WHAT programs exist and what lessons can we learn from their successes and challenges

Communities across the country have developed school-based oral health programs to increase children’s access to oral health services. School-based programs can integrate oral health into the fabric of the learning environment, and provide opportunities to assess the oral health of all children in a school. In schools with School-Based Health Centers, the sponsoring organization, or community programs can partner with existing medical and behavioral health services to offer integrated dental services to students onsite.

SBHCs already have a presence and well-established relationships within the school, have a defined health facility for existing services, understand the needs of the student population, and understand how to work within the school environment.  The SBHC can serve as a dental home if they offer comprehensive dental services, or can partner with community dental providers to ensure that students have an established dental home – a critical component of continuity of care.

We wanted to add dental services to our SBHC program. We visited a well-established school dental program in a community similar to ours. Armed with data from their program, our dental team screened students in 5 schools with SBHCs in the first year to gather community-specific data, screening 95% of students in each school. We provided hygiene services to students in need, and then shared aggregate data with the principals to demonstrate rates of decay and the ongoing need for dental services in the schools.

Sue Peters, MPH, APRN, RN, Director of School Health Programs, New Haven Public Schools Tweet

Many factors affect the planning and implementation of a program, including the community oral health environment, existing infrastructures, cultural influences, resource availability, the extent of oral disease, equitable access to services, and political considerations at the local and state level. Community needs, partnerships, regulations, state practice laws, and resources greatly influence the services and delivery models offered by various school-based dental programs.

Advantages of school-based oral health program and services:

  • Conduct screening and education programs in a variety of settings with minimal supplies
  • Conduct school-based dental sealant programs on a specified, limited schedule and require some supplies
  • Mobile vans and programs using portable dental equipment operate on a specific schedule and tend to be set up at the school temporarily. Once all enrolled students receive services, the equipment or van moves to another school location. These programs provide hygiene services and may provide restorative services for children requiring treatment for dental caries. Mobile and portable programs require equipment and supplies to provide direct care; portable programs may utilize temporarily assigned space in the school buildings
  • Fixed-site programs have a specified, permanent location in school buildings or on school grounds and may use portable or fixed equipment.

Common considerations for school-based oral health programs:

  • Identifying a healthcare sponsor for the school-based dental program
  • Developing a referral source or network to accept students needing restorative treatment outside the school setting
  • Providing in-school services or community services for students without dental insurance
  • Decreasing numbers of providers that accept Medicaid insurance in some states or communities
  • Identifying funds for initial equipment purchases and ongoing need for disposable supplies
  • Ensuring adequate utilization of the program to sustain the services
  • Expect a slow first year for new programs, as generally year two is when programs become cost-effective
  • Obtain a reliable process for data collection and processing to ensure data is not lost; develop a tracking mechanism to demonstrate the cost-effectiveness of the in-school dental program
  • Adopting best practices and innovative approaches to improve consent form return rates, which can be a primary barrier in the successful functioning of school-based programs.

School based dental programs are a long game. Every advance that you achieve places you one step closer to your vision for the oral health of the children. You must have patience and perseverance, try new things, and adapt and evolve as things change. You need to recognize and care for your team, and nurture them so they feel valued.

Terri Chandler, RDH, Future Smiles Founder and Executive Director Tweet

Types of Programs

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The following programs represent a cross-section of types of services and delivery models. The School-Based Health Alliance describes the main program types and most common delivery models in its white paper, School Oral Health: An Organizational Framework to Improve Outcomes for Children and Adolescents.

There are five main program types:

  • Oral health education
  • Oral health screenings with referrals for care
  • School-based dental sealant/varnish programs
  • School-based dental hygiene program
  • School-based hygiene and restorative treatment programs.

There are five common delivery models, including:

  • Fixed dental centers located in schools (most often associated with school-based health centers)
  • Portable equipment carried into schools and located in temporary spaces (the most common delivery model)
  • Teledentistry-emerging models including integration with school-based primary care or school nurses
  • Mobile vans parked on school property
  • Mixed delivery models.

Described below are the various models:

  • Fixed site—Fixed dental centers are often part of school-based health centers (SBHCs) located in school buildings or on school grounds, or may be permanent dental centers operated by an outside agency. In general, fixed sites occupy a dedicated, permanent space in the school building but may use some portable equipment.
  • Portable equipment—Portable dental equipment is relatively easy to move and is used to bring dental services to schools. The equipment occupies a fairly small space and can set up in empty classrooms, all-purpose rooms, unused offices, or in other available spaces.
  • Teledentistry models—Teledentistry models aim to improve oral health using telehealth-connected teams and virtual dental homes. This relatively new operational model will continue to grow in the future as a way to increase access to care and utilize technology to connect dentists offsite with team-based care delivered on-site.
  • Mobile van—Mobile vans are recreational vehicle–style vans that health professionals use to bring health services to schools. The vans may be equipped with exam rooms and medical equipment or outfitted with a full dental operatory.
  • Mixed delivery models—Mixed delivery models may include the use of portable equipment or teledentistry at one or more schools and a fixed site at another school. Mixed delivery models often adapt to the size of the student body at the individual schools and the oral health needs of students in each school.

School-Based Health Centers

Many School-Based Health Centers (SBHC) have added dental care to their comprehensive health services. SBHCs, defined in federal statute as health clinics that (i) locate in or near school facilities of school districts or boards or Indian tribes or tribal organizations; (ii) organize through school, community, and health professional relationships; (iii) administer by sponsoring facilities; (iv) use health professionals to provide primary care services to children per state and local laws, including laws relating to licensure and certification; and (v) satisfy such other requirements as states may establish for the operation of such clinics.

Our relationship with the established School-Based Health Centers, and the relationship they already had with the school, helped to foster acceptance and trust of the School Dental Centers. The SBHCs paved the way for acceptance of the addition of dental services. The school was accustomed to First Health providing medical and behavioral health services in the school, so it was not a hard sell to add dental services. The SBHC nurse practitioners and school nurses make referrals to the dental center – the schools understand that the need for onsite dental care exists for these children.

Dena Hunt, Dental Assistant, First Health of the Carolinas Tweet

School-based dental programs can be oral health components of SBHCs.  School-Based Health Centers that provide medical and behavioral health services may include oral health services in their comprehensive health approach.  Services can range from oral health screenings to sealant programs to full hygiene and restorative treatment.  The SBHC may develop a fixed site delivery model within the SBHC facility or in another location within the school. Students benefit from the cross-referral practices between medical and dental providers.  Many fixed site models use portable dental equipment that remains in the SBHC location, but can be moved if necessary. SBHCs that utilize the services of dental hygienists and dentists can serve as the student’s dental home.

A variety of sponsoring organizations can provide support and oversight to school-based dental programs. Some of the most common sponsoring organization types include:

Federally Qualified Health Centers—Federally Qualified Health Centers (FQHC) are public or private not-for-profit organizations that provide preventive and primary health care to populations with limited access to health services. Students can benefit from the provision of dental services in school, with a linkage to a dental home in the FQHC.  For additional information:  http://www.nnoha.org/nnoha-content/uploads/2014/07/SBHC-Report-FINAL_2014-07-28.pdf

State Health Departments – Many state health departments disburse funds to implement statewide school-based dental sealant programs and provide guidelines and metrics to guide the implementation, promotion, data collection, and best practice approaches. For additional information on the CDC School Sealant Programs:  https://www.cdc.gov/oralhealth/dental_sealant_program/school-sealant-programs.htm

Private Nonprofit Corporations – Nonprofit organizations may provide a variety of healthcare programs that may include school dental services, or may form solely to offer dental programs in schools.

Hospitals and Medical Centers – SBHCs sponsored by hospitals may be considered satellite locations or outpatient clinic sites affiliated with the hospital or medical center.  Students may link to the primary locations for services outside the scope of the school-based dental program.

School Systems – Local boards of education may sponsor SBHCs and or school dental programs. Upon written consent, all children are eligible to receive services. Staff may be school employees, increasing coordination of care with other school programs and services.

Tools for School-Based Oral Health Programs

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Planning Tools

Risk Assessments

Partnerships

  • https://www.ada.org/en/public-programs/national-childrens-dental-health-month The National Children’s Dental Health Month Program Planning Guide offers program coordinators resources to promote the benefits of good oral health to children. This month-long national health observance brings together thousands of dedicated dental professionals, health care providers, and others to promote the benefits of good oral health to children and adults, caregivers, teachers, and many others. The guide includes easy-to-do activities, program planning timetable tips, a sample NCDHM proclamation, and much, much more.
  • https://www.adafoundation.org/en/give-kids-a-smile?source=ADAsite&medium=PPLeftNav&content=GKAS  Launched in 2003 by the American Dental Association, more than 5.5 million underserved children received free oral health services on ‘Give Kids a Smile Day’ throughout the country.  Volunteers provide free services, including 10,000 dentists annually, along with 30,000 other dental team members.
  • https://www.mchoralhealth.org/state.php You can find links to state offices of Oral Health and Medicaid Provider Enrollment information on this site.

Treatment consent

For students not yet enrolled in the dental program, we send home a consent form with the student’s name written on it, as well as a sticker on their shirt that says Sign Me Up. This is done every 4-6 weeks. Bracelets have been made that say the same thing. This is done 4-5 times a year, and then phone calls to parents are made. A $50 gift card is given to teachers to get signed enrollment forms back to the school dental program. We sponsor a contest in the school where students develop oral health slogans — the slogan chosen for the school is printed on silicone bracelets and students receive them for each restorative treatment.

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

Exemplary School-Based Dental Program Models

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The following resources describe exemplary school-based dental program models with a national, statewide, and local focus.  The models include sealant programs, hygiene programs, restorative programs, and mixed service models.  There are many successful school-based dental programs; the following models are provided for guidance as you design your program based on community needs.

National Models:

  • http://www.nnoha.org/nnoha-content/uploads/2014/07/SBHC-Report-FINAL_2014-07-28.pdf   The final report represents the results of a national online survey of community health centers conducted in June 2013 by the National Network for Oral Health Access (NNOHA) to obtain information about oral health programs located in school-based health centers.
  • https://www.mchoralhealth.org/seal/  Seal America: The Prevention Invention assists health professionals in launching and sustaining school-based dental sealant programs. In addition to offering a step-wise approach for planning and implementing school-based dental sealant programs, this manual addresses issues related to referring students with unmet oral health needs to a dental clinic or office.
  • https://www.astdd.org/docs/sealant-bpar-update-11-2017-final.pdf  This report from the Association of State and Territorial Dental Directors highlights best practice approaches and exemplary state examples for state and community school-based oral health programs.
  • http://www.sbh4all.org/wp-content/uploads/2018/04/DQF_WP_SchoolOralHealth_F.pdf: School Oral Health: An Organizational Framework to Improve Outcomes for Children and Adolescents provides a framework that addresses the five major components of school-based oral health programs that span education, preventive services, and treatment services.

State Models:

  • https://www.dhs.wisconsin.gov/oral-health/programs/seal-smile.htm Wisconsin Seal-A-Smile (SAS) is a collaborative effort between the Wisconsin Department of Health Services, Delta Dental of Wisconsin, and Children’s Health Alliance of Wisconsin. The program’s mission is to improve the oral health of Wisconsin children by providing school-based dental sealants. Each year, SAS provides funding to local programs to implement school-based oral health services. Grantees include local health departments, dentists, dental hygienists, schools, hospitals, community health centers, and non-profit safety net dental clinics.
  • https://www.michigan.gov/mdhhs/0,5885,7-339-73971_4911_4912_6226-279800–,00.html  The Michigan Department of Community Health‘s SEAL! Michigan dental sealant program works to prevent dental disease through prevention. SEAL! Michigan provides dental sealants, fluoride varnish, and oral health education to students in Michigan in their school settings. By utilizing Registered Dental Hygienists who travel to schools to provide prevention services onsite, cost-saving is realized. The SEAL! Michigan program delivers dental sealants, fluoride varnish, and oral health education to children for less than $100 per student.
  • https://paoralhealth.org/courses/oral-health-for-community-health-workers/  The Pennsylvania Oral Health Coalition offers online oral health training courses for Community Health Workers. CHWs can help to improve oral health because they are already trusted members of the community and understand community needs; they promote prevention and manage chronic diseases for the rest of the body. Since CHWs have regular, consistent contact with individuals and families, they are able to be valuable resources for oral health information.
  • www.futuresmiles.net Future Smiles is determined to end oral pain and suffering among Nevada’s neediest children by partnering with the community to deliver essential preventive, restorative, and educational services. Services provided at the local schools include preventive oral health care screenings and education, dental cleanings, protective sealants, and fluoride varnish. Future Smiles operates EPOD (Education and Prevention of Oral Disease) at school-based locations throughout Southern Nevada. School-based care is a unique delivery system that provides essential preventive oral health services and education. They address oral health at the earliest preventive stages to decrease the incidence of oral disease.
  • http://wellaheadla.com/LouisianaSealsSmiles State level dental sealant program with six steps to implementing the Louisiana Seals Smiles in your school or community.
  • http://smartmouthssmartkids.org/?page_id=426  This short video describes maintaining a successful mobile/portable school-based dental program in multiple schools and counties in Colorado, and how to sustain the program for maximum impact.

Local Models:

  1. https://onlinelibrary.wiley.com/doi/abs/10.1111/jphd.12216 This article describes the implementation of a scalable and sustainable school-based oral health program in the Los Angeles Unified School District for low-income urban children using a public health model to reduce oral health disparities.
  2. https://www.hartfordschools.org/dental-program/  The Hartford Public Schools Dental Program is sponsored by the Hartford Board of Education and provides comprehensive dental services in 17 urban schools. The Dental Department provides high quality, full-service dental care to school children in the city to ensure they are healthy participants in the educational process. Full service dental care is provided in 17 in-school dental clinics, servings students from Pre-K through 12th Grade, including those who are uninsured.
  3. https://www.readysetsmile.org/ Ready Set Smile (RSS) is a community-based organization whose mission is to prepare and empower all children to care for their oral health through education and preventive services. RSS provides on-site non-traumatic dental services and classroom education for under-resourced children in twenty-seven Minneapolis schools serving children from pre-K through 8th grade. The clinical team includes community health workers (CHWs) to serve as dental assistants, teach in the classrooms, and serve as the liaisons to school staff and parents. CHWs and others can access our oral health training modules to understand better dental caries, fluoride, nutrition, motivational interviewing, and more. The newly licensed midlevel dental practitioner, the dental therapist, also is employed in our clinics.

Dental Sealants:

Dental sealants provide a protective covering that keeps food from collecting, and plaque from developing, in the grooves of teeth. Sealants are a coating applied to the chewing surfaces of molars and premolars (back teeth), which hardens to provide a protective cover over the tooth’s surface. Sealants reduce the risk of decay on the chewing surfaces of permanent molars. Research strongly supports the application of sealants.

  • https://www.thecommunityguide.org/sites/default/files/assets/OnePager-OralHealth-School-Sealants.pdf  A fact-filled page on dental sealants, major findings, with links to national organizations for more information.
  • https://www.mchoralhealth.org/Dental-Sealant/  The Maternal Child Health Oral Health website – Dental Sealant section focuses on a series of modules designed to ensure that school-based dental sealant program staff have a thorough understanding of the history, operations, and underlying principles of these programs.
  • https://www.cdc.gov/oralhealth/dental_sealant_program/implementation-of-school-sealant-programs.htm  The Community Preventive Services Task Force strongly recommends school-based sealant delivery programs to prevent cavities among children. The link provides guidelines and recommendations and a review of the evidence.
  • https://www.mchoralhealth.org/seal/  SEAL AMERICA – The Prevention Invention assists health professionals in launching and sustaining school-based dental sealant programs. The manual includes a step-wise approach for planning and implementing school-based dental sealant programs, addressing issues relating to referral to a dental clinic.  The manual is a good source for improving the quality of an existing sealant program.
  • https://www.mchoralhealth.org/Dental-Sealant/  School-Based Dental Sealant Program Learning Modules are a series of modules designed to ensure that school-based dental sealant program staff have a thorough understanding of the history, operations, and underlying principles of these programs. The modules provide detailed guidelines for infection control in school-based programs; discuss tooth selection and assessment for dental sealants; review the dental-sealant-application process; and provide information about program operations, with an emphasis on the specific requirements that apply to programs funded by the Ohio Department of Health.

Silver Diamine Fluoride:

Silver Diamine Fluoride is a topical, minimally invasive treatment used to prevent and arrest tooth decay and decrease tooth sensitivity. It can be used on children and adults and is very cost-effective, using only one drop to treat multiple teeth. Silver Diamine Fluoride is an FDA-approved antibiotic liquid clinically applied to control active dental caries and prevent further progression of oral disease.

Fluoride Varnish

Fluoride varnish is a safe and effective way to strengthen tooth enamel and prevent tooth decay. Due to its sticky form and the small amount used per application, the risk of swallowing is very low. It is safe to apply fluoride varnish as early as the eruption of the first baby tooth and throughout a person’s lifetime. Fluoride varnish offers an additional opportunity toward improving the prevention and control of dental caries along with the cornerstones of dental sealants, fluoridated water, and fluoridated toothpastes.

  1. https://www.astdd.org/www/docs/fl-varnish-research-brief.pdf  The research brief includes 2014 updated information on such topics as fluoride varnish, effectiveness, safety and community, and school programs.
  2. https://www.cdc.gov/fluoridation/faqs/index.htm  FAQ about fluoride and water fluoridation.

Community Health Worker: