Oral Health of Young Children, Adolescents & Foster Youth – Comprehensive Study Notes

Page 1

Session & Presenter
• Course: D1 Health Promotion, NYU Dentistry (Lecture date: 7/17/25)
• Topic Focus: Oral health of Young Children & Adolescents
• Lecturer: Liz Best, MPH

Page 2 – Objectives

1. Young Children (≤5 yrs)
   • Unique demographic trends
   • Oral-health status
   • Access points for care

2. Adolescents (10-24 yrs)
   • Unique demographic trends
   • Oral-health status
   • Risk factors

3. Foster Care Population
   • Current trends
   • Oral-health implications

Page 3 – Young-Child Demographics

• Population ≤5 yrs (2020 Census): 22.3\text{ million} \; (\approx6\%\text{ of U.S.})
• First U.S. majority-minority cohort
• Highest poverty rate of any age group
– Kids in poverty: 3.8\text{ million}\;(17\%)
• Data sources: 2020 Census, Pew, Children’s Defense Fund, KidsCount

Page 4 – Policy Impact (Child-Poverty Rates)

Page 5 – Oral-Health Status (Ages 2-5)

• Total caries prevalence: 21\%
• Untreated caries: 11\%
• Stark disparities:
– Poor vs. non-poor untreated caries: 18\% vs. 7\%
– Minority children disproportionately affected
• Sources: NHANES 2016; Indian Health Service 2014

Page 6 – “Never-Visited Dentist” (Age 1-5)

• NHIS 2006-2016 trend illustrates high first-visit deficit; emphasizes importance of establishing a Dental Home by age 1.

Page 7 – Historic Access Programs

Legacies of Lyndon B. Johnson’s “War on Poverty”:

1. Medicaid (1965)

2. Head Start (1965)

3. WIC – Women, Infants & Children (1974)

Page 8 – Federal Poverty Context (2025)

• FPL (4-person family): \$32{,}150 yr ≈ \$2{,}679 mo (pre-tax)
• Federal Minimum Wage (FMW): \$7.25 \;/\text{hr}\;(\$15{,}080\;yr)
– 20 states allow wages ≤ FMW
• NYC Minimum Wage: \$16.50\;/hr \;(\$34{,}320\;yr ≈\$2{,}860\;mo)
– Median 1-BR rent NYC: \$3{,}800/mo
• Implication: Employment ≠ Economic security → impacts ability to obtain dental care & essentials.

Page 9 – Public Insurance Snapshot

• Medicaid: 30.4\text{ million} children
– Covers low-income kids, pregnant women, disabled adults
• CHIP: 7.1\text{ million} children
– For families earning too much for Medicaid yet too little for private plans
• Combined: >40 % of all young U.S. children

Page 10 – Recent Insurance Trends

• 2017: First rise in uninsured kids in a decade
• 2018: 2\% drop in Medicaid/CHIP child enrollment
• 2020-2022: Pandemic → 16\% enrollment increase
• Apr 2023: End of COVID continuous enrollment → 4.5\text{ million} fewer covered kids (69 % procedural terminations)
• Clinical takeaway: Prepare for coverage churn; confirm eligibility frequently.

Page 11 – Head Start Philosophy

• Goal: Break the cycle of poverty & close school-readiness gaps
• Comprehensive support: emotional, social, health, nutrition, psychological
– By Kindergarten, poor kids already behind; program intervenes early.

Page 12 – Head Start / Early Head Start (EHS)

• Serves ≈ 800{,}000 children, pregnant women & families via 3{,}000 programs
• Eligibility: Income-based; automatic for homeless & foster children
• Services:
– Medical & dental screenings/exams
– Disability/developmental screening
– Parenting classes, health-ed, crisis intervention
– Early childhood education & free meals

Page 13 – Dental Requirements in HS/EHS

• EHS (0-2 yrs)
– Establish Dental Home
– Caries-risk screening
• HS (3-5 yrs)
– Dental Home + full dental exam
– Required follow-up treatment
• Align with EPSDT (Early & Periodic Screening, Diagnostic & Treatment) mandates.

Page 14 – WIC Overview

• Supplemental nutrition for pregnant/post-partum women, infants, children ≤5.
• Scale: 6.4\text{ million} participants; >10{,}000 clinic sites
– >50 % are children aged 1-4
• Eligibility: Low-income & nutritional risk

Page 15 – WIC & Oral Health

• Provides: Nutritious food packages, nutrition ed., breastfeeding support, health-care referrals (inc. dental)
• Evidence: 2004 NC study—WIC kids more likely to visit dentist & less likely to need ED for dental issues.
• Proposed 2025 cuts: Would slash fruit/veg benefits 67\text{–}75\% for 5\text{ million} recipients → nutritional & oral-health ramifications.

Page 16 – What Dental Professionals Can Do

• Advocacy for equitable policies
• Become Medicaid providers
• Accept HS/EHS & WIC referrals
• Serve on Head Start Health Advisory Boards
• Offer community education & screenings
• Ethical imperative: “These kids are literally our future.”

Page 17 – Transition Topic

Focus shifts to Adolescents & Young Adults.

Page 18 – Ice-breaker

“How many of you are \le25?” (Establishes personal relevance.)

Page 19 – Developmental Timeline

Page 20 – Why Focus on Adolescents?

• Begin managing their own oral hygiene & appointments
• Hormonal/physiologic changes affect perio tissues (e.g., puberty-related gingivitis)
• Brain immaturity → risk-taking & addiction susceptibility
• Care often shifts from pediatric → general dentists & specialists

Page 21 – Gen Z Demographics

• Urban/Suburban: Only 13\% live rural (lowest ever)
• Education: 59\% of 18-20 yr-olds in college; projected most-educated cohort
• Gender Fluidity: Inclusive of non-binary IDs; comfortable with pronoun options
• Size: 63\text{ million} aged 10-24

Page 22 – Adolescent Oral-Health Status (12-19 yrs)

• Total caries prevalence: 54\%
• Untreated caries: 13\%
• Never visited dentist: 1.8\% (YRBSS 2023)
• Dental-visit frequency better than in early childhood, but disease burden still high.

Page 23 – ACA Policy Impact

• Affordable Care Act (2010): Children may stay on parent insurance until age 26.
• By 2014, employer/insurer “grace” period ended → uninsured youth declined markedly.

Page 24 – Adolescent Risk Domains

• Diet
• Tobacco/vaping
• Alcohol & drugs
• Oral piercings
• Sexual activity
• Injuries/violence
• Sports & hobby accidents

Page 25 – Current Risk Trends (YRBSS 2023)

Diet
• Daily soda down to 14.5\% (was 27\% in 2013).
• Fruit/veg intake improving (but 7\% hadn’t eaten any in past week).
• Obesity: 16\%, trending slightly downward.
Tobacco/Vaping
• Cigarette use: 3.5\% HS students (was 16\% in 2013).
• Vaping: 16.8\% in 2023 (down from 33\% in 2019).
Substance Use
• Marijuana: 17\% (↓ since 2013).
• Alcohol (current use): 22\% (↓ from 50\% in 1990s).

Page 26 – Opioid Landscape (Teens & Young Adults)

• Non-prescribed pain-med use: 11.6\% HS students (2023)
• Overdose deaths: 2024 saw 27 % decline; nevertheless >54,000 deaths (was 107,000 in 2021).
– Largest decline 47\% among 20-29 yr olds (still critical).
• Reduction credited to public-health interventions (naloxone, fentanyl test strips, ed.).

Page 27 – Macro-Economics & Litigation

• Since 1999: 1\text{ million} opioid deaths.
• 2020 economic burden: \$1.5\text{ trillion} (Senate JEC).
• Settlements: Johnson & Johnson + 3 distributors \$26\text{ billion}; Sackler family \$6\text{ billion}.
• 15 % deaths involved Rx opioids → underscores prescriber responsibility.

Page 28 – Dentistry’s Role in Opioid Exposure

• 2013 SC review: Dentists = <9 % of prescribers but ≈45 % of initial opioid Rx (McCauley).
• 2010-2015 national trend: Opioid Rx ↑ among dentists; 11-18 yr-olds largest increase (Gupta).
• 2019 Stanford study: Dentists issued 30 % of first opioid Rx to 18-25 yr olds; median 20 pills.
• Within one year, ≈6 % of those recipients had documented opioid-abuse diagnosis (Schroeder).
• Implication: Prefer NSAID protocols, limit pill counts, educate patients.

Page 29 – Sexual Activity Trend

• % of 9th graders ever had intercourse dropped from 34.4\% (2001) → 15.9\% (2021).
• Fewer sexual partners & later sexual debut → potential ↓ STIs but vigilance required.

Page 30 – HPV & Oropharyngeal Cancer

• 80\% of Americans infected with HPV at some point; 99\% clear it naturally.
• 2019: 20{,}000 U.S. oropharyngeal cancers; 70\% HPV-linked, 50\% HPV-16.
• Twice as common in men → value of gender-neutral vaccination messaging.

Page 31 – HPV Vaccine Evolution

• 2006: Gardasil (types 6,11,16,18) approved for females 11-26.
• 2009: Indication expands to males ≤21 & age floor lowered to 9.
• 2014: Gardasil 9 → covers ≈90 % oncogenic types in women, 95 % in men.
• Upper-age now 45 yrs; 2 other vaccines exist (bivalent & quadrivalent).

Page 32 – Vaccine Impact & Counseling

• NHANES ’11-’14 analysis: Oral HPV 6/11/16/18 infections 88 % lower among ≥1-dose recipients.
• No difference for non-covered HPV types → underscores type-specific efficacy.
• Clinical-action: Intra-oral exam is opportunity to ask vaccine status & recommend.
• Note: Political targeting of HPV vaccine is possible—be prepared to counter misinformation.

Page 33 – Shifting Scope of Dentistry

• 2018: ADA mandates CE on opioid prescribing.
• 2019: Oregon first state letting dentists administer all vaccines.
• 2019: Missouri restricts dentists from prescribing OxyContin, limits other opioids.
• 2020: Dentists mobilized for COVID-19 vaccination roll-out.
• Outlook: Preventive & public-health roles expanding.

Page 34 – Public-Health Horizon (Reasons to Hope … & Warnings)

Successes
• Opioid-overdose decline credited to federal-state-local synergy (Naloxone, fentanyl strips, youth ed., mental-health services).
• Adolescent tobacco use at historic lows ↔ robust CDC/FDA tobacco-control.
Threats
• March 2025: \$11\text{ billion} cut from addiction & mental-health programs → jeopardizes gains.
• Proposed elimination of CDC Office of Smoking & Health & FDA Center for Tobacco Products → could reverse tobacco progress.
• Cultural resurgence of cigarettes in pop media → vigilance required.

Page 35 – Foster Care Overview

• 343{,}077 children in U.S. foster care (ACF 2023).
• Definition: Child removed from parental custody by CPS for maltreatment.
• Placements: Majority with foster parents/kin; minority in group homes/institutions.
• NYU Dentistry provides care for NYC foster youth → experiential relevance.

Page 36 – Foster-Care Statistics (2023)

• Age: 38\% ≤5 yrs; median = 7 yrs.
• Reasons (multiple possible):
– Neglect 64\%
– Parental drug abuse 35\%
– Physical/sexual abuse 17\%
– Housing issues 9\%
• Duration: Median time in care 14.6 mo; 42\% <1 yr, 31\% ≥2 yrs.

Page 37 – Predictors of Foster Placement

• Poverty (strongest)
• Housing instability/homelessness
• “Fishbowl effect” – heightened scrutiny of low-income families.

Page 38 – Foster Care in New York (2024)

• Children in care: 14,500
• Duration: 58\% <12 mo; 80\% <2 yrs.
• Outcomes: 54\% reunified, 21\% adopted, remainder age out.
• Oral-health needs: 35\% significant needs (AAP).
• Treatment barriers: Frequent moves, limited time, consent complexity.

Page 39 – Dental Logistics in Foster Care

• Automatic Medicaid enrollment
• Intake mandate: Comprehensive dental exam
• Complete treatment when feasible within predicted care window.
• Consent nuance: Foster parents cannot sign → need bio-parent or supervising agency.

Page 40 – Best Practices for Treating Foster Youth

1. Gather full social history (placement details, anticipated moves).

2. Document thoroughly; obtain multiple contacts (caseworker, agency, court officer).

3. Prioritize urgent needs (pain, infection, rampant caries).

4. Provide holistic care—address trauma, anxiety, systemic health.

Page 41 – Closing

“Thank you and good luck with dental school!” – Encouragement to integrate public-health perspective into daily practice.