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School-Based Dental Health
Considerations for Program
Development
By: Erica M. Allen
Intern, Center for Health and Health Care in Schools
Candidate for MPH, MCP Hahnemann University
School of Public Health-Philadelphia
Preface
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
2
Why is Oral Health
Important?
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
3
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.
4
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)
80
71%
67%
70
57%
60
50
40
30
20
10
0
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%
44%
40
30
21%
20
10
0
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
14
12
10
8
Percent
6
4
2
0
1994 1995 1996 1997 1998 1999
Af. American Hispanic Nat. American Total
7
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.
8
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: http://www.hcfa.gov. 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”
10
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
year.
• 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
decay.
• 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.
11
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)
12
Partnerships for
Oral Health Programs in Schools
School
Schools of Community
Personnel
Dentistry Dental Practice
PARENTS
Dental Health + Policy
Organizations KIDS Administrators
Medicaid/SCHIP
City Health
Department
13
School Based Oral/Dental Health
Evaluation
Program Implementation Program
•Of goals
•Of mission
A Step-by-Step Process Implementation •Of outcomes
•Of
•Parent/Child education clinical services
…………...
•Staff training
Policy •Chart audits
•On-going needs assessment
Context •Program
Characteristics for success: modification
•Flexibility
•Local/ state regulations •Motivation
•State licensure requirements
•Medicaid provisions
Program •Other dental insurance provisions
Design
•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
14
13
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
Follow-Up
Management 16
A Proposed School-Based Oral/Dental
Health Service Scheme: Another View
Medical or Dental
Professional
EPSDT
1. Risk 2. Establish
Assessment Periodicity
Family
+
Child
5. Education
Individual/
Parent
3. Diagnosis/
Treatment
4. Guidance/
Referral
EPSDT
Medical or Dental
Professional
17
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
cessation/reduction
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
