A painful measure of inequality exists among students in nearly half of this city’s elementary schools, new data obtained by the Toronto Star shows.

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Toronto Public Health hygienists looked inside the mouths of nearly 220,000 students from junior kindergarten to Grade 8 last year as part of an annual free dental health screening program in schools. In the process, 44 per cent of schools were designated “high risk” based on the rotting condition of children’s teeth.

“Sometimes the children have been complaining of pain, sometimes they haven’t been because they’ve been living with the pain so long they can’t tell otherwise,” said Dr. Michele Wong, a manager of dental and oral health services for Toronto Public Health.

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Photographs of students’ mouths taken during dental screenings portray a startling picture of a public health problem in Toronto that has flown under the radar for years. Broken teeth. Bubbling abscesses. Dark pools of leathery decay.

Root canals are “not uncommon” among these children, said Wong, who started working as a dentist in the public health clinics in 1994. “Seeing a 6-year-old with cavities in every single tooth they have — that’s pretty heartbreaking as well.”

At two schools in North York, nearly one out of every two students was suspected of having a cavity. At Grenoble Public School in Flemingdon Park, a “high-priority” area where the student population represents more than 73 different languages, more than a quarter of these children required urgent care.

“This is all news to me,” said city councillor John Parker, who represents the Don Valley West riding where Grenoble is located. “It’s an area where I expect there would be less attention to dental health but I wouldn’t have guessed at the magnitude.”

In contrast, Toronto hygienists found no signs of cavities in any of the students at Cottingham Public School, which is sandwiched between the affluent Rosedale and Summerhill neighbourhoods. Three of 108 students were recommended for dental cleaning.

Toronto Public Health defines “high-risk” schools as those where the suspected rate of cavities is 14 per cent or higher.

The rate signals a “difference in health that is avoidable and unacceptable,” said Dr. Jai Kanhai, an oral health services manager with Toronto Public Health. “A high-risk school illustrates the inequality of health and in turn should facilitate action to address and reduce it, by prevention and increasing access to care, ultimately by universal dental health care.”

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Kanhai worked in private practice for nearly 16 years before joining Toronto Public Health three months ago.

“I had no clue,” he said of the tens of thousands of families in this city who are without access to dental health services. “I walked away (from private practice) thinking, ‘Hey, Toronto’s a pretty health city as far as dental care is concerned. Once you see a few, you realize things are not quite as rosy as you would expect.”

Kanhai and Wong see a direct correlation between the state of children’s mouths and their socioeconomic backgrounds. Deliberate parental neglect is rarely the root the problem, they say, though in some cases, where guardians have refused to seek recommended care even when free appointments have been set up for the children, health officials have had to report them to the Children’s Aid Society.

The majority of high-risk cases are found in the city’s poorer, peripheral regions of North York, Scarborough and Etobicoke.

A new study out of St. Michael’s Hospital, published on Monday in Pediatrics, cites sociodemographic conditions and the lack of universal access to dental health care as a threat to early childhood health.

Nearly 40 per cent of 2,505 Toronto children surveyed in the study — newborns to age 7 — have never seen a dentist. Children from families that reported the lowest income (0-$59,999) were most likely to have not seen a dentist.

While the Canadian Dental Association recommends children visit a dentist within six months of their first tooth breaking through, fewer than 2 per cent of the kids surveyed had done so by age 2.

“For a lot of people, visiting the dentist is an unrealistic expectation,” said Dr. Jonathon Maguire, a pediatrician at St. Michael’s Hospital and one of the study’s authors. “They can’t afford preventive care. But we know when children do go to a dentist within the first year, there are cost savings. It prevents a lot of problems down the road.”

A large cavity, if left untreated, can result in an abscess. In a worst-case scenario, the abscess can spread, infecting the bloodstream.

“It’s a ticking time bomb,” Wong said. Nerve damage may prevent the child from feeling pain but “you still have bacteria in there, eating away.

“There have been situations where the abscess has spread to the brain,” Wong said. “Ultimately, it can lead to death.”

More common, though, are speech problems, nutritional deficiencies, lack of sleep, behavioural problems as a result of pain and stigma, and reduced capacity for learning.

Last year, the Canadian Paediatric Society issued a position statement recommending all levels of government hold dental care to the same standards of accessibility as other services under the Canadian Health Act.