Eight years after an independent state watchdog agency harshly criticized the state for failing to provide dental care to low-income children, California has failed to remedy the problem or fully implement the commission’s recommendations, according to a follow-up review published last week.

The Little Hoover Commission found that less than half of the children in Medi-Cal received an annual dental visit in 2022 — 3% higher than when the initial report was released in 2016, which implored the state to do more to ensure that children have access to needed care.

“California is still doing a miserable job,” said Pedro Nava, chair of the commission and a former member of the state Assembly. “We have failed generations of children. We and they deserve better.”

The 2016 report was one of the most scathing reports that the commission had generated in years, Nava said. It found that only 44.5% of children in the Medi-Cal program had a visit with a dentist in 2016, a key indicator of whether children are receiving the care they need to prevent painful dental decay, and recommended that the state increase the rate to 66%. Lawmakers responded with a law requiring the health department to set a target of at least 60% of children.

Last fall, after the publication of an L.A. Times story on high rates of dental disease among California children, the commission initiated a follow-up review of the state’s progress.

It found that the state had fallen far short of the goal; in 2022, the most recent data provided in the report, 47.6% of children with Medi-Cal visited a dentist, a 3-percentage-point increase from 2016.

“If you were an investor in a private company, and that was the best they could do, you’d sell your stock and invest it somewhere else,” Nava said. “It is a disappointment that low-income families with children have to shoulder the burden of this every day.”

California has made some improvements since 2016, the report said, fully implementing one recommendation and partially implementing seven of the commission’s eight others.

The state health department, however, disputes those findings and said they have fully implemented all of the recommendations from the 2016 report. The percentage of kids going to the dentist had been increasing significantly, they said — up to 49.6% in 2019 — but the pandemic interrupted that growth.

“California, along with every other state in the nation, was profoundly impacted by the effects of the COVID-19 pandemic. Virtually every state within the U.S. decreased and had a recovery period that lasted at least two years to return to pre-COVID figures,” the Department of Health Care Services wrote in a statement provided to The Times.

Since 2016, the department has made a number of important changes, the department wrote, including expanding the use of tele-dentistry to reach members across the state, increasing provider networks and creating a public education and outreach media campaign for Medi-Cal patients and providers.

In 2023 the percentage of children who visited the dentist “recovered to 2019 levels. Even higher utilization is projected in 2024,” the health department said, although data have not been been released on this upward trend.

“I don’t think this response really questions the fact that they have not come close to reaching the recommendation set by the Legislature of 60% of kids getting in to see the dentist, let alone our rate of 66%,” said Ethan Rarick, executive director of the Little Hoover Commission. “Kids’ dental health is among the worst in the country, and much more needs to be done.”

California children have among the worst rates of dental disease in the nation. A national survey from 2020 to 2021 found that 14.8% of the state’s children ages 1 to 17 had decayed teeth or cavities in the last 12 months studied — ranking 47th out of 51 among all the states and the District of Columbia, with only Louisiana and Wyoming faring worse. “I don’t understand,” Nava said. “If you’re the fifth-largest economy in the world, you ought to be a leader in children’s health.”

Nationwide, more than half of children develop cavities by the age of 8, usually because of poor nutrition, bad hygiene habits or a lack of dental care.

The reality of dental disease can be devastating to children, causing pain and difficulty eating, sleeping and focusing in school, and low-income children of color are at greatest risk. L.A. County’s Smile Survey, which was conducted by the public health department, found that on any given day, more than 4,500 Los Angeles County kindergarten and third-grade children need urgent dental care, which means they may be experiencing mouth pain or a serious infection.

The state increased the payment rate for evaluating a child’s teeth, for example, from $15 to $45, and up to $100 if a dentist sees the same child two years in a row, according to the California Dental Assn. The reimbursement for a filling increased from $48 to $67.20. These rate increases were funded by Proposition 56, a 2016 tobacco tax that raised money for Medi-Cal payments, and by CalAIM, a state initiative to transform Medi-Cal. The Proposition 56 money was also used to fund county oral health plans and repay student loans for new dentists.

The state has made it easier for dentists to enroll as Medi-Cal providers by simplifying the enrollment forms and putting them online, the report said. It also began a pilot program for telehealth to help bring care to healthcare deserts through the Dental Transformation Initiative.

Between the Medi-Cal payment rate and fewer administrative burdens, dentists appear to have taken note: 40% of all California dentists in the state now take Medi-Cal, a 34% increase since 2017, according to the dental association.

“The program had such a huge hole to dig out of, and COVID really derailed everything,” said Brianna Pittman-Spencer, senior director of government affairs at the California Dental Assn. “There have been improvements but obviously still a long way to go for the impact we want.”

Eileen Espejo, who leads the oral health project at Children Now, said she was pleased to see that the state had at least started to implement most of the recommendations, but that the numbers suggest the approach may not be working. “If we’re going to do better, it doesn’t seem like we should do more than the same,” she said.

In particular, she worries about children in far northern counties and those bordering Nevada, where dentists are hard to find. Twenty-one counties have five or fewer dental providers that take Medi-Cal, the report found. “How are we going to get providers to live in parts of the state where they aren’t yet?” she asked, adding that using more telehealth dentistry and allowing dental hygienists to provide more care could be part of the solution.

“Hopefully this report will light a fire and get more people engaged,” Espejo said. “I certainly think it opens the pathway for advocates to ask for more resources to help improve the program.”

This article is part of The Times’ early childhood education initiative, focusing on the learning and development of California children from birth to age 5. For more information about the initiative and its philanthropic funders, go to latimes.com/earlyed.

An industrial chemical used in plastic products has been cropping up in illegal drugs from California to Maine, a sudden and puzzling shift in the drug supply that has alarmed health researchers.

Its name is bis(2,2,6,6-tetramethyl-4-piperidyl) sebacate, commonly abbreviated as BTMPS. The chemical is used in plastic for protection against ultraviolet rays, as well as for other commercial uses.

In an analysis released Monday, researchers from UCLA, the National Institute of Standards and Technology (NIST) and other academic institutions and harm reduction groups collected and tested more than 170 samples of drugs that had been sold as fentanyl in Los Angeles and Philadelphia this summer. They found roughly a quarter of the drugs contained BTMPS.

Researchers called it the most sudden change in the U.S. illegal drug supply in recent history, based on chemical prevalence. They found that BTMPS sometimes dramatically exceeded the amount of fentanyl in drug samples and, in some cases, had made up more than a third of the drug sample.

It was also a growing presence in fentanyl over the summer: In June, none of the L.A. fentanyl samples tested by the team contained BTMPS, the analysis found. By August, it was detected in 41% of them.

“This is effectively unprecedented,” said Morgan Godvin, one of the authors of the study and project director for Drug Checking Los Angeles, a UCLA project that works in partnership with the L.A. County Department of Public Health to analyze illicit drugs.

“We have no idea just how many people have been exposed,” Godvin said, but if the high prevalence among drug samples tested so far is any indication, “that translates to tens of thousands of fentanyl users being exposed to BTEMPS, sometimes at very high volume.”

The findings were publicly released as a preprint — research that has not been peer reviewed — on the website of Drug Checking Los Angeles and have been submitted to medRxiv, a website where scientists share preliminary findings.

BTMPS has been studied in rats for its potential to reduce withdrawal symptoms from morphine and affect nicotine use, but it can be toxic and even deadly to rodents at sufficient doses, and health researchers say there is an urgent need for more studies on its effects on the human body.

The PubChem database lists a number of possible hazards associated with BTMPS, including skin irritation and eye damage. Godvin was alarmed by animal studies indicating dangers from inhaling BTMPS — such as tremors and shortness of breath — because smoking is now common in L.A. among people who use fentanyl.

People who use drugs have said that BTMPS can smell like bug spray or plastic and have reported blurred vision, nausea and coughing after ingesting it. One told researchers that “it smelled so bad I could barely smoke it.” The UCLA and NIST researchers warned that “with such a sudden and sustained prevalence in the drug supply, users are at risk of repeated, ongoing exposures, which may compound health effects.”

A 35-year-old man in Los Angeles said that in recent months, he had noticed a rubbery or synthetic taste in the fentanyl he used. “I was asking my friend that I buy from, ‘What the hell is this?’” said the man, who requested anonymity to speak about his drug use.

When he took samples that were supposed to be fentanyl to Drug Checking Los Angeles to analyze, he learned that some contained the strange chemical. The 35-year-old said he now tries to avoid BTMPS, but “a lot of people are just trying to get anything to keep from being sick” from opioid withdrawal.

Whatever clandestine labs are doing, he said, “we’re the guinea pigs.”

L.A. and Philadelphia are far from the only places where the chemical has popped up: The team also detected BTMPS in trace amounts of drugs left behind on drug paraphernalia from other locations, including Delaware, Maryland and Nevada.

As of last week, a University of North Carolina program that tests drug samples from across the country had also found BTMPS in more than 200 samples from a dozen states stretching from the West Coast to Maine. UNC senior scientist Nabarun Dasgupta said the chemical began showing up in drug samples that it tested this summer, most often mingled with fentanyl, both in powder form and in fake pills.

Alex Krotulski, a director at the nonprofit Center for Forensic Science Research and Education in Pennsylvania, said the amount of BTMPS found in drug samples it has tested varies dramatically — sometimes making up a small amount, sometimes amounting to the “primary component” in the sample.

Unlike other adulterants added to fentanyl for their psychoactive effects, “it’s not like it’s something that you go out and you use a bunch of to get high,” Krotulski said. The UCLA and NIST team found that people who use drugs rated samples high in BTMPS as “bunk” — low in quality — and broadly saw it as “highly undesirable.”

Yet another oddity is that BTMPS has not followed a familiar path for new drugs in the U.S. Instead of showing up in one area and spreading to others, “this one has hit all at once across the U.S. within a two-week period,” said Tara Stamos-Buesig, founder and chief executive of the Harm Reduction Coalition of San Diego.

Stamos-Buesig, whose group helps analyze the contents of illegal drugs in San Diego to inform and protect people, said that “I’ve told people for a while — we can’t hyper-focus on fentanyl” as if it were the only threat.

“There’s a lot of other stuff coming on board,” Stamos-Buesig said.

The UCLA and NIST analysis suggested one possible scenario: Illegal drug manufacturers might be adding BTMPS to fentanyl precursors or to the final product “at a high level in the supply chain,” possibly to stabilize them from degrading from light or heat exposure as illicit drugs are made, stored and transported, they wrote.

UCLA assistant professor Chelsea Shover added that the team had found BTMPS for sale on online platforms like Amazon and Alibaba with similar wording to what Chinese chemical companies had used in the past to market to fentanyl producers, with sellers touting their “experience getting through Mexican customs.”

“This is clearly implying that this is to be used to make illicit drugs,” Shover said. “It’s stuff you wouldn’t expect to see if it was just selling an industrial chemical in a standard way.”

As it stands, there is no test strip that can quickly detect BTMPS as there is for fentanyl. Nor is the chemical routinely tested for by doctors or medical examiners, which means that if someone has been harmed by BTMPS they took accidentally, “clinicians would have no way of knowing,” the UCLA and NIST team wrote.

The UNC Street Drug Analysis Lab likewise said that much remains unknown at this point, including whether BTMPS poses an overdose risk, although the lab cautions that “EVERY substance at some volume will be toxic.”

Dasgupta said the detection of BTMPS represents the first example of the burgeoning network of drug checking programs working together to find a substance “before any health authorities or any law enforcement did.” Godvin said that “just a few years ago, we wouldn’t have even known about this” and urged Angelenos to get drugs analyzed through Drug Checking Los Angeles if they are able.

In a drug supply already riddled with threats like fentanyl and the animal tranquilizer xylazine, “this gives us a whole other thing to worry about,” Godvin said.

Approximately 600 times a day, the esophagus ferries whatever is in your mouth down to your stomach. It’s usually a one-way route, but sometimes acid escapes the stomach and travels back up. That can damage the cells lining the esophagus, prompting them to grow back with genetic mistakes.

About 22,370 times a year in the United States, those mistakes culminate in cancer.

Esophageal cancer can be cured if it’s discovered and treated before it burrows in deep or spreads to other organs. But that’s rarely the case.

“The way this usually goes is a patient has had reflux symptoms for many years, they’ve taken Tums or something, and then all of a sudden they have difficulty swallowing so they come to the ER,” said Dr. Allon Kahn, a gastroenterologist and associate professor of medicine at the Mayo Clinic in Arizona. That’s when doctors discover a tumor that has grown into the walls of the esophagus, and likely beyond.

“At that point,” Kahn said, “it’s incurable.”

This is why only about 20% of Americans with esophageal cancer are still alive five years after their diagnosis. To improve on that figure, doctors say they don’t necessarily need better medicines. What they need are better ways to find the cancer while it’s still in its earliest, highly treatable stages.

And to do that, they need a breakthrough in screening for the disease.

“The concept of screening is to find dangerous things before they do dangerous things,” said Dr. Daniel Boffa, chief of thoracic surgery at Yale.

It works for diseases like breast, lung and colon cancer. In those cases, there’s a clear progression of steps that leads to cancer — and only to cancer.

But that doesn’t seem to be the case with esophageal cancer.

“We don’t really know who to screen, how often to screen, and what is the thing that we can see that will tell us, ‘This person is going to develop a dangerous cancer,’” Boffa said.

He likened the situation to the difficulty of forecasting a tornado.

“Most tornadoes happen when conditions are favorable for a tornado,” he said. “But most of the time that conditions are favorable for a tornado, there’s not a tornado. And a lot of the time, tornadoes happen outside of those conditions.”

Another complicating factor is that cases of esophageal cancer are rare, accounting for about 1% of all cancers diagnosed in the U.S.

Picture the 100,000 college football fans packed into Michigan Stadium in Ann Arbor on a game day, said Dr. Joel Rubenstein, a research scientist based 3 miles away at the Lt. Col. Charles S. Kettles VA Medical Center and a gastroenterologist at the University of Michigan. Then picture yourself having to figure out which four of those fans will develop esophageal cancer this year.

Screening someone for esophageal cancer is not a trivial procedure.

The standard method involves inserting an endoscope — a flexible tube with a camera on one end — into a patient’s throat and threading it down to the stomach. The camera allows doctors to inspect the esophagus up close and check for abnormal cells that could become cancerous.

The tube also serves as a conduit for tools that can collect tissue samples, which can be sent to a pathology lab for diagnostic analysis. If a doctor sees a growth that looks like early-stage cancer, it can be removed on the spot.

It sounds straightforward, but patients must be sedated for the procedure, which means they lose a day of work. Endoscopy is also expensive, and there’s a shortage of doctors who can do it.

“We’re only catching 7% of cancers through endoscopy,” Kahn said. “We’ve got to find a way to increase that number.”

In the U.S., the most common form of the cancer begins at the base of the esophagus. The cells there aren’t built to withstand exposure to stomach acid, so in people with chronic acid reflux, they sometimes adapt by becoming more like intestinal tissue. That condition is called Barrett’s esophagus, and about 5% of U.S. adults have it.

“If that’s all that was, we’d say, ‘That’s great,’” Kahn said. “But unfortunately, when it makes that change in cell type, there are genetic changes that predispose a patient to cancer.”

About 0.3% of people with Barrett’s esophagus develop esophageal cancer each year, said Dr. Sachin Wani, a gastroenterologist and professor at the University of Colorado School of Medicine. And compared to people without Barrett’s, they are roughly nine times more likely to die of esophageal cancer.

That means screening for Barrett’s is tantamount to screening for esophageal cancer.

Doctors largely agree on a core group of risk factors, including chronic gastroesophageal reflux disease, smoking and carrying extra pounds in the abdomen. Other risk factors include being at least 50 years old, male, white and having a family history of either Barrett’s or esophageal cancer.

There is less agreement about how many risk factors a person must have to justify screening.

Based on recommendations from the American College of Gastroenterology, more than 31 million people are eligible for screening. Guidelines from the American Society for Gastrointestinal Endoscopy raise that figure to 52 million, and the American Gastroenterological Assn.’s advice expands it to 120 million, said Dr. Gary Falk, a gastroenterologist and professor of medicine emeritus at the University of Pennsylvania’s Perelman School of Medicine.

All of these recommendations leave room for improvement. Only 50% to 60% of people who meet screening requirements actually have Barrett’s, said Dr. Prasad Iyer, the chair of gastroenterology at the Mayo Clinic in Arizona.

“The screening criteria are not accurate enough,” he said.

Indeed, at least 90% of people who have risk factors for Barrett’s don’t actually have the condition, Iyer said. That includes the vast majority of people with acid reflux.

So doctors are turning to artificial intelligence to identify additional characteristics that can improve their ability to identify those most likely to have Barrett’s and esophageal cancer.

“Everyone in medicine is looking at AI,” Falk said. “We think it’s going to revolutionize things.”

Iyer and his colleagues are developing an AI tool that scours the electronic medical records of Mayo Clinic patients to find those who should be screened for Barrett’s. The tool considers more than 7,500 distinct data points, including past medical procedures, lab test results, prescriptions and more. (Among the surprises: A patient’s triglycerides and electrolytes had predictive value.)

“This is probably something a human would not be able to do efficiently,” Iyer said.

In tests, the overall accuracy of both tools was 84%. While those are substantial improvements, the team would like to bump that up to 90% before they are rolled out in the clinic, Iyer said.

Rubenstein and his colleagues in Michigan created something similar, using machine learning techniques to analyze the health records of VA patients across the country. Their tool also performed better than the official guidelines of medical societies, with an accuracy of 77%. Now the team is working to refine its threshold for screening by adding cost-effectiveness to the mix.

Once in use, tools like these could lighten the load of overburdened primary care doctors, who aren’t necessarily up to date on the latest screening guidelines and refer fewer than half of their eligible patients for testing.

“It will flag a patient and say, ‘This patient should be screened,’ or, ‘This patient should not be screened,’” Iyer said. “That’s what the future really needs.”