A Perfect Smile Comes at a Cost: How Poverty and Food Insecurity Cement Disparities in Oral Health

Posted & filed under Children's Oral Health and Fluoride, Fluoride and Public Health, Fluoride, Oral Health, and Access to Care.

Contributed by Qadira Ali Huff, MD, MPH

Overview- Why This Matters:

A picture-perfect smile falls just out of reach for many children living in poverty. Dental caries is the most common chronic childhood disease, and the burden of dental caries falls disproportionately on low-income and minority children (Dye et al. 2012). Children living in poverty have about five times more untreated dental decay than children from higher income families (GAO Report 2000). The socioeconomic forces that place these children at risk of food insecurity are the very same ones that increase their risk of developing early childhood caries. This disparity in poor oral health adversely impacts these children’s ability to eat, speak, and learn, further cementing social inequities already stacked against this vulnerable population.

Nutrition and Oral Health Connection:

GirlBrushingTeeth1.jpgOften the phrase “childhood food insecurity” conjures an image of a child with insufficient access to an adequate quantity of food. The reality is that food security is about both adequate food quantity and food quality to ensure proper growth and nutrition. Approximately 15.8 million (or 1 in 5) US children under 18 years live in households unable to consistently access sufficient nutritious food necessary to lead a healthy life (Coleman-Jensen et al 2014). The childhood obesity and overweight epidemic’s preponderance in lower income children speaks to the problem of overnourishment as a form of malnutrition (Singh et al 2010a). The food landscape in many high poverty communities reveals a dearth of grocery stores selling produce, high nutrient and low calorie foods, and an abundance of fast food outlets, corner stores and markets selling poorer quality foods high in sugar and simple carbohydrates (Galvez et al. 2008). Food insecure families tend to have less control over deliberate food selections, especially if dependent on food pantries, kitchens, or other nongovernmental sources of supplemental food. Evidence has consistently shown that dietary sugar is the single most important nutritional factor in developing caries (Moynihan and Petersen 2004). The nutritional scale in lower income communities is thus often tipped towards more cariogenic foods.

Poverty and Oral Health Disparities:

Limited access to preventive dental services compounds the oral health risk of children living in poverty beyond that caused by cariogenic diets. Children living in poverty do not visit the dentist as regularly, or as early on in life, as their higher income despite fairly broad Medicaid/CHIP dental coverage. Scant data exists regarding the barriers to accessing dental care beyond insurance coverage, but factors such as provider office location and whether a practice accepts Medicaid insurance could impact utilization. The result of the epidemic of untreated dental caries is manifold: missed activity and school days, poor school concentration due to dental pain, infection risk, speech and eating difficulties, and increased risk of poor oral health in adulthood. The rate of untreated caries among children from poor families continues to increase, thereby highlighting the importance of ongoing oral health advocacy, including work to elucidate these barriers to accessing dental care.

Role of Pediatricians:

Female Doctor and ChildAdvocacy efforts surrounding improving children’s oral health may simultaneously promote routine access to nutritious food for all children, healthy weight status, as well as prevention of caries and metabolic syndrome associated chronic diseases increasingly being diagnosed in children. In alignment with the 2014 American Academy of Pediatrics (AAP) Policy Statement “Maintaining and Improving the Oral Health of Young Children,” pediatricians may act to promote healthy teeth, as well as healthy bodies, in the following ways:

  1. Primary prevention through caries risk assessments at every well-child visit! Print out a copy of the AAP Bright Futures Oral Health Risk Assessment Tool in both English and Spanish.
  2. Provide anticipatory nutritional guidance in clinic regarding strategies to reduce impact of sugars in the development of caries. For example: discourage continual bottle/sippy cup use, avoid frequent snacking and bottle propping, limit juice to no more than 4-6 ounces per day, and encourage only water between meals!
  3. Provide oral hygiene anticipatory guidance on twice daily tooth brushing with fluoridated toothpaste once teeth erupt and encourage establishment of a dental home by age 1 year, as recommended by AAP and American Academy of Pediatric Dentistry (AAPD).
  4. Advocacy for drinking plenty of fluoridated tap water and for fluoride varnish application in the primary care setting. Check out this online fluoride varnish training.
  5. Antipoverty advocacy that addresses the social determinants of health, including food/nutrition, health care access, education, and employment. As families have more life resources, they are better empowered to raise healthy children.
Resident Advocacy Steps for Promoting Improved Oral Health for Kids:




Contributor Biography:

Qadira Ali Huff, MD, MPH is a native Washingtonian entering her final year of pediatrics residency at Children’s National in Washington, DC. She began her term as AAP Section on Medical Students, Residents and Fellowship Trainees (SOMSRFT) Section on Oral Health (SOOH) Liaison in November 2014. She completed undergraduate medical education at the University Of Maryland School Of Medicine and her Master of Public Health at Johns Hopkins Bloomberg School of Public Health. She is passionate about racial-socioeconomic health disparities research and action, particularly surrounding the issues of oral health, early childhood education, and nutrition. She plans on pursuing a hybrid career post-residency that integrates primary care and advocacy work.


Works Cited:
  • Coleman-Jensen A, Gregory C, Singh A. Household Food Security in the United States in 2013. USDA ERS. 2014.
  • Dye BA, Li X, Beltran-Aguilar ED. Selected oral health indicators in the United States, 2005-2008. NCHS Data Brief. 2012;(96):1–8.
  • Galvez MP, Morland K, Raines C, Kobil J, Siskind J, Godbold J, Brenner B. Race and food store availability in an inner city neighbourhood. Public Health Nutr. 2008;11(6):624–631.
  • Mobley C, Marshall TA, Milgrom P, et al. The Contribution of Dietary Factors to Dental Caries and Disparities in Caries. Academic Pediatrics. 2009;9:6; 410-414.
  • Moynihan P, Petersen PE. Diet, nutrition and the prevention of dental diseases. Public Health Nutrition. 2004;7(1A):201-226.  Accessed 7/7/2015 at http://www.who.int/nutrition/publications/public_health_nut7.pdf.
  • Muirhead V, Quinonez C, Figueiredo R, et al. Oral health disparities and food insecurity in working poor Canadians. Community Dentistry and Oral Epidemiology. 2009;37(4):294-304.
  • Oral Health: Dental Disease is a chronic problem among Low-income populations. United States General Accounting Office. Report to Congressional Requesters: April 2000. Accessed on 7/7/2015 http://www.gao.gov/new.items/he00072.pdf.
  • Sheiham A. Oral health, general health, and quality of life. Bulletin of the World Health Organization. 2005;83(9):644-645. Accessed on 7/7/2015 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2626333/pdf/16211151.pdf.
  • Singh GK, Siahpush M, Kogan MD. Rising social inequalities in US childhood obesity, 2003-2007. Annals of Epidemiology. 2010;20(1):40-52.