the rise in the number of children in need of such treatment is evidence of poor oral health literacy. Children with complex and extensive dental disease can often be treated in a clinic setting; however, if the disease is located in multiple quadrants of the mouth, treatment can be lengthy and challenging. Children are often in pain and they are scared. Children with severe behavioral problems usually need to be hospitalized and sedated, which is an approach as a last resort. In most cases, the need for hospitalization can be avoided with the use of prevention and early intervention strategies.

In the health center’s school-based oral prevention program, dental hygienists work in the 30 public schools in the 9-county area, providing preventive services and oral health education. The center’s philosophy is to bring services to the patients, because patients often have a difficult time accessing care at the center. When children are identified with untreated dental disease and they do not have an established dental home, they are referred to the closest center dental office. Children with extensive needs or children with special health needs may have to seek care at the local hospital.

The center’s patients represent 20 percent of the population, but have 80 percent of the community’s dental disease. The disease is often advanced and requires complex treatment. The patients have difficulty navigating the local health care system and case management services are used to facilitate appropriate care. Many of the patients have relatively low literacy skills and difficulty understanding how to enroll in or use Medicaid. For example, many of the pregnant women seen at the center do not take advantage of their Medicaid insurance. Some patients are not able to articulate their signs and symptoms of disease. Other problems arise because patients do not adhere to treatment recommendations. Wolpin said that this might be a sign of distrust of providers and described how many clients do not know when or how to ask questions about the treatment options that are present for them or for their children.

Wolpin provided an illustration of the impact of low oral health literacy. The center serves many Spanish-speaking migrant agricultural workers. These workers often live in multifamily dwellings. In order to assure that the working men of the household get a good night’s sleep, mothers will put babies to bed with a bottle of sweet liquid, or they will give babies a pacifier sweetened with honey. The result is that many of the children have early childhood caries, and have to be treated in a hospital.

Wolpin described his early approach to education as preaching. He accepted the need for the baby to have a bottle at bedtime, but asked mothers to fill the bottle with fluoridated water. His patients seemed to be in agreement with his advice during their visits, but did not change their behaviors. It is possible that they were not changing their behaviors



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