It’s been a long day for Bari Levine. Now entering her second year as a resident at Pediatric Dental Associates, a private practice affiliated with Temple University Hospital, Levine regularly sees children from Port Richmond, where the clinic is located, and other nearby North Philadelphia neighborhoods. Most of her patients live with many of the systemic problems common in low-income areas: inadequate or inconsistent nutrition and hygiene, spotty healthcare visits, turbulent social and family environments. Some days, like today, Levine sees how all these factors converge on a trip to the dentist.
“I just saw a child who has had untreated, rampant dental decay for three years. He told me he could barely eat because of the pain, and his one tooth has been bothering him for weeks.” Unfortunately, this is not uncommon. Despite having dental insurance and access to a dentist close to home, his complex family situations have prevented him from being able to see a dentist.
“We don’t have to go far to find serious oral healthcare needs,” she says. Levine sat down after clinic hours to bring us up to date on her work not only here but also in Peru, where she has been building a pediatric dental program since 2013. What began as an add-on to an outreach trip by Temple medical students in 2012 has evolved into a nonprofit, the Growing Smiles Foundation, and an expanding team of volunteer students, dentists, and hygienists who last summer provided over $140,000 worth of free dental services and education to more than 350 children.
Levine reflected on the impact she’s had so early in her career (she just turned 30) and on how her dual DMD-MPH degree program at Temple has shaped her ideas about health and dentistry.
Why did you choose the DMD-MPH program?
Dentistry was a natural fit for me. My mom, Sheryl Radin, and brother, Ross Levine, are both pediatric dentists (their practice is Growing Smiles in Yardley, Pa.) and my dad, Robert Levine, is a periodontist with a practice in Northeast Philadelphia. Also, all are Temple Dental grads! I was always interested in the big picture. As a child, I would say I wanted to save the world. In college, I was interested in environmental science. After college, I was working at an environmental start-up in Trenton and figuring out my next steps. I ended up going to one of my dad’s study clubs where [Kornberg School of Dentistry] Dean Amid Ismail was giving a lecture. He mentioned that Temple had just started the dual degree program in dentistry and public health, and that got me interested in how dentistry can address those bigger-picture questions I had. For me, it was a fascinating way to combine dentistry with a degree that makes you see the world through a different lens.
How does dental health fit into overall personal and community health? I
t’s great to work with patients one on one, but there are so many factors that affect a person’s health. Education and awareness are probably the biggest factors. But poverty, nutrition, access to care, smoking, diabetes, amongst others are very important factors in oral health and overall health. Trying to make changes in the community and tackling these issues will eventually permeate and improve the oral and overall health of the children and their families.
What are some consequences of children not having adequate oral healthcare?
There are many. We say baby teeth are so important because they hold the space for the permanent teeth. Also, if you lose baby teeth early, the other teeth around where the tooth was lost can drift into the space and block the permanent tooth. Or, if a baby tooth is left untreated and decaying in the mouth for a long time, it can harm the development of the permanent tooth underneath. Untreated infections can also spread to other parts of the body. For example, my husband is a cardiologist, and we often talk about how poor oral health care in children can translate in a few decades to poor cardiac outcomes, through different mechanisms but probably mainly related to increased systemic inflammation. Children and adults who eat less sugary snacks reduce their risk of obesity and diabetes as well as cavities. It’s all connected. And because people typically visit their dentist more often than their primary physician, we can detect and address potential problems earlier. It’s also a chance to monitor those social factors and educate parents. So regular dental checkups are a very important piece of overall health!
How did your work in Peru factor into your MPH program?
In 2013 I designed a culturally sensitive, evidence-based oral health intervention for the children at La Sagrada Familia orphanage in Peru with the help of Dean Ismail and the MPH program. I found out what they like to eat, what they like to drink, what they were eating for breakfast, lunch, and dinner. Then we did screenings, education, and a needs assessment – because public health perspectives and principles tell you that you can’t just go in and do an intervention. You need to find out if you’re actually needed and what the need is.
What did you find?
We found that nearly half the children had at least one cavity. Eighty percent of them had the highest levels of plaque. We did a brief intervention, and at a 10- month follow-up the children’s oral health was significantly better than it had been the year before. We compared them with children we didn’t have time to educate, and they needed significantly fewer extractions and other work than the children we did not educate.
How has the program grown since your first trip? We were at the orphanage for four years. We’ve seen a lot of improvements, and Colgate still sends them toothbrushes and toothpaste, so we have some sustainability. Last summer we partnered with a dental school in Lima, Universidad de Ciencias Aplicadas (UPC), to bring services to a school in Chorrillos, Peru, where the oral health was significantly worse than it was in the orphanage. Whereas the children at the orphanage live in a pretty controlled environment, these children go home and are exposed to a variety of different foods and lifestyles. They might be drinking more soda or chips; younger children might be sent to bed with a bottle of milk.
What are some of the overall conditions in Peru that make dental services an urgent area of need?
Across the board in Peru, oral health is a low priority and there’s no public assistance. Even if parents take their children to the local dental school they must pay out of pocket. There’s no blanket healthcare system, so it’s pretty much us bringing the dentistry to them. At UPC, students spend their final six months doing outreach. It’s a huge aspect of their curriculum. This past year they’ve been visiting the school several times a week providing education and preventive services.
How have the children responded to your visits?
The kids and the school have been amazing. They gave us a classroom to set up our clinic in and built a huge tent for us so we had more room to provide our clinical services. They made us beautiful crafts and thank-yous. They were just so accommodating and on board with us. That’s another principle of public health – that the community has to want you there as much as you want to be there. We’re lucky that we’ve found that.
What’s next for the foundation? One thing I’ve learned both in Peru and in my residency is that the need is everywhere. The oral healthcare needs of children in Philadelphia are the same as they are in Lima. So that’s our next goal: to design a program where we can replicate our success in Peru here in Philadelphia.
What’s the first step in making that happen?
Education really is so important. There is so much you can do at home to maintain oral health which we can achieve with some basic awareness. Here in the Philadelphia clinic, we’ve started to do education in the waiting area for parents while their children are in our office. It’s a program that I adapted from our education for the supervisors and parents in Peru.
You’ve grown many times over in the past three years – all with local personnel and donations.
Our dental students are extremely hardworking. We have 17 dental students coming with us this August, and 8 of them have come with us once, twice or even three times before! These incredible students are dedicated to our cause and our truly part of our “Peru Family.” They come as rising second years, then when they come back the following year they’re able to treat patients, and then the third year they’re basically running the show. We have a team of local dentists in and around Philadelphia who have supported us from the beginning. We wouldn’t have been able to do it without them. We’ve had incredible donations of dental instruments and dental materials from the Henry Schein Cares Foundation, and we also have fundraisers every year that help us buy different dental equipment. We have seven portable dental units and 40- plus matching suitcases that contain all our dental instruments, all our materials, everything. Inventory and packing are a huge endeavor! But we can set up a mobile clinic anywhere.
Speaking of setting up mobile clinics anywhere – what are your plans for expanding?
This year we have one dental resident coming from SUNY-Stonybrook and a pediatric dentistry resident from St. Christopher’s Hospital for Children. We’d also like to start bringing different pediatric dental residency programs on board with us. And I would love to create a sustainable model so we can replicate this program in other countries. That would be the goal one day.