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How a Twin Cities partnership is tackling serious dental issues among refugee and immigrant children

For those involved, the Medical Dental Integration Program has put a spotlight on what they see as major gaps in care for some of Minnesota’s newest residents.

Hygienist Kate Iverson talking to a parent about oral health during a dental exam at Roselawn Clinic.
Hygienist Kate Iverson talking to a parent about oral health during a dental exam at Roselawn Clinic.
Photo by Genna Souffle/M Health Fairview

It was happening way too often.

Doctors at M Health Fairview Roselawn Clinic, a family- medicine practice on St. Paul’s East Side, were seeing a number of young children who had been scheduled for surgery to treat their severe dental issues. 

Dr. James Letts, a longtime Roselawn physician, found this trend troubling.

“My partners and I all work with a lot of immigrant and refugee families, specifically a lot of Karen and Hmong families,” Letts explained. “I was seeing pediatric patients for pre-op exams for full dental restoration. These are in-patient dental procedures in hospitals under general anesthesia. It’s a big deal.” 

Children with multiple cavities, tooth abscesses or infections are sometimes sedated so that all of their needed dental procedures can be performed at once. If this was happening rarely, it wouldn’t be a problem, Letts said, but the frequency of these pre-op appointments was a red flag. “It was not just one or two kids,” he said. “It was one kid after another.” 

The children coming in for these exams were experiencing serious pain that impacted their overall health, Letts said. “It was pretty dramatic. So many of their teeth were decayed. Some were black and almost worn away. We were troubled to be seeing kids in our clinic for something that is 100 percent preventable.”

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Letts and his colleagues understood that, for many of their patients, childhood dental care is often at the bottom of their long to-do lists. Building a life in a new country can be overwhelming, and families often struggled just to make it to the doctor for their children’s well-child visits. Figuring out how to see a dentist — let alone afford to pay for an appointment — felt like too much, so many young children in his practice had never had their teeth examined, Letts said.  

James Letts
James Letts
These children’s painful teeth were, “a combination of complete lack of dental services and poor understanding on the part of these refugee families,” said Letts. “They have enough stuff on their plates. Dental care wasn’t on their radar. And they hadn’t had any access to dental care in the refugee camps.”  

Letts and his colleagues believed something had to be done, so they set out to make that happen. Roselawn Clinic is part of a community organization called the East Side Health and Well-Being Collaborative. It was during one of the group’s meetings that clinic staff began a conversation with representatives from Community Dental Care, one of Minnesota’s largest nonprofit dental practices.  

“We started chatting on the side,” Letts recalled, “and we said we were seeing a need for dental care with children in our practice.” Because Roselawn clinic has Karen- and Hmong-speaking  staff who could translate for their non-English-speaking patients, Letts invited Community Dental Care to come to Roselawn for special in-clinic dental visits tied to well-child exams. 

“The Community Dental Care team is very community-focused,” Letts said. “They were a logical partner for us to work with.”

The partnership soon became known as the Medical Dental Integration Program

Community Dental Care staff was enthusiastically on board with the idea of  bringing dental care to the place where patients felt the most comfortable, said Crystal Yang, Community Dental Care director of development. “By having us on-site, patients are already in a trusted environment. Because of that, they soon come to think of Community Dental Care as a trusted dental provider. It’s a win-win situation for everyone involved.” 

Bringing dental care to patients

When the Medical Dental Integration Program launched in 2017, Community Dental Care first sent a dentist to see young patients during their checkups at Roselawn Clinic. But it soon became clear that sending a dentist wasn’t necessary, that what these young patients and their parents really needed most was a welcoming, information-filled visit with a collaborative dental hygienist, a dental professional who, under remote supervision of a dentist, can operate independently in communities with limited access to dental care. 

Kate Iverson is the Community Dental Care hygienist who runs the Medical Dental Integration Program at Roselawn Clinic. She’s been a hygienist for decades, spending nearly 30 years working in a suburban private dental practice before turning to nonprofit dentistry. 

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“Kate Iverson is this program,” said Karen Flanagan Kleinhans, Community Dental Care CEO. “She is amazing. We are so lucky to have her.”  

Iverson, Kleinhans explained, is a Community Dental Care employee. “Our dental director oversees her. She goes to Roselawn Clinic by herself, sets up her mobile equipment.” Because Iverson sees Roselawn patients four times a month, Kleinhans said, “Patients know her and trust her. It is a great partnership.” 

Karen Flanagan Kleinhans
Karen Flanagan Kleinhans
When she worked in a private dental practice, in “really affluent” North Oaks, Iverson said she got used to seeing patients whose financial means and easy access to care meant that they had few dental issues. “Nobody had a lot of decay there,” she said. When Iverson moved into her job at Community Dental Care, she discovered that, unlike what she’d seen in North Oaks, many people still struggle to care for their teeth. 

“I started to see all the need,” Iverson said. “I was shocked. Little children, really small children, had oodles and oodles of decay. That got me really motivated to try and make a change or make a difference.” 

One way that Iverson tries to make a difference is by connecting young patients and their families with affordable dental care. A good example of this, Yang said, is an encounter that Iverson had with a five-year-old Hmong girl she met during a dental clinic at Roselawn.  

“Kate realized that when this girl opened her mouth her two back molars were just shells,” Yang said. “She had cavities that had eaten away all of the enamel in those teeth.” This kind of decay causes significant pain, she explained. “I can’t imagine how that child could eat or sleep or focus in school.”

Crystal Yang
Crystal Yang
The girl’s mother said that she’d taken her daughter to the dentist but was told that it would cost $4,000 to restore her teeth, Yang said. “The mom decided to just wait because she thought the teeth would eventually fall out and it wouldn’t be a big deal.” But decay, even in baby teeth, is, Yang said, “really a huge deal. It could become an abscess and that could be deadly because the infection could be that serious.” With Iverson’s intervention, Community Dental Care was able to secure an appointment for the girl at their clinic.

“We were able to provide care at a reduced cost,” said Iverson.   

Iverson said that she thinks the Medical Dental Integration partnership is particularly helpful because it is an opportunity to work with young children and their families. The earlier a family is introduced to dental care, the better. 

“Partnering with a primary care clinic is a way to get to young families and even hopefully to pregnant moms,” Iverson said. “We are trying to address some of the issues we were seeing developing in really young children. If we see kids really early we’re seeing them before they have significant problems.” 

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With her youngest patients, Iverson does what she calls a “lap exam.” “We sit knee to knee with the parent,” she explained. “The parent lays the infant back into my lap. They are holding the child, looking at them and talking to them. That way I can get in there and look into their mouth and sing to them and distract them. The parent can also look into their child’s mouth and see their teeth.” 

Because many of her patients’ parents have limited history of dental care themselves, Iverson decided to create a book designed to educate adults about how to care for their children’s teeth. The book, produced by M Health Fairview, is titled “I’ve Got Teeth.” 

“I’ve Got Teeth” is written in English, Karen and Spanish. It is given to new parents at an early well-baby checkup.

“It is written in the form of a letter,” Iverson explained. “It is from a little child to their parents, asking them to take care of their teeth.” The book, she added, “tells parents a few basic things about oral care and explains how baby teeth are important and how to take care of them.”

"I've Got Teeth" is a multilingual book Kate Iverson wrote for parents about the importance of dental care for children.
Photo by Genna Souffle/M Health Fairview
"I've Got Teeth" is a multilingual book Kate Iverson wrote for parents about the importance of dental care for children.
Iverson’s visits to Roselawn started out small, with just a few dozen children treated in 2017.  In 2021, she saw 226 young patients ranging from just a few months to 17 years old. More than half of her patients had never seen a dentist before. About 36 percent had obvious, untreated decay. 

Numbers like these help Iverson feel that she is making a difference.

“In a lot of cases I feel like having a visit with me really gets families over a hump, gives them an opportunity to take control of their child’s health,” said the hygienist. 

She’s heard many parents say that they didn’t understand that decay in baby teeth can cause lasting damage in permanent teeth. She feels lucky to have the opportunity to explain how parents can help prevent oral health issues for the rest of their children’s lives. “It is one more step in moving them toward overall health,” she said.

Access for everyone 

For Letts and his colleagues at Roselawn Clinic, the Medical Dental Integration Program has put a spotlight on what they see as major gaps in care for some of Minnesota’s newest residents. After witnessing the success of the program at Roselawn, Letts said clinic staff was inspired to apply for grant funding to expand the program to other clinics. There are pretty deep inequities in healthcare and dental care in Minnesota,” Letts said. ‘This has been a way to start chipping away at some of those inequities.”  

Kleinhans said that Community Dental Care is committed to filling care gaps for low-income or uninsured individuals, though many of the gaps still remain.

“There is uneven access to dental care for people who are uninsured. Private dentists are expensive. We provide affordable, accessible oral-health care for people in need, particularly people in poverty,” said Kleinhans. “We do a lot of preventative care. It is the most effective way to prevent disease.” 

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In their four free-standing Minnesota clinics (a fifth is under construction in Buffalo), Kleinhans said Community Dental Care strives to create treatment spaces that make room for everyone, despite their financial situation, ethnic background or immigration status. 

“Our vision is that everyone will have access to high-quality, affordable dental care in a convenient and responsive environment,” Kleinhans  said.

Community Dental Care is the largest Medicaid dental provider in the state, providing care through 110,000 patient visits a year. 

Letts said one of the greatest strengths of the Medical Dental Integration Program is the educational approach Iverson takes with her patients and their parents. While he’s frustrated with state’s “pretty lousy” Medicaid reimbursement for dental care, he’s hoping that recent rate increases, combined with the success of the Integration Program’s approach, will be able to improve the dental health of more young Minnesotans. 

“We’re now serving hundreds of kids in this program per year,” Letts said. “ I’m seeing that my patients have much better access to dental care.” He reports seeing better oral health in many of his young patients, which he believes will lead to better health overall. 

“I think oral health problems are an underrecognized chronic disease in children with huge implications that people don’t think about, including school performance and malnutrition,” Letts said. “Anyone who’s ever had oral pain sees what a big a deal it is. Programs like this one tackle this problem head-on.”