Date of Report: September 23, 2009

Date of Report: September 23, 2009

A Best Practice Approach is defined as a public health strategy that is supported by evidence for its impact and effectiveness. This Best Practice Approach Report describes a public health strategy, summarizes the strength of evidence of the effectiveness of the strategy, and uses current practice examples to illustrate successful and/or innovative implementation of the strategy. This report serves as a resource to share ideas and promote best practices for state and community oral health programs.

Table of Contents:

1. Best Practice Approach (page 1)
2. Description (page 1)
3. Guidelines and Recommendations from Authoritative Sources (page 11)
4. Research Evidence (page 13)
5. Best Practice Criteria (page 15)
6. State Practice Examples (page 17)
7. References (page 20)
8. Attachments (page 25)

Suggested citation: Association of State and Territorial Dental Directors (ASTDD), Best Practices Committee, Best Practice Approaches for State and Community Oral Health Programs– Improving Children’s Oral Health through Coordinated School Health Programs, September23, 2009.

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Improving Children’s Oral Health through CoordinatedSchool Health Programs1

I. Best Practice Approach

Improving Children’s Oral Health

through Coordinated School

Health Programs

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Improving Children’s Oral Health through CoordinatedSchool Health Programs1

II.Description

A. Children’s Oral Health

Richard H. Carmona, M.D., M.P.H., F.A.C.S., the Surgeon General of the United States Public Health Service during 2002-2006, called oral diseases “a silent epidemic” that is “affecting our most vulnerable citizens – children from families with low incomes, children from racial and ethnic minority groups, and children with special health care needs. No child should suffer the stigma of craniofacial birth defects nor be found unable to concentrate because of the pain of untreated oral infections.”1

For children from families with incomes at or below the federal poverty level:

The prevalence of tooth decay for children ages 2-5 remained unchanged from the early 1970s to the early 1990s.2

Nearly 80 percent of decayed primary teeth have not been treated and restored in children ages 2 through 5.3

Almost 50 percent of decayed primary and permanent teeth have not been restored in children ages 6 through 14.3

The association between tobacco use and oral diseases is well documented. Evidence shows that maternal tobacco use is associated with congenitalabnormality such as cleft palate and cleft lips.4 Although the prevalence of tobacco use among students in grades 9 through 12 has decreased since 1999, 28 percent of students in this age group currently use tobacco products (e.g., cigarettes, spit tobacco and cigars). Of this age group, 15 percent of non-Hispanic black students, 18 percent of Hispanic students, and 25 percent of non-Hispanic white students smoke cigarettes.5

Children’s oral health also include being free from injury of the teeth, mouth and face. Thirty-five percent of children and adolescents will have sustained dental trauma at least once by age 16.6 Head, face and neck injuries occur in more than half of the child abuse cases.7

B. Untreated Dental Disease Affects General Health

Dental disease is progressive and can significantly diminish general health and quality of life for children. Tooth decay continues to be the most common chronic disease of childhood. Failure to prevent dental problems has long-term adverse effects.8 Dental disease compromises children’s growth and function including their ability to be attentive for learning, to develop positive self-esteem, to eat, and to speak. The cost of preventive dental care is low compared to alternatives of suffering, dysfunction and expensive repair.9,10

Millions of children in the United States do not have basic dental care. Oral health care is the most prevalent unmet health care need among children.11 Children without health insurance are four times more likely than those with private health insurance to have unmet oral health care needs (20 percent vs. 5 percent, respectively).12 Hispanic children are almost twice as likely as non-Hispanic white children to have had no contact with a dental professional in the past 2 or more years.12 Although more than 90 percent of general dentists provide care to children, very few provide care to children under age 4, children with high levels of dental caries and children covered by Medicaid.13

C. Relationship of Health and Academic Performance

There is a relationship between health and academic performance.14 The fundamental mission of schools is to provide young people with the knowledge and skills they need to become healthy and productive adults. Promoting healthy and safe behaviors among students is an important part of this mission. Improving student health and safety can:

• increase students’ capacity to learn,
• reduce absenteeism, and
• improve physical fitness and mental alertness.

Good health is necessary for academic success. Students at school have difficulty being successful if they are depressed, tired, being bullied, stressed, sick, using alcohol or other drugs, hungry, or abused. Former Surgeon General, Dr. Antonia Novello said that “health and education go hand in hand: one cannot exist without the other.”15 The U.S. Department of Education acknowledged that health problems and unhealthy behaviors have a major effect on students’ success.16

D. Oral Health and Learning

School nurses report oral health problems in children and the problems including tooth decay, gingival (“gum”) disease, malocclusion (poor bite), loose teeth, and oral trauma.17 When children have poor oral health, it affects their ability to learn.18

An estimated 51 million school hours per year are lost because of dental-related illness.19 Students ages 5 to 17 years missed 1,611,000 school days in 1996 due to acute dental problems averaging 3.1 days per 100 students.20 Children from families with low incomes had nearly 12 times as many restricted-activity days (e.g., missed school days) because of dental problems compared to children from families with higher incomes.21,22

A child with a dental problem may have anxiety, fatigue, irritability, and depression; he or she may withdraw from normal activities.23,24 Children distracted by dental pain may be unable to concentrate and learn, complete school work and score well on tests.25 Poor oral health has been related to decreased school performance, poor social relationships and less success later in life.25-28 When children’s acute dental problems are treated and they are no longer experiencing pain, their learning and school-attendance records improve.29

Tooth loss due to dental decay may lead to failure to thrive, impaired speech development and reduced self-esteem.26 Missing teeth also limit food choices due to chewing problems; this may result in inadequate nutrition.30 Nutritional deficiencies could hinder children’s school performance, reduce their ability to concentrate and perform complex tasks, and affect their behavior.31,32

E. Preventing Dental and Oral Disease

Children needlessly suffer from dental and oral disease which can be prevented. Oral health promotion and prevention strategies would reduce the disease burden and increase quality of life. Preventive dental services are cost-effective in reducing this disease burden.33-38 These services include the following:

Preventive Care – Low-income children who have their first preventive dental visit by age one are less likely to have subsequent restorative or emergency room visits and their average costs for dental care over a five year period are almost 40% lower ($263 compared to $447) than children who receive their first preventive visit after age one.34

Water Fluoridation –Water remains the most cost-effective method of delivering fluoride to communities.39 Community water fluoridation decreases tooth decay by 29 to 51 percent in children ages 4 through 17.40 For every $1 invested in fluoridation, $38 in dental treatment costs is saved.35 Medicaid dental programs costs as much as 50% less in fluoridated communities compared to non-fluoridated communities.36

Dental Sealants –Dental sealants are effective in the prevention of tooth decay in the pits and fissures of teeth and are effective over time as long as they are maintained on the teeth.41 Only 12 percent of children ages 6 through 14 living at or below the federal poverty level have at least one dental sealant (one-third of the percentage of children in families with higher incomes).42Dental sealants have been shown to avert tooth decay over an average of 5-7 years.43,44

Without access to regular preventive dental services, dental care for many children is postponed until symptoms (e.g., a toothache and facial abscess) become so acute that care is sought in hospital emergency rooms.45 This consequence is costly to the health care system. A three-year aggregate comparison of Medicaid reimbursement for inpatient emergency room treatment ($6,498) versus preventive treatment ($660) revealed that on average, the cost to manage symptoms related to dental caries on an in-patient basis is approximately 10 times more than to provide dental care for the same patients in an outpatient dental office.45

Social and demographic factors (e.g., income, race and education) can limit children’s access to preventive dental care.46,47 Low-income children are only half as likely to access preventive dental services as middle or high-income children even though they are two to three times more likely to suffer from untreated dental disease.46,47 Minority children and children whose primary caregivers have less education are less likely to have access to dental services than their white counterparts.46-48

Children with private or public dental insurance coverage are 30 percent more likely than low-income uninsured children to have a preventive dental visit in the previous year.49 Children with Medicaid coverage are more likely to have a usual source of care.49Parents of children covered by Medicaid are 3.5 times less likely to report that their child has an unmet dental need than uninsured children.50 Among young Medicaid-enrolled children, a cost savings of $66-$73 per tooth surface is projected when the need to repair a tooth is avoided.51 It is also estimated that with regular dental screening and early intervention, there is a 7.3 percent savings.52

School-based oral health services have the advantage of reaching children and enable targeting of preventive services to underserved, low-income children.53 School based oral health programs could include a range of services: oral health education and promotion, dental screening, dental sealants, fluoride mouth rinses or tablets, fluoride varnish, referral, case management, establishment of a dental home, and restorative treatment to ensure timely oral health care for children with unmet oral health needs.

F. The Coordinated School Health Program Model

According to the Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health, “Schools by themselves cannot, and should not be expected to address the nation’s most serious health and social problems. Families, health care workers, the media, religious organizations, community organizations that serve youth, and young people themselves also must be systematically involved. However, schools could provide a critical facility in which many agencies might work together to maintain the well-being of young people.”54

CDC developed an eight-component model for a Coordinated School Health Program (CSHP). The model is research-based and identifies policies and practices most likely to be effective in improving youth health risk behaviors. A CSHP is a planned, organized set of health-related programs, policies, and services coordinated to meet the health and safety needs of K-12 students at both the school district and individual school building levels. It is comprised of multiple components that can influence health and learning, which include health education; physical education; health services; nutrition services; counseling and psychological services; a healthy school environment; family/community involvement; and health promotion for staff. The following are the eight components of the CSHP model(

1. Health Education:A planned, sequential, K-12 curriculum that addresses the physical, mental, emotional and social dimensions of health. The curriculum is designed to motivate and assist students to maintain and improve their health, prevent disease, and reduce health-related risk behaviors. It allows students to develop and demonstrate increasingly sophisticated health-related knowledge, attitudes, skills, and practices. The comprehensive health education curriculum includes a variety of topics such as personal health, family health, community health, consumer health, environmental health, sexuality education, mental and emotional health, injury prevention and safety, nutrition, prevention and control of disease, and substance use and abuse. Qualified, trained teachers provide health education.

1. Physical Education: A planned, sequential K-12 curriculum that provides cognitive content and learning experiences in a variety of activity areas such as basic movement skills; physical fitness; rhythms and dance; games; team, dual, and individual sports; tumbling and gymnastics; and aquatics. Quality physical education should promote, through a variety of planned physical activities, each student's optimum physical, mental, emotional, and social development, and should promote activities and sports that all students enjoy and can pursue throughout their lives. Qualified, trained teachers teach physical activity.

1. Health Services:Services provided for students to appraise, protect, and promote health. These services are designed to ensure access or referral to primary health care services or both, foster appropriate use of primary health care services, prevent and control communicable disease and other health problems, provide emergency care for illness or injury, promote and provide optimum sanitary conditions for a safe school facility and school environment, and provide educational and counseling opportunities for promoting and maintaining individual, family, and community health. Qualified professionals such as physicians, nurses, dentists, health educators, and other allied health personnel provide these services.

1. Nutrition Services: Access to a variety of nutritious and appealing meals that accommodate the health and nutrition needs of all students. School nutrition programs reflect the U.S. Dietary Guidelines for Americans and other criteria to achieve nutrition integrity. The school nutrition services offer students a learning laboratory for classroom nutrition and health education, and serve as a resource for linkages with nutrition-related community services. Qualified child nutrition professionals provide these services.

1. Counseling, Psychological, and Social Services: Services provided to improve students' mental, emotional, and social health. These services include individual and group assessments, interventions, and referrals. Organizational assessment and consultation skills of counselors and psychologists contribute not only to the health of students but also to the health of the school environment. Professionals such as certified school counselors, psychologists, and social workers provide these services.

1. HealthySchool Environment: The physical and aesthetic surroundings and the psychosocial climate and culture of the school. Factors that influence the physical environment include the school building and the area surrounding it, any biological or chemical agents that are detrimental to health, and physical conditions such as temperature, noise, and lighting. The psychological environment includes the physical, emotional, and social conditions that affect the well-being of students and staff.

1. Health Promotion for Staff: Opportunities for school staff to improve their health status through activities such as health assessments, health education and health-related fitness activities. These opportunities encourage school staff to pursue a healthy lifestyle that contributes to their improved health status, improved morale, and a greater personal commitment to the school's overall coordinated health program. This personal commitment often transfers into greater commitment to the health of students and creates positive role modeling. Health promotion activities have improved productivity, decreased absenteeism, and reduced health insurance costs.

1. Family/Community Involvement:An integrated school, parent, and community approach for enhancing the health and well-being of students. School health advisory councils, coalitions, and broadly based constituencies for school health can build support for school health program efforts. Schools actively solicit parent involvement and engage community resources and services to respond more effectively to the health-related needs of students.

Coordinated school health programs, or CSHPs, aim to improve the health and academic performance of school children. Effective CSHPsactively involve parents, teachers, students, families and communities in their implementation. The programs work toward long-term results and are designed to promote student success. They help students establish and maintain healthy personal and social behaviors improving student knowledge about health and develop personal and social skills that help them make smart choices in school and in life.

There are existing school based or school linked health programs that may have been previously developed and implemented outside of a coordinated school health initiative. These programs are already addressing one or more components of the CSHP model. It’s important to recognize that these programs’ positive impact and a coordinated school health (CSH) initiative should integrate and coordinate with these programs. CSH initiative should ensure continuity for preventive health measures and a CSHP should building upon the success and effectiveness, and leverage off, of existing school health programs.