“Teeth are so important in so many ways, forms and fashion,” Tonya Fuqua, D.D.S., director of Child Oral Health at the Center for Children’s Health, led by Cook Children’s Health Care System. “The mouth is the gateway to our body, and it is connected to the rest of our body. And it starts with once a kid is born.”

The assessment also revealed 57% of children (about 651,000) received at least two or more preventive dental visits aligning with the American Academy of Pediatric Dentistry recommendations.

 A Celebration to Sink Your Teeth Into

In honor of National Children’s Dental Health Month in February, the Cook Children’s Save-A-Smile program hosted a celebration this week in collaboration with the Fort Worth District Dental Society, the Texas Dental Association, and the Children’s Oral Health Coalition.

The organizations transformed the Cook Children's Medical Center Fort Worth Atrium into a dental-themed landscape. Patients received age-appropriate oral health kits, participated in arts and crafts, and chose a Build-A-Bear teddy bear or "tooth" to keep as a reminder of good oral hygiene.

“Healthy mouth, healthy body because if your mouth is healthy, that will hopefully lead you to a healthier body,” said Dr. Fuqua.

The Community Health Needs Assessment provides valuable insights from parents, caregivers and community leaders across our eight county service area – Collin, Denton, Grayson, Hood, Johnson, Parker, Tarrant and Wise Counties. These assessments help Cook Children’s identify community health needs and develop and implement strategies to address them.

On June 3, Cook Children’s shared those findings and subsequent calls to action. The health topics discussed during session two were mental health, caregiver support, injury prevention and oral health.

The full assessment can be found here, including demographic breakdowns, responses by county and caregiver, community leader, and expert quotes. See more tools for result breakdowns at the interactive data dashboard.

Mental Health
Across the eight-county service area, community leaders interviewed reported mental health care or counseling for behavioral/emotional concerns as the most needed health service in their community.

Nearly two in seven children (about 237,000) in our eight-county service area have at least one of the four most commonly diagnosed mental health conditions. The top two diagnosed mental health conditions were anxiety and ADD/ADHD.

Of the approximately 269,700 school-age children who needed mental health treatment or counseling, nearly half (48%) have a caregiver who had difficulty accessing needed mental health care for children. Families with an income under $50,000 in particular were more likely to report having difficulty accessing mental health treatment.

Caregiver Support
Caregivers’ challenges can contribute to adverse childhood experiences, or ACEs, which are potentially traumatic events that occur during childhood and can have lasting effects. The summit highlighted the prevalence of ACEs among children in our area and the impact those experiences may have.

About 18% of children in our service area (about 216,600) had two or more ACEs, according to the survey. The most common ACEs included having difficulty covering basic needs, like food or housing, and caregiver divorce or separation. Nearly 36% of under-resourced families reported it was hard to cover basic needs on the family’s income.

In the eight-county service area, more than half of caregivers (57%) said they are coping very well with day-to-day demands. However, that leaves about 43,100 children with caregivers who report they are not coping well.

Cook Children’s can continue to support families through the creation of parent and family community support groups and collaboration with existing programs. One particularly vulnerable population is people who have just given birth; the first 12 weeks after birth is a crucial time for caregiver support and child development. Cook Children’s can continue to support access to critical resources such as postpartum mental health support, treatment, and programs to meet the needs of families during this time.

Injury Prevention
Unintentional injuries, also known as accidental injuries, are the leading cause of death for children in the United States, according to the Centers for Disease Control and Prevention (CDC). Nearly one in five children (about 233,300) in our service area received emergency care for an accidental injury. The most common type of unintentional injury varies by age.

The most common unintentional injury for infants is suffocation, mostly due to unsafe sleep environments.

For children ages 1 to 4, drowning (fatal and nonfatal) is the most common unintentional injury. From 2021 to 2023, Cook Children’s Medical Centers in Fort Worth and Prosper treated 224 drowning-related injuries that happened in bathtubs, open water, and pools or hot tubs, according to Cook Children’s Health Care analytics. Of those, 85% were pool/hot tub related, and overall, 8% were fatal.

In 2022, firearms were the leading cause of death among children and teens ages 1 to 19 in the United States, according to the CDC. From 2021 to 2023, according to Cook Children’s analytics, Cook Children's treated 23 patients for firearm-related injuries and 44 patients for injuries related to other gun types (i.e., bb guns, airsoft guns). Of households with guns in our service area, about 1 in 5 children (about 120,300) live in a home with a gun that is not always safely locked up.

For young kids and teenagers (ages 5 to 17) the leading cause of death in the U.S. is car accidents in the United States, according to the CDC. The risk of severe injuries and deaths in car crashes can be greatly reduced when kids are correctly secured in car seats, booster seats or seat belts that are appropriate for their age and size.

Accidental poisoning is another common danger, often from medication or chemical products. The survey revealed more than half of children live in homes where cleaning products and/or medications are not locked away.

Some ways in which Cook Children’s combats accidental injuries include educating caregivers about these dangers, providing resources and prevention tools and advocating for public policy changes.

Oral Health
The last portion of session two focused on oral health.

Two out of seven children (about 328,300) in our service area do not have “excellent” or “very good” oral health. In our service area, 57% of children (about 651,000) received at least two or more preventive dental visits aligning with American Academy of Pediatric Dentistry recommendations. Community leaders said some of the obstacles families face are a lack of providers and affordability of dental care. Others may not know the importance of oral health on growth and development.

Awareness and education are our most important tools to help families with oral health care. About 62% of children (about 726,200) have a caregiver who is unaware that a child should have their first dental visit by age one.

Since children visit pediatricians more frequently than dentists, collaboration between medical and dental professionals improves overall health outcomes for children through screening and education. In the eight-county service area, nearly 2 in 3 children had a medical professional recommend regular dental checkups for preventive care, and nearly 1 in 3 children were advised to visit a dentist for a dental problem. 

Recordings and slide decks from both sessions will be available on the Center for Community Health website.

If you are interested in learning more or have questions about the data, please email CHNAFeedback@cookchildrens.org.

With nearly 30 years of experience, Dr. Fuqua has devoted herself to improving children’s oral health, spearheading community programs like Save a Smile, and bridging the gap between dental care and overall wellness. Join us on Apple Podcasts, Spotify or YouTube as we delve into Dr. Fuqua’s story—an inspiring journey of compassion, dedication, and her belief in the power of a smile.

How many times has your child told you that they brushed their teeth only to find a dry toothbrush when you inevitably go check? How many times did you tell your own parents that you brushed your teeth when you, in fact, did not? Brushing teeth might be the most lied about subject in my home. As far as I know, there has not been a research study on why children lie about brushing their teeth, but it seems to be a universal phenomenon.  Honestly, brushing your teeth is like any other good habit. It must be taught, practiced, and repeated to become a daily habit. Your children do not know or understand the long-term effects of not brushing their teeth, nor do they see an immediate reward for brushing. For all of us, not practicing good oral health has its consequences at least once every six months if you are seeing a dentist. The lack of good oral health can lead to long-term health consequences and years of dental work that can not only be painful but costly. However, children do not have the forethought to know this or the ability to understand it.

This is why it is so important to establish good oral health habits at home. Good oral health is crucial to your child’s overall health and development. As parents, the way we approach oral health in the home can help to establish life-long habits for our children. While it can be difficult and time-consuming to help your children brush their teeth daily, it is a habit that can help prevent them from having to experience difficult and traumatizing dental procedures now or later in life.

Betsy Hillyard, CCLS (Certified Child Life Specialist) and oral health program coordinator at Cook Children’s Center for Community Health has three tips to encourage parents as you establish good oral health habits at home. As parents, modeling good oral health, having realistic expectations, and having the right tools available can help to make the daily practice of oral health easier for children.

1. Model good oral health. As parents and caregivers, much of what we teach our children stems from what we do. If your children don’t see you brushing your teeth, flossing or prioritizing your own oral health, they are not likely going to want to do it. However, children are often motivated by what they see adults doing and often want to do those things simply because an adult is doing them. Allowing your young children to brush their teeth alongside you can be a great way to encourage them while also monitoring their brushing times and techniques. It is also important to start modeling from a very young age. You can start brushing even your baby’s teeth with a toothbrush (no toothpaste) to begin to get them used to it.  Modeling frequency and times will help your children be able to establish their routine. If you brush your teeth 2 times a day every day, before leaving the house and again before going to bed, your children will likely adopt this same routine. It’s important to model whatever your expectations are. This is true for any habit you are trying to teach your children. It is also encouraged that you monitor your child’s oral health routine until they are 9 years old.
2. Have realistic expectations. If oral health has always been a challenge for your family, it is important to start somewhere, and it is never too late to start implementing good oral health practices. If your child is currently not getting their teeth brushed at all during the day, start with making it a priority to get at least one time a day in and increase to 2 times a day. If your children don’t spend enough time brushing their teeth, it may be good to have them try to brush for at least 30 seconds and then adding more time as they accomplish their goals. Take time to celebrate the one time a day or the 30 seconds that your child can brush. The goal would be to work up to 2 minutes of brushing time, 2 times a day. If your child has mastered brushing their teeth, but flossing is not happening, start with a goal of flossing once or twice a week and work your way up to daily. It’s important to keep oral health a positive topic with your kids. Giving them manageable and attainable goals will help to build their confidence. Positive reinforcement is always helpful when establishing a habit. Using brushing incentive calendars is a great way to keep your expectations realistic while rewarding any goals your child accomplishes. Setting a goal like brushing ten times a week and flossing twice could mean a small prize or extra screen time at the end of the week.
3. Have the right tools available to your kids. Brushing your teeth can be much more fun if you love your toothbrush and the flavor of your toothpaste. This is a great place to allow your child to have choices. While it is important to get your child the right sized toothbrush, allowing your child to pick a toothbrush that they love with their favorite color or character can help. Also, it is important to choose a flavor of toothpaste that your child likes. I know my girls often found minty toothpaste to be way too “spicy” for them when they were younger. Just make sure that you choose a toothpaste that is approved by the ADA (American Dental Association). Finding some type of timer that works for your children is also helpful. It can be a simple sand timer or there are apps with brushing timers for kids. When encouraging flossing, I find that for myself and for my girls that flosser holders are much more user friendly than string floss. They also make flossers in fun colors. My girls get flossing done more easily and frequently with flossing holders available. Anything that can aide your child in meeting their brushing and flossing goals is a win!

As always, it can be helpful to use books and videos to help encourage your children’s oral health.

• I Care for My Teeth by Martha E. H. Rustad
• Caring for Your Teeth by Sian Smith
• Daniel Tiger’s Brushing Teeth Song by PBS

Brushing teeth and flossing are habits that help your child’s overall health for their lifetime. While it can be challenging to establish any good habit, it is important to remember that the effort and time you take to help your children will allow them to continue healthy habits into adulthood. If you run into any challenges or difficulties (i.e. thumb sucking, pacifiers, dexterity with the toothbrush, etc) with your child’s oral health, it is important to reach out to your child’s dentist as they can help you navigate this. Happy brushing!

A child’s smile holds enormous potential for fostering emotional well-being, communicating happiness and building connections with others. It can also be a powerful indicator of physical health.

“There is a clear connection between oral health and overall mental and physical health,” said Tonya K. Fuqua, DDS, director of oral health for the Center for Community Health, led by Cook Children’s. “Teeth can be very telling about what is going on in a child’s life, the socioeconomic barriers they face and underlying health issues they may have. That’s why it’s so important for the dental health of children to be as high a priority as their physical health.”

Connecting the dots between oral and physical health to improve a child’s overall wellness is the purpose of a grant awarded by the American Academy of Pediatric Dentistry (AAPD) Foundation to Cook Children’s Health Care System’s Renaissance Neighborhood Health Center and the Center for Community Health’s Save-A-Smile Program. Cook Children’s is one of only two recipients nationwide to receive the grant.

“The AAPD Foundation is dedicated to making dental care accessible to all children by supporting nonprofit clinics providing routine cleanings, advanced treatments and ongoing care that helps kids in need,” said Douglas Keck, DMD, MSHed, AAPD Foundation president, pediatric dentist, and dental director of a Federally Qualified Health Center in Florida. “Our support of Save-A-Smile and its medical dental interface initiative represents a pivotal step in bridging the gap between oral health care providers and primary health care practitioners. By working together, we aim to provide sustainable compassionate care for children in need.”

The grant supports a three-year pilot project aimed at developing best practices for bridging the gaps between pediatric medical and dental care. It makes way for a community health worker (CHW) to be embedded with Renaissance Neighborhood Health Center to educate and support families while identifying and addressing any barriers that keep them from completing care.

Cook Children’s Renaissance Neighborhood Health Center is a primary health care home for children living in southeast Fort Worth. The center has both a dental and medical clinic under one roof, making it the ideal location to conduct the pilot. Many within the center’s patient population are considered financially vulnerable and qualify for government-supported health programs such as Medicaid and Children’s Health Insurance Program (CHIP). They may also face non-medical drivers of health such as food insecurity, housing issues and adverse childhood experiences.

Making Connections

Juanita Valles is the community health worker assigned to this medical/dental integration project at Renaissance.

“Families tell me their problems and I listen,” Valles said. “Right now, everyone is struggling financially. Sometimes they need transportation to appointments, childcare, clothing, diaper assistance, car seats for the kiddos, household items or even dental care for the parents themselves. That’s where I come in.”

When a family has a need, Valles works to clear the path to make it easier for them to follow through with medical and dental care. She even goes so far as to make in-home visits with her trusty stuffed assistant, Leo the Lion, when working to educate a family and overcome barriers.

“I take Leo with me everywhere I go and use him to show kiddos how to brush their teeth the right way,” she said. “We also teach them to drink lots of water and stay away from sugary drinks.”

Children with untreated dental problems often have difficulty with pain, eating, sleeping, self-esteem, school attendance and grades. Cook Children’s 2021 Community Health Needs Assessment revealed that more than 175,000, or 1 in 7, children living in Cook Children’s eight-county service area were not able to get the dental care they needed. This rate is 9 times higher than national estimates and 5 times higher than state estimates. Stated barriers included inadequate dental insurance coverage, difficulty scheduling and lack of education and resources for dental care.

“You really relieve all barriers by addressing the social service component of why families may not get the dental care they need for their kids,” Dr. Fuqua said. “And the pediatrician’s office is the perfect place to start because children often visit their pediatricians more frequently in their first years of life than they do dentists.”

Leveling Up

Results from year one of the pilot, which began in January 2023, have already triggered system-wide change, Dr. Fuqua says. Dental screening questions were implemented across all of Cook Children’s Health Care System for well-child visits ages 0 to 3. Children in the pilot project who screen positive are connected with the community health worker. Other opportunities to scale-up and implement new solutions for year two include streamlining pilot data collection and analysis, refining criteria for patient referrals to the community health worker and examining system-wide dental screening data.

In the first 10 months of the pilot, more than 1,000 patients responded to dental screening questions during a well-child check and subsequently scheduled a dental appointment at Renaissance. Of those, 429 patients completed initial dental appointments at Renaissance. In that same time, Valles attempted or completed contact with families 247 times and provided tailored oral health instruction in person or by phone to 50 families.

“That's the beauty of this program and having a community health worker,” Dr. Fuqua said. “It's not as simple as just saying, ‘Oh, your kid needs help and here's where to go.’ These families have so many barriers and so many reasons why they haven't gotten a child to the dentist, but Juanita and this program make a way for them.”

About Cook Children's Neighborhood Clinic Renaissance

At Cook Children's Neighborhood Clinic Renaissance, we're here to help you raise a healthy child from infancy through the transition to adulthood. We offer well checks, immunizations, school and sports physicals, injury treatment, and care for both short-term illnesses and longer-lasting conditions.

If your child needs additional help, we can connect you with more than 60 Cook Children's specialty clinics. We're always ready to answer questions and share resources. Feel free to reach out. We're looking forward to your visit with us in Fort Worth. Learn more about our pediatricians, services and support here.

About Save-A-Smile – Cook Children's Center For Community Health

Save a Smile was founded in 2003 by Cook Children’s to address a gap in oral health services for underserved children. Save a Smile is an innovative, nationally recognized, collaborative program dedicated to providing restorative and preventive dental care to children from low-income families in the community through volunteer dentists. Children eligible for the program are pre-kindergarten through sixth grade at high risk for dental disease from schools pre-selected by the Save a Smile program and participating school districts.