Photos of decaying baby teeth will greet New York subway riders each time they climb on the train over the next few months. The arresting images are part of the New York Department of Health’s campaign to improve oral health in children by educating their parents.

The campaign, which promotes brushing teeth and limiting sugary drinks, seeks to address a larger unresolved policy issue that the United States has been struggling with for several years: how to provide affordable dental care to its citizens. New York’s Department of Health (DOH) takes a preventive approach by focusing on children, but their project begs the question of what will happen to the oral health of these kids in the upcoming years. Even if citizens develop good dental habits when they’re young, long-term oral health depends on regular visits to the dentist. Unfortunately, the dentist’s office is a luxury not easily accessible for the underserved New Yorkers who are the primary target group of the ads.

Just a quick look at the subway posters shows that the DOH is well aware of this lack of access. Only a few designs actually suggest visiting the dentist; most posters focus instead on what parents can do at home.

Dr. Amanda Parsons, deputy commissioner at the Department of Health, says that leaving dentists out of the campaign was intentional. “Telling someone to go see a dentist when they don’t have easy access can be disempowering,” she explains. Although the American Dental Association suggests that children visit a dentist when their first tooth comes in, the DOH knows that this is unlikely to happen in families where money is tight. Parsons emphasizes that the ideal outcome of the campaign is to educate parents so that their children’s mouths are as healthy as possible, whether or not they see a dentist.

First bite was a survey

In New York, as in most states, the correlation between socioeconomic status and healthy teeth is striking. Poor children and adults receive significantly fewer dental services than the population as a whole, and over time, lack of access to dental care can affect more than just teeth. According to the CDC’s website, untreated gum disease is linked to chronic illnesses such as diabetes and stroke, both of which, like oral health issues, disproportionally affect poorer communities.

Before unrolling this poster campaign, the DOH knew very little about dental health risk factors for kids living in the city. In order to learn more, Parsons says that the DOH surveyed parents of kids who attend city-run daycare centers. The surveys asked questions like: how many baby bottles does your child have between meals? Has your child had cavities? Do you help your children brush their teeth? The city collected 2,500 replies – information that served as the basis for designing the posters that New Yorkers now see in subway cars throughout the city.

Parsons has made it her goal to revive the DOH’s oral health bureau, which was shut down a few years ago due to lack of funding. For now, the DOH can’t always count on resources for dental-related programs, and Parsons says the timing of this campaign was dependent on the availability of money to pay for it. The DOH used leftover funds from last year’s budget in addition to a large grant from DentaQuest: a private foundation headquartered in Massachusetts.

DentaQuest is an organization with three major components: the business, which administers Medicaid and children’s Medicaid dental benefits for 27 states; the foundation (funded by the business) which provides $13 million in grants every year to projects that aim to improve oral health; and the institute, which runs a dental clinic for low-income patients in Westborough, a town in central Massachusetts.

Patrick Finnerty is a senior advisor to the DentaQuest foundation; before joining DentaQuest, he ran Virginia’s Medicaid program for eight years. According to Finnerty, the DentaQuest foundation seeks to fund organizations with big-picture ideas. “We saw this campaign as a way to improve oral health literacy,” says Finnerty. He adds that DentaQuest chooses projects based on potential impact. The foundation asks itself, “rather than just putting a new chair in the dental office, can we provide grants that change the system?”

Finnerty was attracted to the DOH proposal because of its ability to educate millions of people quickly. “The things that [the campaign] mentions are the things that people don’t really understand,” Finnerty explains. He quoted one startling fact that is printed on posters: cavities are a bacterial infection, and can be passed from parent to child. “Even if they don’t do it, people know that going to the dentist is good,” says Finnerty. “But few people know that they can transmit their own cavities to their baby.”

Dr. Victor Badner, chairman of the dental department at Jacobi Medical Center, says dentists aren’t sure whether campaigns like this one actually make a difference in how people care for their teeth; studies done on the topic are inconclusive. But “it’s sort of like chicken soup,” he said. “Couldn’t hurt.”

Teeth vs. test prep

The DOH plans to publicize the campaign in news outlets like “AM New York” and “Metro,” free newspapers that are distributed to subway riders every morning. The DOH also hopes to work with Scholastic, a publisher that distributes educational magazines to classrooms. Parsons mentioned that coloring sections in Scholastic magazine could depict teeth and toothbrushes rather than zoo animals: an easy way to remind kids of the importance of good oral health.

The DOH also hopes to reach out to the schools themselves. According to a paper published in 2011 by the American Journal of Public Health, children with poor oral health were nearly three times more likely to miss school because of tooth pain than their healthier counterparts.

Even more significant? Absences caused by mouth pain were associated with poorer school performance, but absences for routine dental care were not. In the DOH’s own survey of daycares, most kids hadn’t yet visited the dentist – but of those that did, 20 percent arrived with cavities.

Despite the striking statistics, Parsons has encountered resistance from public schools. Every minute taken away from test prep is precious to teachers, says Parsons; this in the face of numbers suggesting that hundreds of classroom minutes are lost every week because of poor oral health.

Will wider access spur broader use?

While the DOH posters were being installed in subway cars, a dental office in midtown Manhattan sent out a press release announcing a discounted price for its tooth-whitening club: $400 for a year instead of $4000, highlighting the gulf between those who can think about dental aesthetics and those who cannot even afford a cleaning.

New York State hopes to shrink this disparity. In early April, Governor Cuomo mandated that Medicaid include adult dental services as part of the upcoming state health exchange: a significant victory in the fight for teeth and gums to be recognized as part of a healthy body. Currently, Medicaid only covers limited services such as cleanings and x-rays, and Medicare may not even get you a filling.

Cuomo’s statute is an important step in making dental care more accessible for New Yorkers. But having insurance coverage is not a guarantee that patients will actually receive dental care. In New York, Children’s Medicaid and Child Health Plus both cover dentist visits for kids, and have for years. Yet in 2009, only about 35 percent of children enrolled in Medicaid received dental services. And a 2011 study published in Pediatrics found that dentists, including those participating in Medicaid, were less likely to treat a child needing urgent dental care if the child had public insurance.

Thanks to Cuomo’s mandate and the Affordable Care Act’s requirement to provide coverage to children who weren’t previously insured, millions more patients in New York alone will have dental insurance when the health exchange begins in October. Theoretically, these patients should then be able to address dental issues without paying out of pocket or visiting an emergency room.

But will this translate into more New Yorkers actually accessing care? Much of our current policy still reflects the notion that the mouth and teeth are somehow separate from the body when it comes to medical coverage, and Badner explains that changing this attitude will take time.

"We just don't know," he says.