Oral Health of Kindergarten and Third Grade Children with Special Education Needs in Los Angeles County

ABSTRACT

Background

Little is known about the oral health of children with a special education need (SEN). The purpose of this report is to compare the prevalence of decay experience and untreated decay among children with and without an SEN to determine if children with an SEN are at increased risk of caries.

Methods

Kindergarten and third grade children in a representative sample of 72 public elementary schools in Los Angeles County received an oral health screening that collected information on the number of teeth with treated and untreated decay. Child-specific information on race/ethnicity, socioeconomic status, primary language and special education status was obtained from the California Department of Education.

Results

Data is available for 10,392 children. Overall, 11.0% had an SEN. Third graders (13.6%) and males (15.2%) were more likely than kindergartners (9.6%) and females (7.5%) to have an SEN. Asian Americans (6.3%) and children from households with a primary language other than English or Spanish (5.1%) were the least likely to have an SEN. Children with an SEN had a slightly higher prevalence of decay experience compared to children without an SEN (57.6% versus 54.6%) but the difference was not statistically significant (p > 0.05). There were no statistically significant differences in the prevalence of untreated decay (19.6% versus 19.7%) or the mean number of teeth with decay experience (2.7 versus 2.6).

Conclusion

In Los Angeles County, kindergarten and third grade children with an SEN, compared to those without an SEN, are not at increased risk of developing dental caries.

KEYWORDS:

• Special education
• dental caries
• oral health survey

Prior to the mid-1970s, public schools in the United States educated only one in five children with disabilities, and many states had laws excluding certain students, including children who were deaf, blind, emotionally disturbed or had an intellectual disability.¹ A series of federal court decisions between 1971–1973, however, made it clear that schools owed students the equal protection of the law without discrimination based on disability.² Once the courts made clear the states’ responsibility for providing a free, appropriate, public education to all children, regardless of disability, states joined advocates in seeking the passage of federal legislation to provide federal leadership and subsidies for the cost of special education.² Congress responded by passing legislation addressing nondiscrimination, through the Rehabilitation Act, and an educational grant program, through the Education for All Handicapped Children Act. The 1973 Rehabilitation Act, Public Law 93–112, provided that any recipient of federal financial assistance, including state and local education agencies, must end discrimination in the offering of services to persons with disabilities. Signed into law in 1975 (Public Law 94–142), the Education for All Handicapped Children Act (EHA), required that all students with disabilities receive a free, appropriate public education and provided a funding mechanism to help with the excess costs of offering such programs.² The EHA name changed to the Individuals with Disabilities Education Act (IDEA) in a 1990 reauthorization.

IDEA considers a child to have a special education need (SEN) if they have an intellectual disability, a hearing impairment, a speech or language impairment, a visual impairment, a serious emotional disturbance, an orthopedic impairment, autism, traumatic brain injury, another health impairment, a specific learning disability such as dyslexia or multiple disabilities.³ Section 504 of the Rehabilitation Act provides certain rights to students with any condition that affects one or more major life activities, including walking, seeing, breathing and concentrating.⁴ Qualifying conditions range from disabilities that also qualify students for special education, such as autism, to conditions that do not typically qualify students for special education, such as diabetes or severe allergies. Students with qualifying conditions are entitled to a 504 plan that specifies how schools will accommodate their medical needs.

Approximately 13% of California public school students have an SEN.⁵ Compared to other California students, students with an SEN are disproportionately low income.⁶ The majority of students with disabilities have relatively mild conditions such as specific learning disorders (e.g., dyslexia, 38%) or speech/language impairments (21%).⁷ The number of students with relatively severe disabilities, however, has been increasing. The most notable rise is in autism, which affected 1 in 600 students in 1997–1998 compared to 1 in 50 students in 2017–2018.⁶ About 57% of children with an SEN are taught in a mainstream classroom, 20% are taught in special day classrooms alongside other students with disabilities, 20% split their time between mainstream and special day classrooms and about 3% of students with disabilities are educated in separate schools exclusively serving students with disabilities.⁶

Students with disabilities, on average, have less favorable academic outcomes than students without disabilities. In 2017–2018, the average test score on state reading and math assessments for SEN children was at the 18th percentile of all test takers, notably below that of low-income students and English learners. Students with disabilities also have a lower four-year graduation rate than other student groups; a suspension rate that is almost double the statewide average; and a relatively high rate of chronic absenteeism, with almost 1 in 5 students with disabilities missing 10% or more of the school year.⁶

Information on the oral health status of a representative sample of children with an SEN is limited. While several studies have assessed the oral health of SEN subgroups, such as convenience samples of children with Down’s Syndrome or children with autism, only two published studies compared the oral health of children with and without an SEN using a community-based sample that was representative of the population of interest. The California Smile Survey, which compared the oral health of children with and without an SEN among a representative sample of California’s third grade children, found that children with an SEN were not at increased risk of decay.⁸ A recent Scottish study, which used national health and education databases to link SEN status to oral health status, was able to assess the relationship between SEN and oral health at a more granular level.⁹ Scotland’s education database includes four SEN classifications: (1) intellectual disability, (2) autism spectrum disorder, (3) social SEN such as English as a second language, communication support needs, substance misuse or family issues and (4) other SEN including dyslexia, other specific learning difficulty, visual impairment, hearing impairment, physical or motor impairment, language or speech disorder, physical health problem or mental health problem. This study found that children with any SEN had higher rates of caries experience than those with no SEN; however, after adjustment for socioeconomic status, sex, year and school type, only those with a social or other SEN remained at increased risk.⁹

The purpose of this report is to use data from the Los Angeles County Smile Survey (LACSS), an oral health assessment of kindergarten and third grade children, to evaluate and compare the oral health status of public school children with an SEN and/or a 504 plan to children without an SEN/504 plan. This will provide information on whether Los Angeles County children with an SEN are a vulnerable population that should be targeted for public health interventions.

Methods

The LACSS screened kindergarten and third grade children at a representative sample of public elementary schools in Los Angeles County (LA County). The sampling frame included all nonvirtual public and public charter schools with at least 25 children in third grade. Forty-three percent of LA County’s kindergarten and third grade children attend schools within the Los Angeles Unified School District (LAUSD). Because of this, the sampling frame was ordered by LAUSD (no/yes), then by geographic location (LA County service planning area) and, finally, by percentage of students eligible for the National School Lunch Program (NSLP). To be eligible for the NSLP, a child must live in a household with an annual income at or below 185% of the federal poverty level.¹⁰ A systematic probability proportional to size (PPS) sampling scheme, as recommended by the Association of State and Territorial Dental Directors,¹¹ was used to select 70 schools with third grade. Of the selected schools, two did not have kindergarten students, so the appropriate kindergarten feeder schools were added to the sample, resulting in 72 schools representing 70 sampling intervals. The selected schools included 33 schools (31 sampling intervals) in LAUSD and 39 schools (39 sampling intervals) in districts other than LAUSD. If a school declined to participate, a replacement school from the same sampling interval was randomly selected. A systematic sampling process with implicit stratification by school district (LAUSD versus non-LAUSD), geographic region and NSLP participation helped to ensure that the sample was representative of the county in terms of geographic location and socioeconomic status.

The Los Angeles County Department of Public Health contracted with the UCLA School of Dentistry to complete the oral health screenings. Screenings were completed during the 2018–2019 and 2019–2020 school years (October 2018 to November 2019). Even though California Senate Bill 379 allows for children to receive oral health assessments through passive consent, positive consent was used by two school districts (LAUSD and one non-LAUSD district) while all other districts used passive consent. Among schools using positive consent, the response rate was 62%, while the response rate among schools using passive consent was 84%, resulting in an overall response rate of 74%. Trained dental examiners completed the screenings using gloves, penlights and disposable mouth mirrors. The training consisted of a two-hour didactic session followed by a two-hour clinical training session. Inter- and intra-rater reliability were not determined. The diagnostic criteria outlined in the Association of State and Territorial Dental Director’s publication “Basic Screening Surveys: An Approach to Monitoring Community Oral Health” were used¹². The information collected as part of the oral health screening included state student identification number (SSID), number of teeth with untreated decay, number of teeth with treated decay, status of each permanent first molar (decayed, filled, sealed, sound, unerupted) and urgency of need for dental care (none, early, urgent).

Child-level information on parent-reported sex (female, male), race/ethnicity (Asian, Black/African American, Hispanic/Latinx, white, other), socioeconomic status (socioeconomically disadvantaged, not socioeconomically disadvantaged), parent’s primary language (English, Spanish, other) and school-reported information on SEN status (no, yes) and 504-plan status (no, yes) was obtained from the California Department of Education (CDE) through a memorandum of understanding and data use agreement with the California Department of Public Health (CDPH). The CDE provided CDPH a file containing demographic information for all kindergarten and third grade children in California. Using the child’s unique SSID, CDPH merged the demographic information with the oral health data. After the merge, all unique identifiers were removed from the data file. In terms of socioeconomic status, CDE considers a child to be disadvantaged if they are identified as being a migrant, a foster child or homeless at any time during the academic year; being eligible for the NSLP at any time during the academic year; or having parents who did not receive a high school diploma.

Raking, a model-based approach using known population totals, was used to generate weights to ensure that the survey totals matched the known population totals.¹³ Raking weights were created using R (R Foundation for Statistical Computing, Vienna, Austria). All statistical analyses were performed using SAS complex survey procedures (Version 9.4; SAS Institute Inc., Cary, NC). A total of 10,489 children received a dental screening; however, due to missing demographic data needed to calculate sampling weights, 97 children were excluded from all the analyses. All analyses are limited to the 10,392 children with demographic data.

Results

Information is available for 5,829 kindergarten and 4,563 third grade children. Overall, 11.0% of LA County children were classified as having an SEN, 0.5% had a 504 plan and 11.4% had an SEN and/or 504 plan (SEN-504). Third grade children (13.6%) and males (15.2%) were more likely than kindergarten children (9.6%) and females (7.5%) to have an SEN 504 (Table 1). Asian Americans (6.3%) and children from households with a primary language other than English or Spanish (5.1%) were the least likely to have an SEN-504 (Table 1).

Table 1. Percentage of LA County children with an SEN and/or a 504 plan by selected characteristics.

Characteristic	Number with data	Percentage with SEN-504	Lower 95% confidence limit	Upper 95% confidence limit
All children	10,392	11.4	10.1	12.7
Grade
Kindergarten	5,829	9.6	8.2	11.0
Third Grade	4,563	13.6	11.9	15.3
Sex
Female	5,133	7.5	6.4	8.6
Male	5,259	15.2	13.4	17.0
Race/ethnicity
Asian	1,393	6.3	4.5	8.1
Black/African American	783	13.7	10.1	17.3
Hispanic/Latinx	6,682	11.8	10.4	13.2
White	1,132	11.6	7.8	15.4
Multi-racial/other race	402	13.0	7.9	18.0
Socioeconomic status
Not disadvantaged	3,101	10.6	8.4	12.9
Disadvantaged*	7,291	11.7	10.4	13.1
Language spoken at home
English	6,033	11.8	10.2	13.4
Spanish	3,248	12.2	10.5	14.0
Other	1,111	5.1	3.3	6.9

SEN-504 = special education need and/or 504-plan.

*A child is classified as disadvantaged if they are a foster child, homeless, eligible for the National School Lunch Program or have parents who did not receive a high school diploma.

The percentage of children with decay experience, the percentage with untreated decay and the mean number of teeth with decay experience by grade and SEN-504 status is presented in Table 2. Although kindergarten and third grade children with an SEN-504 had a slightly higher prevalence of decay experience compared to children without an SEN-504 (57.6% versus 54.6%), the difference was not statistically significant (p > 0.05). Similarly, there were no statistically significant differences in the prevalence of untreated decay or the mean number of teeth with decay experience. Analyses that controlled for grade, sex, race/ethnicity, socioeconomic status and language found no significant differences in the oral health of children with and without an SEN-504 (data not presented). Additional information on the oral health of LA County children is available elsewhere.¹⁴

Table 2. Percentage with decay experience and untreated decay and mean number of teeth with decay experience among LA County children with and without an SEN and/or 504 plan by grade.

Grade	Has SEN or 504 plan				No SEN or 504 plan
	Number children	Percent or mean	Lower 95% CL	Upper 95% CL	Number children	Percent or mean	Lower 95% CL	Upper 95% CL
Kindergarten
Decay experience (%)	529	47.5%	41.5%	53.5%	5,300	46.8%	42.8%	50.7%
Untreated decay (%)	529	18.6%	14.7%	22.6%	5,300	18.9%	17.1%	20.7%
Number of teeth with decay experience (mean)	529	2.19	1.80	2.59	5,300	2.26	2.01	2.52
Third grade
Decay experience (%)	599	66.0%	59.5%	72.5%	3,964	64.5%	59.8%	69.2%
Untreated decay (%)	599	20.5%	16.4%	24.6%	3,964	20.7%	18.1%	23.4%
Number of teeth with decay experience (mean)	599	3.11	2.68	3.53	3,964	3.03	2.72	3.35
Both grades
Decay experience (%)	1,128	57.6%	52.5%	62.6%	9,264	54.6%	50.5%	58.7%
Untreated decay (%)	1,128	19.6%	16.6%	22.6%	9,264	19.7%	17.8%	21.6%
Number of teeth with decay experience (mean)	1,128	2.69	2.35	3.03	9,264	2.61	2.34	2.87

CL = confidence limit.

Discussion

As with the previously mentioned California and Scottish surveys,^8,9 we found no association between SEN and oral health status using a dichotomous measure of disability (SEN versus no SEN). While California is the first state to publish data on the oral health of SEN children, two other states (Oregon and Connecticut) have conducted similar surveys but have not published results. Connecticut’s 2021–2022 survey of kindergarten and third grade children found no difference in the prevalence of decay experience or untreated decay between SEN and non-SEN children (Budris L, personal communication, July 18, 2022). Oregon’s 2016–2018 survey of children in first, second and third grade found a higher prevalence of decay experience among SEN children (55% versus 48%, p < .05) but no difference in the prevalence of untreated decay (K. Hansen, personal communication, November 28, 2018).

Most SEN children in California have relatively mild disabilities, and the results of our survey suggest that their disabilities do not increase their risk of developing dental caries or their ability to access dental care. To determine if children with more severe disabilities have poorer oral health, a more granular measure of SEN, such as that used in the Scottish survey, is needed. Obtaining a more granular measure of SEN from a state department of education, however, may not be possible. First, some state departments of education do not collect child-specific disability type – that information is provided to the state by school districts as aggregate rather than individual data. Second, to protect a child’s identity, most, if not all educational data systems suppress or mask data when a cell contains fewer than 10 individuals. This means that if there are fewer than 10 kindergarten children in a school with an SEN subtype such as dyslexia, that information would be suppressed. If we cannot identify children with a disability severe enough to potentially impact their oral health or access to dental care using educational databases, we need to develop a different system that allows us to monitor the oral health of children with more severe disabilities.

As highlighted by Stewart and Meisel in the June 2022 issue of the CDA Journal,¹⁵ to adequately monitor the oral health of children with severe disabilities, California should expand its oral health surveillance system to include a measure of oral health among those with severe disabilities. Based on surveillance system attributes described by the Centers for Disease Control and Prevention (CDC),¹⁶ an oral health surveillance system for children with severe disabilities should be simple, flexible, cost efficient, representative and acceptable.

One potential method for obtaining oral health status estimates for children with more severe disabilities is to modify the design of California’s and LA County’s existing Smile Surveys so they oversample schools that exclusively serve students with disabilities. In addition, within selected mainstream schools, a code could be assigned to each classroom screened (mainstream versus special education) so children in a special education classroom could be identified during the analysis. The current Smile Survey design codes each school but not the classroom, and although special education classrooms are screened, the children in those classrooms cannot be identified. To increase the number of special education children screened within a given school, all children in special education classrooms could be screened regardless of the child’s grade. This modification to the Smile Survey would provide detailed information on the oral health of the 23% of SEN children who receive their education outside of the mainstream classroom. The benefit of this approach is that it builds upon an existing surveillance system making it cost efficient, representative and repeatable. In addition, it will result in a large sample of children with severe disabilities, which will provide better estimates of oral health and allow for the development of appropriate oral health recommendations for public school children with severe disabilities.

The LACSS has two major limitations. The first, as previously discussed, is the dichotomous SEN variable that does not allow for the identification of children with more severe disabilities. The second is the fact that only public and public charter schools were screened. In California, about 7% of school-aged children are enrolled in private schools.⁶ Information on the number of private school students with an SEN is not available. Federal law, however, requires that public school districts offer special education services to qualified children in private schools, and in 2017–2018, California schools provided special education services to about 2,300 private school students.⁶

Conclusion

In Los Angeles County, kindergarten and third grade children with an SEN, compared to those without an SEN, are not at increased risk of developing dental caries.

Acknowledgments

The Los Angeles County Smile Survey was an enormous collaborative undertaking, and the Los Angeles County Department of Public Health Oral Health Program extends our sincere thanks to the California Department of Education, California Department of Public Health, Los Angeles County Office of Education, The Los Angeles Trust for Children’s Health, Los Angeles Unified School District, and the University of California, Los Angeles (UCLA). We would like to acknowledge and thank all the schools and students who participated in this project. We particularly want to thank the school administrators, school nurses, and volunteers who assisted our staff with distributing parental consents, organizing screening days, and helping to facilitate the screening process. Without the cooperation of the schools, this project would not have been possible.

Additional information

Funding

The work was funded by the Office of Oral Health, California Department of Public Health Contract 17-10698 [17-10698].

Notes on contributors

Kathy Phipps

Kathy R. Phipps, MPH, DrPH is the Oral Epidemiology Consultant for the Los Angeles County Department of Public Health Oral Health Program. She received her master’s and doctoral degrees from the University of Michigan, School of Public Health.

Maritza Cabezas

Maritza Cabezas, DDS, MPH is the Dental Director for the Los Angeles County Department of Public Health Oral Health Program. She obtained her doctorate in dentistry from the University of Sao Paulo, Brazil, her masters’ degree from the University of Michigan, School of Public Health and completed a Dental Public Health residency at University of California San Francisco.