Dental student Andrew Swiatowicz stood next to the extra-large set of model teeth positioned in a corner of the National Museum of Dentistry and asked young onlookers how many times a day they should brush.
Two or three, belted out the kindergartners from George Washington Elementary School in Southwest Baltimore.
It seems like an obvious question, but museum officials say not every kid from the poorer parts of Baltimore and Maryland - those who rarely or never see a dentist - know the answer.
A decade ago, access to care in Maryland had been among the nation's worst. That has been changing, especially since the 2007 death of Deamonte Driver, a 12-year-old from Prince George's County who died after an infection in an untreated tooth spread to his brain.
With February's National Children's Dental Health Month upon them, academic, industry and government leaders can point to improvements. They formed a Dental Action Committee that has won aid for local health centers; streamlined the Medicaid program; and sent hygienists into the community to provide screenings. They've been gaining commitments from dentists to treat poor children. They worry, however, that the bad economy will set back efforts and that there will be less money for care at a time when people are losing their jobs and private health care.
"The problem is huge," said Rosemary Fetter, executive director of the Baltimore dental museum, where about 60 kids got some hands-on education as well as dental screenings this month as part of an annual event. "Problems with teeth keep kids out of school, some statistics say, more than anything else."
Student volunteers from the nearby University of Maryland Dental School said the children's mouths didn't look too bad during the recent visit. Many had been to dentists, as evidenced by work done on their baby teeth. The volunteers also thought they were keeping the kids' attention during the oral-hygiene lessons by using props and computers.
"This is much better than a video," said Gloria Gillian, one of the kindergarteners' teachers. "It'll stick with them. They'll go home and tell their parents. And when they're in the store, they'll remind them to get floss."
Kiniya Coleman, who was missing her front teeth, said she'd brush the ones she has. Classmate Nia Thompson said her mother had already taught her "everything" about brushing.
"Up and down, up and down," she said. Then, while demonstrating on those giant teeth, she told her classmates, "You got to get in the back."
Such events are also reaching children who aren't seeing dentists regularly, said Dr. Marc Nuger, president of the Maryland State Dental Association. And Nuger and others on the Dental Action Committee, including Dr. Norman Tinanoff, chair of the UM Dental School's Department of Health Promotion and Policy, said they can point to other successes:
* The state was able to simplify its Medicaid system by reducing the number of companies serving patients to one from seven or eight. Patients and dentists will call only one number as of July 1.
* Reimbursements for dentists taking Medicaid patients are increasing, which is luring more professionals to treat the poor. The first raise came in July, and two more are planned, though the recession is causing a delay.
* State health workers received an extra $1.5 million to bolster care in community centers.
* Dental hygienists received permission to screen more children in public health settings.
* Dentists were offered training in pediatric dentistry so they could more confidently treat children.
* Doctors who treat Medicaid patients will soon be compensated for providing fluoride treatments in their offices after they complete a training course.
Nuger said the changes, including the single-payer system for Medicaid, have already netted almost 100 new dentists in the Medicaid system in the past two years, bringing the total to about 400. The group is looking for about 200 more. There are about 4,000 dentists in Maryland.
"The new system is going to be a big plus," Nuger said. "There are some 400,000 on the Medicaid roles in Maryland, and we'd like to get more to see a dentist regularly."
Nationwide, despite fluoridated water and toothpaste and increased dental visits, dental disease and cavities among preschoolers are rising, largely among poor children, according to data from the American Dental Association and the National Institute of Dental and Craniofacial Research.
About a quarter of the nation's children ages 2 to 11 have never been to the dentist, though professionals recommend children see one by their first birthday. Lack of dental insurance is a prime culprit, and for every American child with insurance there are about 2.5 without.
Tinanoff, of the dental school, said there is increasing interest in pediatric dentistry, but Maryland admits only six students a year due to staffing. Last year, 120 applied. That's the same number of practicing pediatric dentists in the state.
He believes some of the gaps in pediatric care will continue to be filled by other dentists, doctors and hygienists. And despite the economy, he believes state lawmakers will continue funding.
"I think the story of Deamonte Driver hit home," Tinanoff said. "It shocked people around the world; people couldn't believe a child in the United States could die of a dental infection. We had been working on the problem slowly, but this really brought attention."
It was the reason the dental committee was created by state Health Secretary John M. Colmers, who was in office for three weeks when Deamonte died, said Harry Goodman, director of the state Department of Health and Mental Hygiene's Office of Oral Health.
The biggest issue remains education, Goodman said. Many low-income families don't look for a dentist, miss appointments or don't properly care for their teeth at home, he said. The committee is looking for funding for an extensive education campaign.
"Deamonte Driver was failed on both ends," he said. "He couldn't find a dentist for treatment, and he was failed on the prevention end as well. We know for the most part how to prevent disease with oral hygiene. He didn't have access to those messages. An education campaign is our greatest challenge now."
A September 2007 report from the Dental Action Committee found, among other things:
* Less than a third of children on Medicaid were receiving dental services in a given year
* More than half of Head Start children had tooth decay, and most of it was untreated
* Only half of the local health departments offered dental services, and only nine provided care to children on Medicaid
* Only 19 percent of dentists provided services to children on Medicaid
For more information or to find a dentist, call 410-767-5300 or go to fha.state.md.us/oralhealth.