But when you are plagued with mental illness or poor oral health—or a combination of both—it can be hard to turn a frown upside down, and that can have a profound impact on a child’s overall well-being.

“Our children don’t smile if they are hurting,” said Tonya Fuqua, DDS, director of child oral health at Cook Children’s. “If they have oral health disease and pain, or they are embarrassed by their smile, they don’t eat, or talk, or socialize, and they have trouble learning in school or being the best they can be as a kid. It’s the same with their mental health. If they are not in a good state of mind kids disconnect and aren’t the best kid they can be, and a domino effect happens.”

When people think about health, they rarely consider mental and oral health as part of the equation, but the two can be as taxing on the body as any other ailment. In Cook Children’s 2021 Community Health Needs Assessment (CHNA) survey of parents and guardians in the North Texas region, more than 180,000 children ages 0 to 17 went without needed dental care, and more than 63,000 without needed mental health care.

“People don’t realize the importance of oral and mental health to their overall health,” Dr. Fuqua said. “But dental disease is connected to heart health, and if you have cancer and are using certain medications, or you’re an asthmatic and using inhalers, that is going to impact your oral health. It’s the same with mental health. If you have to cope with one of these chronic illnesses, it’s going to impact your mental health, and poor mental health can stress other body systems and lead to other health issues.”

Oral and mental health also have a direct impact on each other. People with severe mental illness often neglect good oral hygiene practices and are 2.7 times more likely to lose their teeth, according to an article published in the Canadian Journal of Psychiatry. Add in an unhealthy coping strategy and your mouth and teeth are at even greater risk of disease.

“There is a clear connection between your emotions and how you handle stress,” said Kim Cox, a clinical therapist and manager of Cook Children’s Save a Smile program. “Sometimes kids handle stress in non-productive ways, like smoking and vaping, for example. That all affects your oral health as well.”

The risk is present in reverse, too. Poor oral health often leads to worsening mental health as people grapple with chronic pain and self-consciousness from an imperfect smile.

Add the stress of the pandemic on top of all of this and it’s easy to understand the recent decline in both mental and dental health among children. Cook Children’s has recorded a record number of suicide attempts in the past 12 months and, according to the CHNA parent survey, more than 170,000 children have had dental problems in the past 12 months. Parents identified the impact of COVID-19 as one of the top three barriers to their children getting the care they needed.

“There has been a marked increase in dental disease since the pandemic,” Dr. Fuqua said. “There is no surprise that when kids are stressed, disconnected or depressed, they eat. This leads to bad habits that can result in increased cavities. Also, when kids are off their routine, like during the pandemic, things go by the wayside, such as brushing and good oral health habits. Then, when kids get lots of cavities, they will not smile or even talk as much because they are embarrassed by the way their teeth look. This is a huge social inconvenience and causes kids to be even more distant and traumatized emotionally.”

Connecting the Dots

More often than not, mental illness and dental disease are treated in a silo. There is little recognition of their ties to and impact on other health issues and body systems, and little coordination between specialties in their treatment, according to Cox.

“If you have heart disease and go see a cardiologist, just because you are going to see a specialist for a specific issue doesn’t mean that part of your body is disconnected from other parts of your body and its function,” Cox said. “But for some reason, oral and mental health are seen that way. Dentists and therapists are seen as treating systems completely disconnected from a person’s overall physical health.”

Both share a similar stigma, too. Embarrassment leads many to suffer in silence.

“I call it the silent epidemic,” Dr. Fuqua said. “Nobody talks about mental health because there’s a stigma attached to it. Nobody wants to admit their child is going through a difficult time or kids don’t speak up about it. We see the same in dentistry. Many are embarrassed to admit they have issues with their teeth.”

A lack of insurance keeps many from getting the dental and mental health care they need, according to the CHNA parent survey. Insurance companies don’t cover services for mental and oral health as robustly as they do for other issues, making treatment unaffordable for many families. Dental insurance, for example, usually provides a capped maximum payout for treatment per year, but many dental procedures and treatments cost well above the typical yearly maximum.

The first step to breaking these shared barriers is for physicians and parents to talk about oral and mental health as much as they talk about diabetes, obesity, asthma, nutrition, childhood vaccinations and viruses.

“We need all of us—dentists, pediatricians and parents—talking about mental and oral health and looking at kids as a whole,” Dr. Fuqua said. “We need to always be in tune and watching for signs and symptoms. Doctors can take a quick look at a child’s teeth at their well-child check and ask them if they are seeing a dentist. Parents can talk to their kids about how their mind and mouth are feeling, and help them understand that their mental and oral health and hygiene are as important as any other part of their body.”

After all, a healthy mouth and mind help make a healthy body, not to mention a big, beautiful and bright smile.

Cook Children’s Medical Center has something to smile about these days.

Despite the toll of a lengthy pandemic, the hospital system hit two milestones since the inception of its Save a Smile program—it reached a 100,000-oral-screenings mark at the end of the 2020-21 school year in August, as well as tallied more than $10 million in value dentistry completed by private practice dentists who volunteered their services.

“It’s huge! I’m so proud we hit these milestones in such a difficult year,” says Tonya Fuqua, DDS, director of Child Oral Health at Cook Children’s. “And then to know that we were the only ones who went the extra mile to make things really happen (in oral screenings) and we didn’t give up.”

Instead of shutting down during the pandemic, the team suited up in personal protective equipment (PPE), created new safety protocol and procedures with the help of Cook Children’s infectious disease specialists, and took every precaution to safely enter schools, conduct screenings and treat children in need of oral health care.

“We were going to be at dental screenings where kids’ mouths would be open, so all of a sudden, it was like, ‘We have to rethink how we do this and do it safely,’” Dr. Fuqua says.

Other similar programs within the state paused operations during the pandemic, Dr. Fuqua says, but Save a Smile was boosted by “the generosity and quick thinking of a lot of people within our system,” including Cook Children’s leadership, infectious disease team, Children’s Oral Health Coalition, The Center for Children’s Health and legal department. The program also received funding for two new vans, which allowed the Save a Smile community health workers to offer free and safe transport for patients (and their accompanying parents) to dentists’ offices when needed for treatment.

“It took all of us together to make this happen…knowing we were going to do this effectively and safely for all—not just for our team, but for the kids and families and the schools’ staff, as well,” Dr. Fuqua says.

And our volunteer dentists didn’t say no either, she says. About 100 area dentists participate in Save a Smile, including Dr. Fuqua, who is in private practice while overseeing the program on a part-time basis.

“The dentists could have said, ‘It’s too scary out there right now…we’re not going into schools. Or my practice was impacted, and I’m not going to do free dentistry.’ But they didn’t do that. They didn’t tell us no,” Dr. Fuqua says. “I’ve always thought, ‘Wow. These dentists already do so much’—but to do it through a pandemic? It just makes me that much more proud to know they really feel there’s a need and that our program is worthy. That the kids are deserving of the treatment.”

The school-based, grassroots program has been part of the Promise that’s guided Cook Children’s Medical Center’s efforts to connect children in our communities with the care they need, says Chris Pedigo, senior vice president for System Planning, Health Analytics and The Center for Children’s Health.

“We’re beyond proud of the work Save a Smile has done in addressing the oral health of our children, especially during challenging times,” Pedigo says. “It’s fulfilling our Promise to the families we serve, and it’s what sets Cook Children’s apart.”

Save a Smile, which began in 2003, targets 21 elementary schools that are Title I schools (where at least 80% of the student body receive free and reduced-cost lunches) in Tarrant County. The schools are in Fort Worth, HEB and Keller school districts, respectively. Throughout the school year, the program’s team screens students to determine the level of urgency for immediate and potential oral health needs.

The program’s community health workers also help families determine if they are eligible for oral health care under Medicaid or CHIP coverage and get them connected to an appropriate provider. Students’ families who may not be eligible for those programs—but still can’t afford the cost of oral health care—are helped through Save a Smile.

The coordinated care and social service component of the program is the key element, Dr. Fuqua says, to ensuring children receive the dental care they most desperately need to be happy, healthy and productive in school.