the standard reimbursement for services to Denti-Cal patients, including oral exams of children age 3 and under. Denti-Cal provides dental care to beneficiaries of Medi-Cal, California’s version of Medicaid.

Alameda County will offer dentists an extra $20, on top of that statewide increase for appointments with Denti-Cal-covered children that include a thorough exam of the baby’s mouth, a fluoride varnish if needed, a talk with parents about prevention and a demonstration of how to brush their baby’s teeth.

The Alameda and San Francisco training programs, funded by grants from Medi-Cal, could be replicated throughout California if they are successful, according to the Department of Health Care Services.

Maritza Barron came to UCSF after her own dentist — despite the best of intentions — was unable to examine her baby’s mouth. “He tried to say ‘open up’ to him but he wouldn’t do it,” Barron said of the failed attempt, which left her son in tears.

Alston, the Oakland dentist, once faced similar challenges treating very young children, but she has since undergone a transformation. She blames dentists’ wariness of young patients on a lack of experience. When she graduated from dental school in 1982, she said, she had no training that prepared her to work with children younger than 6.

“I didn’t feel like I could manage their behavior,” Alston said.

Over time, however, it became increasingly clear to her that she wasn’t seeing children early enough.

Almost all of the kids who came to her for their first dental visit at age 6 had mouths riddled with tooth decay, Alston said. She had to refer them to specialists for treatment that required sedation. She kept lowering the minimum age for a first visit in her practice, then left it at age 3 for a long time.

But even 3-year-olds were coming in with cavities. Ultimately, she learned how to treat infants and toddlers through a program run by Alameda County’s public health department — not unlike the training to be offered by the new pilot programs.

Today, Alston is passionate about treating very young children and has lined up pediatricians to refer infants to her. And she has revised her guidance on when kids should get their first oral exam, advising parents to bring their children in when their first tooth starts to erupt.

She also trains dental students to examine infants. An important trick she teaches them is how to avoid being bitten: “Put your finger behind the last tooth!”

Communicating directly with children during dental exams can help reduce their stress, saod both Alston and Stewart, the UCSF dental professor.

At a recent visit to UCSF’s Pediatric Dentistry Faculty Clinic, 18-month-old Sebastian King scrutinized the dental mirror Stewart handed to him.

“That’s what I’m going to put in your mouth to look at your teeth!” Stewart told him exuberantly.

He asked the young boy to show him where his mouth was. Sebastian smiled with delight as Stewart handed him a blue exam glove he’d blown up into a balloon, and the young boy remained calm throughout the exam.

Helping parents understand their role is also critical, dentists say.

In addition to advising parents not to share eating utensils with their children, Stewart urges them not to let their kids fall asleep with a bottle of milk and to limit their consumption of fruit juice. He also says they should wipe their infants’ gums and teeth with a cloth after feeding them to remove residue that can cause cavities.

That’s the message Calvo, the dental resident, gave to Barron, whose baby sat happily on his mother’s lap after his exam. The boy had cavities because he had been falling asleep with his bottle.

Barron said she recognized that weaning Allen from the bottle at night would be a challenge.

But “it’s really logical,” she told Calvo, adding that she was determined to give it a try.

This story was produced by , which publishes , an editorially independent service of the .

KHN’s coverage of children’s health care issues is supported in part by a grant from .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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The proposed legislation, mostly sponsored by Republicans, is among the first public bids for revenue from the statewide tobacco tax that voters approved in November.

The bill, introduced by Assemblyman Brian Maienschein, R-San Diego, would require the Department of Health Care Services, which oversees Denti-Cal, to boost pay for participating dentists. California’s reimbursements for these dentists have long been among the lowest in the nation, and they have not changed since 2001.

The bill would increase reimbursements for the 15 most common services for prevention and treatment, such as teeth cleaning and cavity filling. Rates would be increased to average commercial rates and would take effect in 2018.

California dental providers receive about a third of what their colleagues in other states get when treating Medicaid-eligible patients, according to an April by the state’s Little Hoover Commission, an independent oversight agency.

As a result, the shortage of dentists willing to take Denti-Cal has contributed to an “epidemic of tooth disease in which toddlers by the thousands have mouthfuls of cavities,” the report says. Denti-Cal, part of California’s Medi-Cal program, serves half of California’s children and about a third of adults.

The bill itself does not detail where additional funding for Denti-Cal would come from. But in a letter to Gov. Jerry Brown, Senate and Assembly Republican leaders said funding should come from proceeds of Prop. 56, the new statewide tax raising the price of a pack of cigarettes by $2.

The new tax “specifically provides new funding to address the shortage of dentists, prevent and treat dental diseases, and improve existing programs to provide quality healthcare and access to healthcare services for families and children,” wrote Assembly Republican Leader Chad Mayes, R-Yucca Valley and Senate Republican Leader Jean Fuller, R-Bakersfield.

One Democratic lawmaker, Sen. Toni Atkins, D-San Diego, is among the bill’s cosponsors.

The letter notes that the Legislative Analyst’s Office estimated the tobacco tax would bring in about $1 billion in revenue to the state. “These funds are clearly available to fix Denti-Cal,” the leaders wrote.

The state’s Department of Health Care Services declined comment on pending legislation.

According to the bill, the goal is to attract and keep more providers in the Denti-Cal program, which serves 13 million Californians. Low reimbursement rates have been noted as a big reason for the short supply of Denti-Cal providers across the state.

For instance, the Denti-Cal reimbursement payment to California dentists for an oral exam is about $15. This compares to the national average of $45.61 for the same exam, according to 2015 state data.

A found that only about 44 percent of children enrolled in Denti-Cal had seen a dentist in the previous year. The review also found that there were no Denti-Cal providers in five counties and in 11 other counties Denti-Cal providers were not accepting new patients.

Dentists who do take Denti-Cal patients are often inundated.

Dr. Santosh Sundaresan, the chair of community dental programs at the Herman Ostrow School of Dentistry at USC, said the prospect of higher pay is good news for both dentists and patients. When Denti-Cal providers have to see as many as 40 patients a day to sustain their business, at some point quality is compromised, he said.

“Increased rates make it more realistic for dentists to take care of the general population,” Sundaresan said. “I would like to see the scope of services [covered by Denti-Cal] expand, too. But one step at a time.”

Dr. Naina Bhoot, a dentist in Glendale, Calif., says the gaping need for dental services keeps her from cutting ties with the state program.

About half of her patients are covered through Denti-Cal. Her reimbursement for services rendered to these patients is about 25 percent of her usual service fee for patients with other coverage, she says.

Bhoot, who has been practicing for 27 years, said she has formed bonds with many of her patients, but she also needs an incentive and some reassurance that she can keep her practice afloat.

News that legislators are looking into the issue, she said, gives her some hope.

This story was produced by , which publishes , an editorially independent service of the .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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