By Laura Krueger

Dr. Mandy Ashley, DMD, MS, MSEDU, opened Sky Pediatric Dentistry in 2013 to serve Bowling Green and neighboring communities in western Kentucky. Her practice specializes in treating children up to age 18 and special needs adults throughout their lives.

Sky Pediatric Dentistry participates in the region’s Mighty Molar program, administered by the Barren River Health District, which helps connect at-risk children to area dentists in order to establish a permanent dental home (watch a YouTube clip about the program, featuring Dr. Ashley and her practice at Sky Pediatric Dentistry, below).

Dr. Ashley was interviewed by KET’s production team as part of the ongoing Inside Oral Health Care initiative, funded in part by Foundation for a Healthy Kentucky.

What type of oral health problems do you see in your practice?

The oral health issues that we see most often usually relate to children’s cavities. I am a pediatric dentist, so that is our specialty. We see quite a few kids that have decay that their parents have recognized, and we also see kids that have unrecognized decay that you can pick up on an X-ray.

When I was a general dentist practicing up in Barrow, Alaska, I thought I would see the worst decay that was out there because I was practicing at the Indian health service in a remote village on the edge of the Earth, basically, right on the Arctic Ocean coast. When I left that community to become a pediatric dentist, and then when we moved here to Bowling Green, a surprise that I had was that the rates of decay for kids in this community are just as high as the rates of decay in Barrow, Alaska.

That’s one of the reasons why we really, really focus on prevention and trying to see kids as early as possible.  We focus on baby smiles exams. That’s where we see kids in the age group of 1- to 3-year-olds, before they even have all of their baby teeth in, so we can come up with a great comprehensive plan to prevent decay.  Because by the time kids are 4, 5, or 6 years old often they have quite a few cavities and need fillings. We can back up and start a lot earlier than that, develop the right habits, develop the right nutritional guidance, and the right intervals for dental visits, and give kids a much, much better chance at having great teeth throughout their whole life.

How difficult is the challenge of getting parents to buy in at that early age?

One of the things is just getting information out. We need to make sure that we get the information to parents so we actually participate in the Expectant Parent Fair (offered by the Bowling Green Medical Center). So, even before the baby comes out, we’re getting the information to the moms and the new dads to understand the importance of oral health.

So, that’s one way. Another is just by word of mouth and by spreading the word in our community that baby teeth matter and baby teeth are important. They are not something that just stays there without any need for treatment; you do have to actively manage your child’s baby teeth to protect their adult teeth that are developing.

Is there a misconception that baby teeth don’t matter?

I think that in some families, maybe because of parents’ or grandparents’ history with dental issues, people might not consider baby teeth as being that important. But I can’t tell you how many times we see parents who have said, “I had perfect teeth growing up and my child has so many cavities, I don’t understand why.” And there’s so much that has to do with diet. Maybe the parents grew up in an era where they weren’t exposed to sugar as frequently, maybe they didn’t drink juice as often. And the child may be living with grandparents and may be exposed to frequent snacking on, and frequent sipping of, cavity-causing products. So, this is something we really take an active role in with education and helping people understand where cavities come from.

So, then it’s the eating and drinking habits that you think are making a bigger impact on poor dental health?

Dental health really has three components. One is the obvious: brushing and flossing. Are you using a fluoride mouth rinse? What are you using to brush your teeth? Are you using a fluoride toothpaste?

A second component is, what is the enamel like in your teeth and in your family members’ teeth? Do you have soft teeth? Do you have teeth that are more prone to cavities?

The third component is diet. What are you eating? Are you snacking? Are you sipping soda? Are you eating a lot of what we call cariogenic foods – ones that have a high likelihood of causing cavities, products like sugary drinks, sugary foods, or sticky foods like gummies? It’s those three components that all mesh together to sometimes create the perfect storm of cavities for kids.

What are the most important advances in oral health care in the last decade?

There are so many new advances in dentistry that make dental care so much more comfortable now for children – especially preventive dental care for children. Sealants are a wonderful way to seal up all the nooks and crannies on the permanent molars, and reduce a child’s risk of decay on those teeth in the future.

Another thing is fluoride treatments, these can actually help change the tooth enamel and make it stronger and more resistant over time to cavities. So, there are a lot of things we can do now, and honestly I do not know if I would have enjoyed being a dentist 30 or 40 years ago without having all of the resources that we have available now.

In what ways have you modified your practice to make the children comfortable?

We have a multitude of different treatment areas. A lot of people think of the dentist office as the dental chair, and that’s where you’re going to sit, and that’s where it’s all going to happen. But in pediatric dentistry you can make dentistry and the educational component happen in so many different areas. So we have one area where it’s just a starry sky ceiling, and little kids can lay down on their parent’s lap and have all of the dental treatment – the exam, the cleaning, and the fluoride – done right in their parent’s lap while looking up at the stars.

We have a little Jeep, a little fun car that kids can sit in. They can pretend to drive while they are getting their teeth cleaned. We also have a playhouse where kids can crawl around the house and play as they get their teeth cleaned and examined. So, we try to meet the kids where they’re at behaviorally and pick the most fun place for them to have their treatment done.

What is your philosophy?

My philosophy is that every child is unique, every child is an individual, and we want to make sure that they have the best chance at having a lifetime of no cavities, a lifetime of healthy smiles. So we work with the parents. I really enjoy having the parents back in the rooms during treatment so they can see what I’m seeing. I can show them specific areas to watch out for, I can show them where to intervene, and I can also kind of coach the parent and the child in improving their oral hygiene.

I also like having parents in the treatment room because I can provide a running commentary so that the parents feel like they’re active participants in the treatment and they can understand what we’re doing.

How would you like to see the dental care system changed so that the best possible care for children is provided?

For me, as a pediatric dentist, one of the most important things is access to care, because you can’t provide treatment for kids who need it unless they come in through the door. One of the thigs that I’ve tried to do in my practice is, I’ve modeled it after a public health practice. We send teams of hygienists and dental health educators from this practice out into the community to reach the kids that we know will never cross the threshold of coming in. We provide a fun skit on an oral health education program, we go out to the schools just so they can get comfortable and familiar with people that are from the dental community and be a little more relaxed when they come into the office.

That’s us as a private office making what is basically a hybrid public health model and doing community outreach. Last year, we reached 15,000 kids this way in our community and in the surrounding 10 counties. And we plan to do more.

What are some of the insurance issues you face?

Many dentists feel that the Medicaid reimbursement rates are significantly lower than the reimbursement rates for private insurance. But, I think that much more than that, the problem is access issues. If you, as a dentist, have a schedule that you’re anticipating as being full, and you’ve staffed up for that schedule, and you’ve laid out your materials for that schedule, and then you have a large percentage of kids that never make it in through the door – and the parents don’t call to cancel, they just don’t show – that can make it very challenging for providers.

But if there was a system in place where parents realized that when they make an appointment, we’re happy to see them, but if they no-show or no-call there’s something that happens, some type of consequence – again, never a consequence to punish the parent or punish the child, but there needs to be some type of action so that the parents realize, just like private insurance parents do, that you just can’t be a no-show or no-call, that’s not okay.

How do you handle missed appointments at your office?

One thing that we do is, we understand that not every parent has reliable transportation, and not every parent can make every appointment. And so we give people two free passes. You can break or miss or cancel an appointment at the last minute. And then, if a third appointment is broken, we never punish the child and kick them out of the practice – because it’s never a 4-year-old’s fault if they didn’t make it in – but what we do is offer standby appointments. So basically that third visit, if you’ve broken or missed your first two you go into a standby registry, where the parent can call up on the day they do have transportation or access  and they can come in and we will fit them in no matter what. There may be a little longer wait, but we’re still willing to see the child.

So, I feel like we just need to start encouraging other offices, and maybe even encouraging the state Department of Medicaid, to take a look at ways to not punish the children if their parents can’t make the appointment. I think that there are ways that can involve some parental responsibility.

It is in my heart that we will always see kids regardless of their insurance status, because they’re kids first and they need to have access to care. But I understand my peers in the pediatric dental field when they say we need to have some help and some assistance from the state with creating a way for parents to have more responsibility.

This KET article is part of the Inside Oral Health Care initiative, funded in part by the Foundation for a Healthy Kentucky.