HOW do you go about increasing access to oral health education, prevention, and services for our school-age children, once you understand WHY there is a great need? There is no ‘right’ way or place to begin – it depends on your community’s needs, existing programs, opportunities for partnerships, policies, regulations, and the will to start somewhere.

There are many critical partners and approaches to HOW. You may be at the beginning of the oral health journey, or you may already provide some services but wish to add additional services or may need to improve the services. The Playbook looks at the national, state, and local resources that support the HOW, with suggestions for working with schools, communities, and engaging families in the school dental program. Approaches range from individual-level oral health care to a broader, public health perspective.

Schools play a significant and unique role in HOW we approach improving access to oral health and improving outcomes for all our children. The range of services that schools can provide or support may address the needs of individuals as well as families and communities. Schools, school nurses, teachers, and school-based health centers (SBHCs) can provide oral health education. School-wide oral health screenings can serve as a baseline for the oral health needs you will address in your school-based dental program. If your school has a school-based health center (SBHC), adding dental services is a natural extension of the primary care services offered by the center.

Schools can become the center for multiple opportunities to improve the oral health and overall health of the students, increasing their chances to stay in school and achieve. Successful school-based oral health programs benefit from thorough planning, community collaboration, and partnerships between schools and health providers to ensure the program meets the needs of students and their families. The Playbook section below describes the benefits and challenges of school-based dental programs, and factors to consider that will help shape your program. The national, state and local resources offer best practices drawn from successful school dental programs throughout the country.

Benefits of school-based oral health program and services:

  • Teaching the importance of oral health to overall health and wellness
  • Developing life-long oral health habits
  • Early screening and identification of oral health conditions
  • Ability to provide hygiene services to improve oral health, with the potential to treat oral health problems
  • Barrier-free access to oral health care within the school environment; particularly for communities that have scarce access to oral health providers
  • Parents can remain at work while children stay in school
  • Ability to improve overall community oral health.

Common challenges of school-based oral health programs:

  • Families and educators understanding the importance of regular oral health care
  • Care coordination with community dental practitioners
  • Obtaining signed consent forms
  • Working with schools to develop an efficient program that contributes to the learning environment
  • Identifying the level of oral health services that are needed and designing an appropriate program
  • Potential state or local policy issues that may impact the provision of services
  • Scheduling and funding challenges to ensure program sustainability.

Integrating Oral Health into the Primary Care Setting

School-based oral health programs are especially effective in reaching children and youth in school, where they spend most of their day. Targeting schools with higher rates of minorities and low-income families also increase access to prevention, education, and care, and decreases disparities.

Yet increasing options for oral health care in schools will not alone solve the burden of oral disease. The two disciplines of primary care and dentistry must work together to systemically change their approach, and bring the mouth back into the whole body through the integration of oral health care into primary care. Integrating oral health into primary care requires multilevel changes in systems, attitudes, and policies. Although integration of oral health into primary care is not the focus of the Playbook, it is key to the broader strategy to decrease oral health disease, especially in children and youth.  For schools with school-based health centers, adding dental services to existing primary care services expands the comprehensive care capabilities of this model.

For more information on this important strategy, the following resources will frame the key elements:

Learning about the oral health — overall health connection needs to start early as health behaviors develop, along with beliefs and attitudes, during the critical school years. The earlier children establish healthy oral health habits and ideas, the better the long-term outcomes.

  • https://pediatrics.aappublications.org/content/pediatrics/134/6/1224.full.pdf  The link provides you the complete policy statement from AAP to maintain and improve the oral health of young children, focused on helping the pediatric provider understand the connection between oral health and overall health and their role in prevention and intervention of oral health disease.
  • https://www.smilesforlifeoralhealth.org/  Smiles for Life is a comprehensive, online learning tool for health professionals made up of learning modules and resources to help integrate oral health and primary care across the lifespan. Look for specific modules on Child Oral Health and Caries Risk Assessment, Fluoride Varnish, and Counseling. Content includes practice tools, patient education, publications, guidelines, education and IPE, videos, interactive games, oral health information links, and Android/IOS apps.
  • https://ilikemyteeth.org/ohpp/  Oral Health Prevention Primer from Campaign for Dental Health, Academy of Pediatrics.  The primer is a comprehensive tool designed to help pediatricians and other health professionals address oral health in practice, understand the roles of oral health allies, and learn how to collaborate and advocate to achieve optimal oral health for their community to prevent dental disease before it starts.

Working with Educational Communities

New York City sealant data among school-aged children indicated a very low uptake rate, an indicator of dental decay in permanent teeth. Most students using SBHC medical services had not had dental services anywhere. This clearly made the case for adding dental services to the existing SBHC program. Each school was challenged with lack of space for dental rooms, yet the desire for dental services was evident. This challenge was overcome eventually, and now all the schools want dental services within their walls.

Margaret E. Rogers DNP, RN, FNP-BC, Director of Primary Health Care, Montefiore School Health Program Tweet

Working effectively with schools requires a vital understanding of how educational systems work, speak, and enact change. There are unique challenges and opportunities when working within educational systems to bring health-related education and services to the students in the school setting.  School administrators and school nurses are instrumental in understanding the health needs of students in the school, and in the design of your oral health program.  Successful school-based oral health programs have learned to work collaboratively with these key stakeholders to promote the program to parents and faculty, design a program that is least disruptive to learning, and navigate the environment unique to each school building.

Oral health problems are one of the top five reasons for chronic school absenteeism.  School-based oral health programs can provide services to reduce or eliminate dental problems or dental pain, improving school attendance for children that may have difficulty accessing care in the community for a multitude of reasons.  Your school dental program can strengthen the collaboration between the sponsoring organization, the school district and administration, the faculty, and school nurses.  School nurses provide an essential service by identifying student’s health needs and serve a key role in determining students in need of oral health care. Working collaboratively with school administration and the school nurse increases the integration of medical and dental health care.

The following resources introduce you to initiatives, philosophies, and strategies to help you work successfully with educational communities.

  • http://healthinschools.org/our-work/school-community-partnerships/#sthash.pPPYvqx4.dpbs  The Center for Health and Health Care in Schools works with state and district-level leaders to integrate and prioritize disparate strategies that range from targeted interventions to broader prevention efforts, coordinate approaches to behavioral, oral, and physical health, and tailor solutions to the unique context of each school and school district.
  • https://www.attendanceworks.org/bringing-dental-care-to-schools/: Attendance Works provides strategies and resources to reduce chronic absence and improve school attendance.  This article highlights the impact of bringing teledentistry to schools to address dental problems right in the school environment.
  • http://healthpolicy.ucla.edu/publications/Documents/PDF/Unaffordable%20Dental%20Care%20Is%20Linked%20to%20Frequent%20School%20Absences.pdf  Unaffordable dental care links to frequent school absences. This UCLA Health Policy Research Brief explains how frequent absences may have significant negative societal and economic consequences.
  • https://ctb.ku.edu/en/get-started  Community Tool Box: how do we begin taking action in the community? Millions of people use the Community Tool Box each year to get help taking action, teaching, and training others in organizing for community development. Dive in to find help assessing community needs and resources, addressing social determinants of health, engaging stakeholders, action planning, building leadership, improving cultural competency, planning and evaluation, and sustaining your efforts over time.
  • https://www.edutopia.org/blog/school-community-collaboration-brendan-okeefe  5 Steps to Better School/Community Collaboration: Simple ideas for creating a stronger network, an author’s perspective on education/school transformation. When families, community groups, businesses, and schools band together to support learning, young people achieve more in school, stay in school longer, and enjoy the experience more.
  • https://www.cdc.gov/healthyschools/wscc/index.htm  The Whole School, Whole Community, Whole Child, or WSCC model, is CDC’s framework for addressing health in schools.  The WSCC model is student-centered and emphasizes the role of the community in supporting the school, the connections between health and academic achievement, and the importance of evidence-based school policies and practices.
  • https://www.astdd.org/www/docs/integrating-oral-health-into-the-whole-school-whole-community-whole-child-school-health-model.pdf  The policy statement from Association of State and Territorial Dental Directors (ASTDD) provides an overview of how one can strategically integrate school-based oral health programs within the Whole School, Whole Community, Whole Child School Health model.
  • https://www.astdd.org/bestpractices/wscc-bpar-final-3-2017.pdf ASTDD provides a comprehensive look at the Best Practice Approach through the Whole School, Whole Community, Whole Child (WSCC) Model. The WSCC model represents the ten components addressing education, public health, and school health alignment for improved health outcomes, and gives specific recommendations for integrating oral health into the WSCC model.

Engaging Families

Offering oral health education and services in schools enable students to more easily access a broad range of services in a safe, familiar environment at minimal or no cost to students and their families.

Family factors have an impact on children’s use of dental services. A recent study found that three key factors improve children’s oral health: continuous enrollment in health insurance, regular check-ups for well-child care, and parents that access their own preventive dental care. (source: https://www.cthealth.org/publication/family-factors-increase-kids-dental-check-ups-and-health-equity).  When policies address these factors, and families are able to access care, there is a reduction in racial and ethnic oral health disparities among all school-aged children.

Schools and school-based health centers can emphasize the importance of regular oral health care to students, families, and the community. When parents, schools, and SBHCs work together, they can deliver clear, consistent messages to children, encourage the development of positive health behaviors, and assist children in getting necessary preventive care in a timely and easily accessible setting within the school environment. When working with parents, the following key points can help engage families in care:

  • Educate parents about school health services and managing chronic health conditions in school settings
  • Provide parents with practical strategies and actions to improve the school health environment – all parents want the best for their children and have great ideas to share.

(source: https://www.cdc.gov/healthyschools/parentsforhealthyschools/resources.htm)

The following are resources supporting family engagement:

Financial Considerations

Early intervention in oral health problems using evidence-based programs can help avoid unnecessary expenses resulting from delayed care.

Multiple factors influence the design and development of a school-based dental program.  Consideration must be given to start-up costs of the program and financial sustainability to continue to operate the program over the long-term. Program costs will vary depending on the level of services offered.  For programs providing direct services, the primary expenses include the initial purchase of equipment and ongoing cost of supplies, transportation methods, and related costs if the equipment moves, staff salaries, marketing, and promotional materials, equipment maintenance, and liability insurance. Financing for start-up costs comes from local, state, or federal grants as well as targeted fundraising campaigns.

The identification of a sponsoring organization for a school dental program will vary depending on location – the rates of reimbursement for direct care services will vary by state and sponsor type.  Reimbursements from Medicaid, CHIP, and private insurance billing are a valuable source of funding when combined with grants or fundraising revenues.  You can use the financial feasibility calculator from Smart Mouths Smart Kids listed below to calculate program expenses, revenues, and sustainability.

The following resources will assist your financial considerations:

Policy Considerations

It is vital to use a multipronged approach – ensuring good oral health care for the individual as well as improving the systems of care that serve them – ensuring accessible, affordable, and equitable care for all.

Each state differs in its licensing and scope of practice for dental professionals. School-based oral health programs may use a combination of professionals to provide services, including dentists, dental hygienists, and emerging provider models such as expanded function dental assistants and dental therapists. The supervision requirements for dental hygienists vary by state and play a critical role in the capacity of school-based oral health programs. The variations in the degree of practice autonomy for dental hygienists and other provider types in your state’s dental practice act will impact the design of your school-based oral health delivery model.

  • https://www.adha.org/resources-docs/7511_Permitted_Services_Supervision_Levels_by_State.pdf  A summary of dental hygiene practice acts for permitted functions and supervision levels by state.
  • https://dentistry.temple.edu/sites/dentistry/files/uploads/PPCT/Oral_Health_Advocacy_Toolkit.pdf  This Oral Health Advocacy Toolkit provides strategies and resources for dental schools and dental hygiene programs to help create advocacy goals, choose allies, build coalitions, frame messages, and present data to build support for your program.
  • https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/Oral-Health.aspx   The American Academy of Pediatrics works to improve children’s oral health through communication and collaboration between the medical and dental homes and to make pediatricians and other health professionals an essential part of the oral health team.
  • https://www.astdd.org/dental-public-health-policy-committee/  ASTDD is the principal voice promoting the leadership capacity of state and territorial oral health programs and the impact that their collective oral disease prevention and health promotion activities have on the nation’s oral health. ASTDD works with a broad array of federal, state, and local public and private partners to educate decision-makers on dental public health issues and concerns of state and territorial oral health programs (S/TOHP).
  • https://nashp.org/policy/maternal-child-and-adolescent-health/child-oral-health/  The National Academy for State Health Policy explores how several states, including Minnesota and Arizona, are expanding their oral health workforce to increase access to care and promote health equity and patient safety.
  • https://familiesusa.org/our-work/  Families USA, a leading national, non-partisan voice for health care consumers, is dedicated to achieving high-quality, affordable health care and improved health for all. Our work is driven by and centered around four pillars: value, equity, coverage, and consumer experience. We view these focus areas — and the various issues unique to each area — as the cornerstones of America’s health care system.
  • https://www.frontiersin.org/articles/10.3389/fpubh.2019.00359/full Advancing Oral Health Equity Through School-Based Oral Health Programs: An Ecological Model and Review.  The authors view school-based oral health programs as vehicles for advancing oral health equity since vulnerable children often lack access to any preventive or treatment services absent on-site care provision at schools. At the same time, they are incapable of achieving sustainable results without attention to multiple levels of influence. Policy solutions that improve the nutritional quality of children’s diets in schools and neighborhoods and engage alternative providers at all levels of influence may be both effective and equitable.
  • https://www.ada.org/en/science-research/health-policy-institute The Health Policy Institute (HPI) aims to be a thought leader and trusted source for critical policy knowledge related to the U.S. dental care system. The key issues that HPI focuses on include health policy reform, access to dental care, the dental workforce, dental care utilization and benefits, dental education, and oral health outcomes.

Improving or Expanding Existing School Dental Programs

Your school dental program may offer oral health education and screenings, but perhaps you want to add dental hygiene services or restorative services. You may provide services but want to measure and improve the quality of the oral health services in your program.  HOW do you begin to measure the impact of your work, or increase the number of students that access the services? What are the measures that will guide your improvement efforts, and HOW do you reach out to school nurses, parents, and students to ensure they have an awareness of your program and services.

The relationships we built up front lasted, and we became part of the school and they treat us like we are part of them. We were committed to offering restorative dental services from the start because we knew we needed to make the whole child healthy. We learned to accommodate our program to what the school needs, and this is a big part of our success.

Georgia Famuliner, Chief Operations Officer, Smiles for a Lifetime, Welvista Tweet

The following resources provide nationally recognized oral health measures and quality improvement guidelines to help you strengthen your existing school dental program:

Advocating for Your School Dental Program

To ensure access to good oral health — dental, medical, and other professionals need to work together.

Advocacy can make a significant difference in ensuring that everyone has access to coverage, care, and improved health.  Are you starting a new school dental program?  You’ll need advocates and champions to promote the program to the school administration, school staff, parents, students, and community dental providers.  Are you advocating for higher reimbursement rates for dental services or changes to dental professionals’ practice locations?  You’ll need champions to help change policies in your state, and an information campaign to increase awareness of your issue.  For both new and established school-based dental programs, you might collect student stories about their struggles with dental pain and school attendance, or difficulty getting to dental appointments.   Students that have an SBHC in their school understand the value and convenience of services in their school, and with their parents, can be effective advocates for adding dental services to school-based programs.  All of these activities require an advocacy strategy and tools to help you succeed. The resources below will help inform your advocacy activities.

Addressing Equity in Your School Dental Program

Health equity exists when all people have the resources they need to lead happy, productive, healthy, and meaningful lives. These resources will be different depending on the person and community and must address the structural and systemic barriers that contribute to health inequities.  Significant disparities exist in oral health across race and ethnicity, gender, geography, education level, and income. Oral health outcomes are often worse among people of color, people who live in more rural areas, and people experiencing poverty. As you design your dental program, making decisions through an equity lens could influence the range of diverse stakeholders that are engaged, hiring practices and staff team composition, distribution of resources, leadership opportunities, and decision-making protocols. Your dental program can make significant and positive changes to the oral health of the youth in your school or district – changes that can impact their health for years to come. The following resources can help increase your understanding of health equity:

Resources

National Resources:

Multiple national organizations provide a focus on oral health and specific connections to school-age children, school-based programs, provider types, and model programs. The following represents a list of broad-spectrum, although not exhaustive, national organizations most often associated with the previous topics and recognizes there are additional organizations that work in the same space.

  • http://www.oralhealth.network/  Oral Health Progress and Equity Network is a diverse network of individuals and organizations working to ensure that policy, financing, care, and community aligns to promote oral health as an essential part of overall health and wellbeing.
  • http://www.dentaquest.com/the-partnership/  The nonprofit DentaQuest Partnership for Oral Health Advancement is laser-focused on transforming our broken health care system to enable better health through oral health. Prioritizing person-centered care, the DentaQuest Partnership will drive health system transformation at the local, state, and national levels in pursuit of DentaQuest’s common mission – to improve the oral health of all.
  • www.sbh4all.org The School-Based Health Alliance works to improve the health of children and youth by advancing and advocating for school-based health care. Our vision is that all children and adolescents are healthy and achieving their fullest potential.
  • www.ada.org The American Dental Association (ADA) exists to power the profession of dentistry and to assist members in advancing the overall oral health of their patients. Together with 163,000+ members, ADA has been driving dentistry forward for 160 years.
  • www.aap.org:  The mission of the American Academy of Pediatrics is to attain optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults. To accomplish this, AAP shall support the professional needs of its members. AAP has 59 US chapters.
  • https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Oral-Health/Pages/State-Information-and-Resources-Map.aspx   Find your state representative from the Chapter Oral Health Advocates, who are pediatricians assisting in training for the incorporation of oral health into the medical home, advocate at the state and local levels, connect pediatricians to others working in their community to improve children’s oral health, and build relationships with dental colleagues in their communities and dental societies to improve access to oral health care.
  • www.adha.org/  Founded in 1923, the American Dental Hygienists’ Association (ADHA) is the largest national organization representing the professional interests of the more than 185,000 registered dental hygienists (RDHs) across the country, with the belief that dental hygienists should be valued and integrated into the broader health care delivery system to improve the public’s oral and overall health.
  • http://ohnep.org  Oral Health Nursing Education and Practice is the vanguard of helping nurse practitioners, nurse-midwives, nurses, and other health professionals incorporate oral health into patient care.
  • www.astdd.org  The Association of State and Territorial Dental Directors (ASTDD) is a national non-profit organization representing the directors and staff of state public health agency programs for oral health. ASTDD formulates and promotes the establishment of national dental public health policy, assists state dental programs in the development and implementation of programs and policies for the prevention of oral diseases; builds awareness and strengthens dental public health professionals’ knowledge and skills by developing position papers and policy statements; provides information on oral health to health officials and policymakers, and conducts conferences for the dental public health community.
  • https://www.nasn.org/home  The National Association of School Nurses is a non-profit specialty nursing organization, first organized in 1968 and incorporated in 1977, representing school nurses exclusively. NASN has more than 17,000 members and 50 affiliates, including one in the District of Columbia and one serving school nurses overseas. The mission of NASN is to optimize student health and learning by advancing the practice of school nursing.
  • https://www.nihb.org/oralhealthinitiative/ National Indian Health Board-The NIHB’s Tribal Oral Health Initiative is a growing body of work that includes a toolkit, research, Tribal leader and Tribal healthcare administrator trainings, and, eventually, the Tribal Oral Health Agenda.
  • https://www.aaphd.org/  American Association of Public Health Dentistry accepts the challenge to improve total health for all citizens through the development and support of effective programs of oral health promotion and disease prevention.
  • http://www.anohc.org/  The American Network of Oral Health Coalitions (ANOHC) is a network of 39 State Oral Health Coalitions that advocate for 294 million Americans. ANOHC members are statewide oral health coalitions that promote lifelong oral health by shaping policy, promoting prevention, and educating the public. ANOHC exists to create a reliable place for state oral health coalitions to share information, ask questions, and leverage time and resources.
  • https://www.aacdp.com/  American Academy of Community Dental Programs supports the efforts of those serving the oral health needs of vulnerable populations at the community level. Members include the staff of city, county, and community-based health programs with interest in oral health issues and access to care.
  • https://www.mchoralhealth.org/  A national center serving the maternal and child health community with high-quality oral health technical assistance, training, and resources.
  • https://www.ruralhealthinfo.org/toolkits/oral-health  The Rural Oral Health Toolkit addresses the unique challenges of providing oral health in rural areas. The Toolkit helps to identify and implement an oral health program in your rural community. It also provides resources and best practices.
  • https://www.cdc.gov/oralhealth/index.html CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same. The link provides oral health resources.
  • https://brightfutures.aap.org/clinical-practice/Pages/default.aspx  Bright Futures is a set of principles, strategies, and tools that are theory-based, evidence-driven, and system-oriented, to improve the health and well-being of all children through culturally appropriate interventions that address the current and emerging health promotion needs at the family, clinical practice, community, health system, and policy levels.
  • https://www.napnap.org/  The National Association of Pediatric Nurse Practitioners is the professional association for pediatric nurse practitioners (PNP) and all pediatric-focused advanced practice registered nurses (APRNs.)
  • https://www.aapa.org/  The American Academy of Physicians Assistants advocates and educates on behalf of the profession and the patients that physicians assistants serve.

State Level Resources: At the state level, you could start your investigation with any or all of the potential partners or avenues listed below.

  • Your state oral health coalition (anohc.org American Network of Oral Health Coalitions)
  • The state health department who might:
    • have a dental director and a state plan
    • collect helpful data
    • support surveillance
    • provide preventive services and education
    • support initiatives that focus on the integration of primary care and oral health, payment reform, and health care transformation
    • oversee school nurse consultants and oral health providers in the schools
  • State Dental associations and Dental Hygiene associations
  • School nurse associations
  • Pediatric providers and state-level chapters of the American Academy of Pediatrics
  • Departments of Education
  • Children with Special Health Care Needs
  • Children’s Advocacy Groups
  • Private foundations with a focus on oral health and equity.

Local Level Resources: At the local level, you have some of the same options listed in the state-level section, and found at the local or county level.  Some examples include:

  • Local oral health coalitions and partnerships
  • Local health departments that may:
    • collect data as part of a community needs assessment
    • undertake surveillance
    • have health educators that provide oral health education
    • partner with organizations to provide dental screenings
    • employ school nurses
  • Local dental associations that meet in your area
  • Federally qualified health centers (FQHCs) that may be effective partners for a school-based oral health program
  • Local children’s advocacy groups
  • School partners, special education departments, school nurses, and public health providers/systems