One basic direction Dr. Mahasti Chalajour gave dental assistant Miriam Montelongo from the start: "You never show a reaction." When a child comes to them for the first time, no matter how many rotting teeth, no matter what his or her breath smells like, no matter how terrible the damage that neglect, bad nutrition or ignorance caused -- you don't gasp, you don't exclaim, you don't look stricken.
Instead they smile. They thank the child for coming and they set to their task, trying to salvage whatever they can, trying to work as painlessly as possible. Because they know in most cases, it's pain that's brought the child in and they try not to add to that.
Their base of operations is an impressively large painted van, a little old, a little weathered, driven by the doctor herself and funded by the Memorial Hermann Hospital System. They are one of three vans that go to certain Houston-area schools -- generally the poorest of the poorest -- in places where uninsured and underinsured families live. The Affordable Care Act doesn't cover dentistry, and even families who qualify for other insurance help often forgo visits to the dentist as a something extra that can't fit in their budgets.
Even if they know treatment is needed.
Last October, a 15-year-old girl arrived at their Lamar clinic on the last day the van was due to be at that site before rotating to their next assignment. The girl complained of pain on the lower left and right sides of her mouth, and her mother told them that as long as she could remember, the teen had toothaches, pain that had spread to her ears and head. They had even gone to a dentist two years before, but did not proceed with treatment after the diagnosis because they couldn't afford it. So she had just lived with it.
The girl's mouth was in terrible condition. Even though Chalajour says she makes it her mission to save as many teeth as possible, she decided she had to extract two teeth immediately to alleviate the pain. The van was scheduled to return to the Lamar clinic in three months, and the girl's mother made the first available appointment to take care of the rest of the teen's needs. On January 15, the girl returned alone -- her mother could not get off work -- and, Chalajour says, "We filled 11 teeth," three of which had very deep cavities.
Eleven-year-old Thomas Toledo is a four-year veteran of the van. He's come to the February location of the van -- outside B.F. Terry High School in Rosenberg -- with his mom for a checkup and there's smiles all round. The van is parked outside the school. When he first saw Chalajour in April 2011, he was about seven years old and matched that with seven cavities. Five were on his baby teeth and two were on permanent teeth. "We put two -stainless-steel crowns on the baby teeth, and we did little baby root canals. The two permanent teeth, one of them the decay was so big it looked like an extraction. But I didn't. I treated it. I put it on watch. It has healed." Chalajour checks it every revisit.
A chart on the Texas Department of State Health Services website using figures from the Texas Board of Dental Examiners shows that in September 2014, there were 9,827 general dentists (not specialists) in Texas. Using a population figure of 27, 161,942 for the state, that means there are 36 dentists for every 100,000 people in this state, showing some counties with no dentists (Kennedy and Presidio, to name a couple) ranging to a high of 1,945 general dentists in Harris County. Fort Bend County has 284 dentists.
So it's not hard to figure out how more than a few people are getting missed.
Efigenia Toledo, a small, smiling woman, is here with her son. She had taken her children to a dentist before Dr. Chalajour, but as Thomas says, "The other doctor charged a lot." When she was told about the Memorial van, she brought in Thomas and his older brother. "It would hurt when I would chew gum. I wouldn't eat on a certain molar because it hurt," says Thomas.
"Enamel is the hardest tissue in the body," Chalajour says, but when that outer layer is breached by cavities, it exposes nerves in the mouth to direct contact with whatever someone eats or drinks.
The No. 1 childhood disease isn't leukemia or allergies or even asthma. It's dental disease, according to the National Children's Oral Health Foundation. It is preventable. It is correctable. But not, of course, if the kid never sees a dentist.
Dr. Mahasti Chalajour says she always wanted to be a dentist. The graduate of the University of Texas School of Dentistry in Houston explains: "It was just like an art. You can create something beautiful. Make it better." She worked in public health before, but prefers the past four years with Memorial Hermann seeing pre-K through twelfth grade patients because she reaches children at a younger age, is able to continue with them over time, and as a result is able to achieve more.
In her present job, besides the scheduling, the dental treatment and the driving she and Montelongo do, she is a constant educator for both children and their parents. It does no good to fix a mouth and have all that work undone by continued bad habits.
Chalajour is also something of a detective. In another case at the Burbank clinic, she was treating a four-year-old pre-K student accompanied by her mother and a younger sister. "As soon as they entered the mobile van, I noticed that the sibling was drinking from a bottle full of milk. I informed the dental assistant that we need to ask the mother the child's age."
The older sister's mouth was filled with decay, Chalajour says, and they gave a quick look at the younger sister, whose mouth was also filled with cavities. The mom told them she had kept all her children on the bottle until about the age of three. Chalajour told her she needed to stop doing that, explaining she was doing far more harm than good.
Deborah Ganelin, director of Memorial Hermann's Community Benefit Corporation, says the hospital system started its Health Centers for Schools program in 1995 and now has agreements with a number of schools in the area (four in the Houston Independent School district, two in Pasadena ISD, two in Lamar Consolidated and one each in Alief and Aldine ISDs). The program, which provides mental health as well as physical health services and includes a Class D pharmacy, bills only for eligible services for Medicaid-enrolled patients, but the dental program serves just the uninsured. The dental vans started in 2000 in response to parents' requests, she says.
The premise is that if health care is brought to the students, they'll be in school more and be more successful while they are there, Ganelin says. Parents are encouraged to accompany their children but don't have to take off work for their children's appointments; a school van shuttles them between clinic and school if needed. Family visits to the ER drop. Clinic services cover mental as well as physical health needs. Three dental vans rotate among the schools.
In a 2012 report, Memorial said that "57.9 percent of the children served at the [then six] clinics do not have any type of health-care coverage. The remaining 42.1 percent are children who will not obtain health care due to transportation issues, parents with low hourly wages who need to balance a day of pay with a visit to a health clinic, high private insurance deductibles or simply lack of parental involvement."
Also in that report, Memorial stated that 80 percent of the children it saw for the first time at the dental vans had cavities, and 33 percent of them had five or more cavities.
Besides pain, the other main factor that drives kids to come in to see Dr. Chalajour is appearance, especially among teenagers.
Sometimes it's too much fluoride in the water -- a common situation in Mexico -- that has broken down the enamel in the children's teeth, she says. Or baby-bottle decay. Or just not brushing and too many sweets, which leads to bacteria buildup in the mouth and to decay.
"We had a brother and sister, teenagers who just came from Mexico. They had too much fluoride in their drinking water. Their front teeth were all black and brown. The young lady was hiding her face behind her father's shoulder; she wouldn't talk. She had 17 cavities."
One thing that Chalajour has learned in such cases is that she waits on any cosmetic bonding work. "I always leave the bonding till the end because I want them to come back. If I do the bonding first, they won't come back because their front teeth are fixed. So that is always the last." In like manner, if a student has a lot of cavities, Chalajour starts with the worst ones, but generally saves the front teeth for last. "I know for that, they will come. They will not miss their appointment."
Chalajour and Montelongo work very hard to quiet the fears of the youngest children, telling them ahead of time what they are doing and offering them the chance to run the suction tube themselves. "It helps if they have older brothers or sisters with them," Montelongo says.
The two have an easy rapport and a lot of war stories. One of Montelongo's favorites is retold by Chalajour. "There was a 16-year-old young man here. He had fluorosis, a lot of decay on his black and brown teeth. When he came in, I asked him to give me a big smile and he told me, 'I don't know how to smile.' I told him, 'Look, I'm here to help you. If I don't see it, I can't help." When she was done with all his treatment, she gave him a handheld mirror "and he cried."
Chalajour attributes most of the situation to a lack of education. "Most of our children we see are immigrants. One of the parents told me, 'I thought if I just provide them food, that's enough, food and clothes.' If their parents had dentures, then it's okay for their children to have dentures."
"We do educate both parents and children. We bring them back every three to six months. A large part of that education is to get across that dental care is essential, not an extra," she says.
Chalajour is one of those bright, cheery people exuding warmth that fools you sometimes when she reels off facts. Ask her why it matters if dental disease goes untreated, and she rapid-fire tracks through the consequences:
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"The pain radiates to the ear. And inflammation of the nerve in the mouth affects the sinus. So they always have headaches and earaches. The worse infection is here on the upper lip, the sinus. If it goes to the brain, you get an infection of the brain and then you die."
And then you die.
Here's some more facts. The National Children's Oral Health Foundation says 52 percent of new military recruits have oral health problems needing such urgent attention that they can't be deployed overseas till the problems are fixed. An estimated 17 million children go without dental care each year. "More than 51 million school hours are lost each year due to dental disease, leading to increased educational disparities."
Put that way, dental care doesn't seem like an extra. The lack of it only contributes to our socioeconomic divides. Later on in life, dental disease links to -- among other things -- heart disease, stroke, diabetes and pneumonia. For kids it means a life with physical pain and public embarrassment. Seems like that alone should be a call to do something better. The Memorial Hermann community outreach is to be commended. But maybe they could use a little help.