As COVID-19 reaches every part and level of the United States, our society’s widespread inequalities will be intensely highlighted and further exacerbated. The outbreak’s effect will also be acutely felt by disadvantaged and underprivileged children.1 Those effects will prominently emerge in our oral health care system, where they will further widen glaring child oral health disparities.
Well before the pandemic, US children living in poverty and those from low-income families or racial and ethnic minorities overrepresented our national dental disease burden.2 Caries has unfairly and unjustly persisted and concentrated among this relatively small part of the US population. And although the national prevalence of caries appears to be decreasing among all children, it continues to stagnate or worsen among this demographic.2
As a result of caries, children’s health, development, and quality of life markedly suffer.3 When compounded with social barriers, the chronic and cumulative consequences of child oral disease contribute to wider health inequities throughout the life course.4
The outbreak's effect will also be acutely felt by disadvantaged and underprivileged children. Those effects will prominently emerge in our oral health care system, where they will further widen glaring child oral health disparities.
COVID-19 Pauses the US Oral Health Care System
In March 2020, the Centers for Disease Control and Prevention recommended that all elective surgeries and nonessential medical, surgical, and dental procedures be delayed during the onset of the COVID-19 outbreak. As a result, dental clinics across the country were temporarily closed to children, triaging patients for only urgent and emergency procedures.
Although this was a necessary precaution, closures disproportionally harmed children in poverty and those from low-income families and racial and ethnic minority groups since they carry the greatest extent and severity of dental disease. In fact, these groups already represented the highest proportion of all US children with unmet dental needs.5
By abruptly pausing the provision of child dental care, COVID-19 adds delays to time-sensitive treatment, worsens the status of already significant caries, and further overburdens our previously strained dental safety net, including community health centers, federally qualified health centers, and hospitals. Here, the pandemic agonizingly reminds us that poor outcomes resulting from our past oral health policies and approaches will continue unless an equity and justice framework is used.
COVID-19 Reveals Holes in US Social Welfare Policies
Children live in families, and as families struggle through instability, it becomes increasingly difficult to maintain a child’s oral health. A growing body of evidence shows a close link between a family’s socioeconomic conditions and child oral health outcomes.6 COVID-19’s spread refocuses our attention to those social inequities, perpetuated by deficient federal and state policies, which carry both direct and unintended consequences for child oral health.
Unemployment and Dental Insurance
COVID-19 has dramatically led to unprecedented job loss in America. Regrettably, employment status in the United States plays a critical role in meeting eligibility requirements to qualify for or maintain health and dental insurance. Parental job losses can trigger the loss of child dental insurance, and, although there are options for keeping or renewing coverage, transitions can result in coverage gaps or changes in benefits and affordability.
Without dental insurance, most families are unable to afford out-of-pocket expenses for dental care.7, 8, 9 Fear of affordability dissuades parents from taking their children to the dentist, and therefore leaves children without a dental home or with unmet dental needs.
Policy reform should prioritize strategies that safeguard vulnerable Americans’ oral health care by increasing state flexibility to expand coverage and streamlining enrollment to ensure uninterrupted coverage. Policy reform should also take meaningful steps to end involuntary work eligibility requirements that discriminate against naturally volatile job markets and thus penalize parent and child oral health coverage.
Income Instability and Health care Affordability
Tied to COVID-19’s cascade of unemployment is a sudden and inescapable fall in family income. But well before the coronavirus, many US households lived paycheck to paycheck, carried a large amount of debt, were unable to cope through emergencies, and lacked disposable income or savings. Furthermore, unjust power relations that stagnate worker salaries without repercussions result in unlivable minimum wages and strangle family livelihoods.
For these families, even slight work disruptions are devastating. As the economic stress of COVID-19 becomes overwhelming, it jeopardizes a family’s ability to afford basic needs. This forces families to prioritize only absolute necessities—such as food, shelter, and utilities—and neglect or delay other expenses, including parents’ or childrens’ oral health care or hygiene supplies.
By delaying or neglecting preventive dental services, caries can result or progress, and opportunities for minimally invasive approaches or early interventions are missed. The delay or neglect of dental care necessitates more advanced treatment options, requiring added time and expense unavailable to many families. This self-reinforcing cycle is accelerated by COVID-19, putting further financial stress on already strained parents and their children.
Policy reform should ease provision of health care by shifting cost burdens away from families. It should also weigh how financial burdens of care can negatively influence health care systems decisions, by both parents who are unable to enter or engage in the system and providers who are unable to freely practice in the system.
Food Insecurity and Unhealthy Alternatives
Lastly, COVID-19 has completely disrupted the US education system, at one point keeping more than 55 million students home, nearly one-half of whom rely on free or reduced-price school meals. With unprecedented school shutdowns, school and summer food service programs are now at serious risk of failing to meet the needs of eligible children.
As a vital source of healthy and balanced nutrition, school-based meal options are especially important for children living in food deserts, in which there is a scarcity of healthy food options. COVID-19 provides a stark window into US child food insecurity in which families are forced to buy cheap, convenient, and unhealthy food alternatives, including highly processed foods with significant salt, fat, and added sugars.
Added sugars are, of course, the leading and primary cause of caries.10 The frequency and volume of sugars consumed is a major risk factor for the development and progression of caries among young children.11
Policy reform should support states with the flexibility to implement school-based meal programs that ensure continuity and avoid disruptions throughout the year. Reforms should also aid system and environmental strategies to improve access to healthy food options and eating habits for all children as well as take meaningful regulatory steps—particularly regarding advertising and food labels—to discourage the consumption of added dietary sugars.
A Justice, Equity Approach: Oral Health in All Policies
Social policy has wide-ranging and disparate effects on child health and oral health, whether direct or indirect, intentional or unintentional. Only by solutions that thoughtfully target the roots of social and economic inequity—through discriminatory practices and unjust power relations—can we meaningfully address the center of child oral health disparities.
COVID-19 heartbreakingly teaches America many important lessons: our interconnectedness and dependence on one another; our individual and collective responsibility for social welfare, and most importantly, our shared humanity. How we collectively address the social conditions of our most marginalized and weak people after the pandemic is over is critical and will shape whether we truly find meaningful, sustainable, and just solutions for the health and oral health of all children.
Biography
Dr. Kalash is a pediatric dentist, Section of Population Oral Health, College of Dental Medicine, Columbia University, New York, NY.
Footnotes
Commentaries represent the opinions of the authors and not necessarily those of the American Dental Association.
Disclosure. Dr. Kalash did not report any disclosures.
References
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