1. Considerations for Program Development School-Based Dental Health By: Erica M. Allen Intern, Center for Health and Health Care in Schools Candidate for MPH, MCP Hahnemann University School of Public Health-Philadelphia

2. 2 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

3. 3  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 Why is Oral Health Important? Mouth (Teeth+Gums+Tissues) Systemic Systems (Nervous, Immune, Vascular) + Craniofacial Tissue (Oral Tissue, Brain, Brain Tissue, Facial Tissue + Oral-Systemic Connection Quotes from text of: DHHS. U.S. Public Health Service. (2001, May). Oral Health in America: A Report of the Surgeon General.

4. 4 Child & Adolescent Oral Health 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. The Problem

5. 5 Child & Adolescent Oral Health Percent untreated tooth decay among poor children ages 2-9 years by Race/Ethnicity (primary teeth only) Disparities DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General, Chapter 4, p63. 67% 57% 71%

6. 6 Child & Adolescent Oral Health Percent untreated tooth decay among poor children ages 12-17 years by Race/Ethnicity (permanent teeth) Disparities DHHS. U.S. Public Health Service. (May, 2001, May). Oral Health in America: A Report of the Surgeon General, Chapter 4, p64. 44% 21% 47%

7. 7 Percent of Total Dental School Enrollment by Underrepresented Minority Populations Percent Community Voices. (March 2001). The Big Cavity: Decreasing Enrollment of Minorities in Dental Schools. A series of Community Voices Publication.

8. 8 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.

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

10. 10 school-based health centers… “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. Oral Health Problems: A Response

11. 11 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. School-Based Dental Health Program Potential Objectives for a

12. 12 Determinants of Good Oral Health “More than just having clean teeth” Determinants of Good Oral Health “More than just having clean teeth” Individual Factors Physical Environment (oral hygiene, fluoride rinse, diet/nutrition, personal risk, care seeking practices, etc.) (potential for unintentional injury/accidents) Social Environment (dental insurance, community awareness) Barriers to Oral/Dental Health Lack of Awareness Lack of Insurance Limited Income Lack of Transportation School-based health centers have the capacity to overcome barriers in access to dental care and to address each of these factors:

13. 13 Partnerships for Oral Health Programs in Schools City Health Department School Personnel Schools of Dentistry PARENTS+ KIDS Policy Administrators Medicaid/SCHIP Community Dental Practice Dental Health Organizations

14. 14 School Based Oral/Dental Health Program Implementation A Step-by-Step Process School Based Oral/Dental Health Program Implementation A Step-by-Step Process Infrastructure Development Program Design Program Implementation Outcomes/ Objectives State/Local priorities School priorities Goals/mission Short-term/long-term Coalitions & Stakeholders Planning process Management structure Needs assessment Oral/dental service selection Resource considerations Staffing availability Equipment availability Supplies/electrical units Outcomes measures Quality assessment Referral networks Follow-up after referral Data collection Forms Parental involvement Parent/Child education Staff training On-going needs assessment Of goals Of mission Of outcomes Of clinical services …………... Chart audits Program modification Policy Context Evaluation Prior to start of school year Local/ state regulations State licensure requirements Medicaid provisions Other dental insurance provisions Characteristics for success: Flexibility Motivation 13

15. 15 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.

16. 16 Child Risk Assessment Low Risk Detection Educate & Inform Parent Follow-Up Notice Exam Reminder High Risk Detection Educate & Inform Parent O n-site Service Follow-Up Management Service Referral Transportation Medicaid Enrollment Community member Lay outreach Health care receptionist Dental hygienist Health educator Letter for parent signature Phone calls A Proposed Oral/Dental Health Service Scheme Coding Procedure Standardized coding Data collection Data analysis Proper documentation Parental Education & Consent Back to school mailing Emphasize importance Increase awareness Student Education Video Presentation Classroom Presentation Individual Counseling

17. 17 A Proposed School-Based Oral/Dental Health Service Scheme: Another View 2. Establish Periodicity 1. Risk Assessment 3. Diagnosis/ Treatment 4. Guidance/ Referral Referral 5. Education Individual/ Parent Family + Child Medical or Dental Professional 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 EPSDT

18. 18 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

19. 19 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 prepared for the Medi-Cal Policy Institute

20. 20 Oral Health Service Outcome Measures Educational (family & child) Behavioral (family & child) Physical Increased awareness of oral health concerns Adoption of on-going oral hygiene and care seeking practices Child has good dental health: teeth free from caries and plaque accumulation Understands personal responsibility Adoption of better parental guidance in oral health & hygiene Child has good occlusal health: functional & stable bite Basic understanding of types of oral health conditions Use of fluoride and acid rinses Child has good periodontal health: healthy gums Understands personal risk factorsAdoption of better dietary habitsChild has 6 and 12 year molar sealants Positive attitude about dental care Drug, tobacco, alcohol cessation/reduction Means to access dental services (Community or SBHC) Use of protective gear to prevent tooth loss and injury 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 19