key: cord-310998-zchtu6cm authors: Kalash, Danny A. title: How COVID-19 Deepens Child Oral Health Inequities date: 2020-05-23 journal: J Am Dent Assoc DOI: 10.1016/j.adaj.2020.05.015 sha: doc_id: 310998 cord_uid: zchtu6cm ABSTRACT The fallout from COVID-19 will reveal the depth and range of social, economic, and political disparities faced by U.S. families and children. Those same injustices, magnified and worsened by COVID-19, are also responsible for perpetuating child oral health disparities. s COVID-19 reaches every part and level of the United States (U.S.), our society's widespread inequalities will be intensely highlighted and further exacerbated. The outbreak's impact will also be acutely felt by disadvantaged and underprivileged children. 1 Those effects will prominently emerge in our oral healthcare system, where they will further widen glaring child oral health disparities. Well before the coronavirus, U.S. children in poverty, from low-income families, or racial and ethnic minorities, overrepresented our national dental disease burden. 2 Dental decay has unfairly and unjustly persisted and concentrated among this relatively small part of the U.S. population. And while the national prevalence of dental decay appears to be decreasing among all children, it continues to stagnate or worsen among this demographic. 2 As a result of dental decay, 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 through the life course. 4 A Earlier in March, the Centers for Disease Control and Prevention (CDC) recommended all elective surgeries, non-essential medical, surgical, and dental procedures be delayed during the coronavirus outbreak. As a result, dental clinics across the country have temporarily closed to children, triaging patients for only urgent and emergency procedures. While this is a necessary precaution, closures will disproportionally harm children in poverty, 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 U.S. 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 decay, 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 utilized. 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 now shows a close link between a family's social and economic 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. COVID-19 has dramatically led to unprecedented job loss in America. Regrettably, employment status in the U.S. plays a critical role in meeting eligibility requirements to qualify or maintain health and dental insurance. Parental job loss can trigger loss of child dental insurance, and while 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 which safeguard vulnerable American's oral health care by increasing state flexibility to expand coverage, and streamlining enrollment to ensure uninterrupted coverage. It should also take meaningful steps to end involuntary work-eligibility requirements which discriminate against naturally volatile jobs, and thus penalize parent and child oral health coverage. Tied to COVID-19's cascade of unemployment is a sudden and inescapable fall in family income. But well before the coronavirus, many American households lived paycheck to paycheck, carried large debt, were unable to cope through emergencies, and lacked disposable income or savings. Furthermore, unjust power relations which stagnate worker salaries result in unlivable minimum wages and strangle family livelihoods. For these families, even slight work disruptions are devastating. As COVID-19's economic stress becomes overwhelming, it jeopardizes a family's ability to afford basic needs. This forces families to prioritize only absolute necessities -like food, shelter, and utilities -and neglect or delay other expenses, including parent or child oral health care or hygiene supplies. By delaying or neglecting preventive dental services, dental decay can result or progress, and opportunities for minimally invasive approaches or early interventions are missed. All of which 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 healthcare systems decisions, both by parents who are unable to enter or engage in the system, as well as by providers who are unable to freely practice in the system. Lastly, COVID-19 has completely disrupted the US education system, keeping over 55 million students home -nearly half of which rely on free or reduced-price school meals. With unprecedented school shutdowns, school meal 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, with a scarcity of healthy food options. COVID-19 provides a stark window into U.S. child food insecurity where families are forced into cheap, convenient, and unhealthy alternatives, including highly processed foods with significant salt, fat, and added sugars. Added sugars are of course the leading and primary cause of dental caries. 10 The frequency and volume consumed is a major risk factor for development and progression of dental decay among young children. 11 Policy reform should support states with flexibility to implement school-based meal programs which ensures continuity and avoids disruptions. It should also aid system and environmental strategies to improve access to healthy food options and eating habits for all children, and, take meaningful regulatory steps -particularly around advertising and food labels -to discourage the consumption of added dietary sugars. Social policy has wide-ranging and disparate effects on child health and oral health, whether direct or indirect, intentional or unintentional. Only by solutions which 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. Coronavirus 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 after coronavirus is critical, and, will shape whether we truly find meaningful, sustainable, and just solutions for the health and oral health of all children. Mitigating the Impacts of the COVID-19 Pandemic Response on At-Risk Children Two decades of persisting incomedisparities in dental caries among US children and adolescents Pediatric Oral Health Research and Policy Center A Life Course Health Development Perspective on Oral Health Handbook of Life Course Health Development Prevalence of total and untreated dental caries among youth: United States Social determinants of pediatric oral health Oral Health for All: Policy for Available, Accessible, and Acceptable Care Barriers to care-seeking for children's oral health among lowincome caregivers The effect of health and dental insurance on US children's dental care utilization for urgent and non-urgent dental problems-2008 Sugars and dental caries Sugar restriction for caries prevention: amount and frequency. Which is more important? Disclosure. Dr. Kalash did not report any disclosures.