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									School-Based Dental Health

  Considerations for Program

                     By: Erica M. Allen
   Intern, Center for Health and Health Care in Schools
     Candidate for MPH, MCP Hahnemann University
            School of Public Health-Philadelphia
 The following is a power-point presentation summarizing current directions in
school-based dental health. Recommendations and proposed strategies were
obtained through personal interviews, published research, oral health conferences,
personal observation of school-based dental centers and educational institutions.
The presentation is intended to serve as guidance, based on best available
information, for successful school-based dental health program development. This
information is presented with the understanding that the oral health needs of
children and adolescents are locality specific and will require flexibility in program
design and implementation. We hope that you will find the following information
useful for presenting dental health issues to partners in your community.   EA

        Why is Oral Health

            Mouth                                                                                       Craniofacial Tissue
       (Teeth+Gums+Tissues)             + Systemic Systems +
                                           (Nervous, Immune, Vascular)
                                                                                                          (Oral Tissue, Brain, Brain Tissue,
                                                                                                                    Facial Tissue

                                              Oral-Systemic Connection
   Good oral health means more than having healthy teeth
   Oral health is integral to general health
   Safe and effective prevention methods exist to improve oral health for everyone
   About 51 million hours of school are lost due to dental problems
   Poor dental health                pain, infection, dysfunction, poor performance
        Quotes from text of: DHHS. U.S. Public Health Service. (2001, May). Oral Health in America: A Report of the Surgeon General.
                                                            Child & Adolescent
                                                                   Oral Health
     The Problem

 Tooth decay is the single most common chronic childhood disease
    • 5 times more common than asthma
    • 7 times more common than hay fever

 Nearly twice as many children with low-SES ages 2-9 years have at
 least three decayed or filled primary teeth than do children from
 families with higher income levels.

National Institute of Dental and Craniofacial Research. (2001, Feb). A Plan to Eliminate Craniofacial, Oral, and Dental Health Disparities.
                                                                               Child & Adolescent
                  Disparities                                                         Oral Health
                              Percent untreated tooth decay among poor children
                              ages 2-9 years by Race/Ethnicity (primary teeth only)

                                                Black                              White                          Hispanic

DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General, Chapter 4, p63.    5
                                                                               Child & Adolescent
                  Disparities                                                         Oral Health
                              Percent untreated tooth decay among poor children
                             ages 12-17 years by Race/Ethnicity (permanent teeth)

                             50                                                                                          47%
                                                Black                              White                          Hispanic

DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General, Chapter 4, p64.   6
                       Percent of Total Dental School
                      Enrollment by Underrepresented
                           Minority Populations

                                1994          1995               1996              1997               1998              1999
                                        Af. American                Hispanic              Nat. American                 Total

Community Voices. (March 2001). The Big Cavity: Decreasing Enrollment of Minorities in Dental Schools. A series of Community Voices Publication.
                                Barriers in Access to
                               Dental Health Services

      Lack of awareness of seriousness of oral health
      Lack of or insufficient dental insurance
      Lack of transportation
      Uncompensated time from work
      Limited income
      Low community-to-private provider ratio
      Dentist non-participation with Medicaid/CHIP
      Low Medicaid program reimbursement rates for dental services
DHHS. U.S. Public Health Service. (May, 2001). Oral Health in America: A Report of the Surgeon General.
                            Cost and Utilization of
                               Dental Services
     • $60,000 billion                                  national dental expenditure for fiscal
                                                        year 2000         1

     • 500 million                                      average number of dental visits in
                                                        the U.S. annually             2

     • 39 million                                       number dental service beneficiaries through
                                                        Medicaid and CHIP                 1

     • 19%                                              percent of total Medicaid & CHIP
                                                        beneficiaries who received preventive dental
                                                        services      2

1 Health Care Finance Administration website: Date Accessed: July 10, 2001                    9
2 U.S. DHHS. CDC. (2000). Improving Oral Health: Preventing Unnecessary Disease Among All Americans: At-A-Glance
Oral Health Problems: A Response

          “One proven strategy for reaching
      children at high-risk for dental disease is”
       providing oral and dental health services
           in school-based health centers…
         supporting linkages with health care
      professionals and other dental partners in
                   the community”

 Grant Makers in Health Issue Dialogue.. (2001, May). Filling the Gap: Strategies for Improving Oral Health. Issue Brief.
                Potential Objectives for a
  School-Based Dental Health Program

• Increase the proportion of children who use the oral health system each
• Increase the proportion of school-based health centers with an oral
  health component.

• Increase the proportion of low-income children and adolescents who
  receive preventive dental services each year.

• Reduce the prevalence of children and adolescents with untreated dental

• Reduce the proportion of children and adolescents who have dental
  caries in their primary or permanent teeth.
  Based on objectives for the Nation in Healthy People 2010.
   Determinants of Good Oral Health
   “More than just having clean teeth”
School-based health centers have the capacity to overcome barriers in access
to dental care and to address each of these factors:

                                   Individual Factors
                                             (oral hygiene, fluoride rinse, diet/nutrition, personal risk,
                                             care seeking practices, etc.)
  Barriers to Oral/Dental Health
  Lack of Awareness
  Lack of Insurance
  Limited Income
  Lack of Transportation

    Social Environment                                Physical Environment
   (dental insurance, community awareness)          (potential for unintentional injury/accidents)

       Partnerships for
 Oral Health Programs in Schools
 Schools of                    Community
  Dentistry                   Dental Practice

Dental Health      +             Policy
Organizations     KIDS        Administrators

                City Health
 School Based Oral/Dental Health
 Program Implementation                                                            Program
                                                                                                                   •Of goals
                                                                                                                   •Of mission
A Step-by-Step Process                                                          Implementation                     •Of outcomes
                                                                                         •Parent/Child education clinical services
                                                                                         •Staff training
                                                                        Policy                                           •Chart audits
                                                                                         •On-going needs assessment
                                                                       Context                                           •Program
                                                                                         Characteristics for success:    modification
                                                                   •Local/ state regulations •Motivation
                                                                   •State licensure requirements
                                                                   •Medicaid provisions
                                               Program             •Other dental insurance provisions

                                               •Needs assessment
                                               •Oral/dental service selection
                                               •Resource considerations
                                               •Staffing availability
                        Outcomes/              •Equipment availability
                                               •Supplies/electrical units
                        Objectives             •Outcomes measures
                       •State/Local priorities •Quality assessment
                       •School priorities      •Referral networks
                       •Goals/mission          •Follow-up after referral
Infrastructure         •Short-term/long-term•Data collection
 Development                                   •Forms
                                               •Parental involvement
•Coalitions & Stakeholders
•Planning process
•Management structure
   School-Based Health Centers,
       in Partnership with
 Community Dental Providers, Can:

Enhance education

      Enhance dental service

             Eliminate barriers to dental care
Quotes from text of: DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General.   15
       A Proposed Oral/Dental Health
             Service Scheme
Student Education                                                   Parental Education & Consent
•Video Presentation       Child Risk Assessment                     •Back to school mailing
                                                                    •Emphasize importance
•Classroom Presentation
•Individual Counseling                                              •Increase awareness

           Low Risk              Coding Procedure
                                 •Standardized coding
                                                                High Risk
           Detection             •Data collection               Detection
                                 •Data analysis
                                 •Proper documentation

                               Community member
          Educate &            •Lay outreach                    Educate &
                               •Health care receptionist
        Inform Parent          •Dental hygienist
                                                              Inform Parent
                               •Health educator
                               •Letter for parent signature
                               •Phone calls             n-site
                                                        O                    Service
      Follow-Up Notice                                 Service               Referral
      Exam Reminder                                                        Transportation
                                                                         Medicaid Enrollment

                                                              Management            16
 A Proposed School-Based Oral/Dental
 Health Service Scheme: Another View
      Medical or Dental

                                  1. Risk                                                      2. Establish
                                  Assessment                                                   Periodicity
                               5. Education
                                                                                                     3. Diagnosis/
                                                            4. Guidance/
                                                                                                    Medical or Dental
Adapted from text of Casamassimo P. (1996). Bright Futures in Practice: Oral Health in America. Arlington, VA: National Center for Education in Maternal and Child Health
    Considerations in Implementing a
     School-Based Dental Program
 Staff recruitment and retention
 Sustainability –establishing a collaborative business plan
 Electrical capacity- “dedicated line” for dental equipment
 Potential use of portable equipment- (California and Oregon vendors)
 Temperature sensitive equipment, AC/fans required
 Availability of X-Ray machine- if unavailable, then referral service crucial
 Emphasis on skills training for long-term oral health maintenance
 Securing parent involvement for follow-up and family awareness
 Securing support from dental school and oral health organizations
 Securing support from local health providers involved in providing dental care
 to underserved populations                                            18
Encouraging Private Dentist Participation

       Emphasize that school-based dental programs are not competitive
  Involve private dental providers in planning for greater cooperation
       Analysis of community-to-private provider ratio:
                      Number of dental providers available to Medicaid & CHIP beneficiaries
                      Number/Percent offices open to new patients
       Private provider acknowledgement of inability to serve all children
                      Provides rationale/support for school-based services
                      More likely to support referrals for preventive/restorative care
       Capacity to follow-up in school-linked programs is crucial
                      Requires referral, annual check-up, and re-assessment
Adapted from text of: William Mercer Inc. (April, 2001). Geographic Managed Care Dental Program Evaluation: Executive Summary   19
prepared for the Medi-Cal Policy Institute
         Oral Health Service Outcome Measures
                                                                          Behavioral                                             Physical
                    Educational                                           (family & child)
                      (family & child)

          Increased awareness of oral health                 Adoption of on-going oral hygiene and                Child has good dental health: teeth free
          concerns                                           care seeking practices                               from caries and plaque accumulation

                                                             Adoption of better parental guidance in              Child has good occlusal health: functional
          Understands personal responsibility
                                                             oral health & hygiene                                & stable bite

          Basic understanding of types of oral                                                                    Child has good periodontal health: healthy
                                                             Use of fluoride and acid rinses
          health conditions                                                                                       gums

          Understands personal risk factors                  Adoption of better dietary habits                    Child has 6 and 12 year molar sealants

                                                             Drug, tobacco, alcohol
          Positive attitude about dental care

                                                             Use of protective gear to prevent tooth
          Means to access dental services                    loss and injury
          (Community or SBHC)
                                                                                                                                                          20           19
Adapted from text of Casamassimo, P. (1996). Bright Futures in Practice: Oral Health in America. Arlington, VA: National Center for Education in Maternal and Child Health

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