The Pollard Dental Screening Program

Privacy Impact Assessment

for

The Pollard Dental Screening Program

A Project of Plaistow Pediatric Dentistry and Orthodontics

1. Information Collected

Data is collected for each student participating in the Pollard Dental Screening Program. The data is used to identify children who need dental care, to help the children in need of care obtain access to care and for statistical analysis of the dental care available for the children in New Hampshire.

Data to be collected will include:

· Decayed, Missing and Filled or Restored Teeth (including sealants) (DMFT)

· Number of children fluoride was applied to and what type of fluoride was used

· If child has a dental home

· Insurance status

· Orthodontic concerns

· Oral hygiene

· Other hard and soft tissue concerns (Abscess teeth, and more)

See Appendix A (Pollard Dental Screening Exam)

See Appendix B (Pollard Dental Screening Results)

2. Overview of data collection and supervisory protocol

Data collected will include number of children in the school, number of children screened, and the number of children with untreated decay, missing and restored teeth. The Oral Health Professional provides services under public health supervision and in accordance with the NH Dental Practice Act and current NH Administrative Rules for Dentistry.

3. Description of data collected and how it is the minimum necessary to accomplish agency goals

The goal of the Pollard Dental Screening Program is to decrease the proportion of elementary school aged children with untreated decay. By collecting the data listed above we will be able to do a statistical analysis to provide a baseline of the current status of DMFT in the elementary school aged children. Over time we will be able to measure the change as a whole.

4. Why data is collected & Who it will be shared with

Parents or legal guardians of participating children will receive the results and recommendations regarding their child on the Pollard Dental Screening Results form (Appendix B).

Appropriate relevant data will be shared with the school nurses as covered by FERPA and dentist that a child may be referred to for follow up care.

Data that is collected will be provided to the NH Board of Dental Examiners per Rule Den 402.02(b, c) and to the Department of Health and Human Services Public Oral Health Program which will assist in securing funding for dental services for children in NH.

Plaistow Pediatric Dentistry and Orthodontics, who is organizing this project, will have access to the data to measure the need and success of the project.

Potential funders may need statistical information to secure necessary financial support.

5. How information is collected, from whom; What/How suppliers and subjects will be told about information collected

Children participating in the Pollard Dental Screening Program will be students in the Timberlane Regional School District which serves the greater Plaistow, NH area. Information regarding a child having a current dentist will be collected from the signed consent to treat forms (see Appendix C).

Students will sit knee-to-knee with participating Dentist or Dental Hygienists in school chairs or on a portable dental chair for the visual screening and applicable fluoride treatment. The participating Dental Health Professional will note the findings and any application of fluoride on the Pollard Dental Screening Exam Form (Appendix A).

Parents or Legal Guardians will receive a written report of screening, if and what type fluoride was applied with follow-up care recommendations including appropriate referrals as needed.

Parents, participating dental health professionals and school staff will be informed that the DMFT will be collected and shared with those listed in Section 4 above and why the information is shared. Why data is collected and whom it will be shared with will be available for review at www.Plaistowsmiles.com, click on the Pollard Dental Screening Program link or on request a printed statement will be made available.

6. Consent regarding information collected and how it is shared

If Parents or Legal Guardians do not wish for the information collected to be shared they are welcome to notify the Program Director of the Pollard Dental Screening Program.

7. Parental/Legal Guardian Approval

Parent or Legal Guardian will be required to sign the Consent to Treat form (Appendix C) for their child to be included in the screening program.

8. How information will be secured

All information collected will be on paper. Any records with protected health information (PHI) will be kept in a file that will not be left unattended by appropriate dental health professionals while at the school or during transport. Dental health professionals and school staff (school nurse) are bound by confidentiality of FERPA and will only share information on as as-needed basis to provide appropriate care for the child.

9. Plans for retention and destruction of data collected

All information collected will be retained at the office of Plaistow Pediatric Dentistry and Orthodontics, which oversees the Pollard Dental Screening Program, for a minimum of 7 years past the child’s age of majority as required by the Dental Practice Act RSA 317-A:27-a.

Upon 7 years past the age of majority being attained the information will be shredded.

10. Applicable privacy system

Family Education Rights and Privacy Act (FERPA) is the system that determines the privacy of the information collected through the Pollard Dental School Program. The complete information collected will be retained as stated in 9 above. The information that is appropriate to be shared with the school nurse will be also retained according to FERPA at the school.

11. Penalties for non-compliance

Privacy is a very serious matter therefor we have a strict policy.

The first offense will result in a review of the Pollard Dental Screening privacy policy and FERPA with either Program Director or with the Supervising Dentist.

The second offense will result in being dismissed from the Pollard Dental Screening Program.

12. How are policies conveyed to employees and volunteers

Policies will be explained at the initial training which every employee or volunteer must attend prior to participating in the Pollard Dental Screening program.

13. Date/s PIA review and endorsed by whom

This PIA will be reviewed yearly by the Program Director.

14. Appendices

See following pages.

Appendix A: Pollard Dental Screening Exam

Appendix B: School Dental Screening Results

Appendix C: Pollard Dental Screening Program Consent to Treat

Appendix D: Parent Letters

Appendix A

Pollard Dental Screening Exam

Students Name: ______DOB: ______

School: ______Patient’s Dentist: ______

Date of Exam:______Examiner: ______

Oral Hygiene

o Good / o Fair / o Poor

Teeth Present: Treatment needed:______

______

Sticker placed here with teeth

Previously Treated Teeth:______

______

Needs to be seen

o For regular check-ups / o Before regular check-up / o As soon as possible

Fluoride applied

o Fluoride Varnish
o Silver Diamine fluoride
o None
Visit # / 1 / 2
Parent Letter
Dentist list sent
Nurse notified
Parent call
Referral to dentist
Urgent

Notes: Office Use Only

o Pain
o Other

Appendix B: School Dental Screening Results

Date______

______received the following:

Preventive Services

o Dental Screening
o by a dentist
o by a dental hygienist / o Silver Diamine Fluoride on these molars______.(Which is a decay-stopping fluoride applied to moderately sized cavities twice during the school year to help slow the progression of a cavity.)
o Fluoride varnish
Dental screenings are based on visual inspection of teeth only. X-rays were not taken, so it is possible that there is decay present in places not visible like between the teeth.
This screening is only a very simple evaluation and does not take the place of a thorough dental examination.

Oral hygiene

o Good / o Plaque found on teeth / o Gums appeared puffy and may bleed easily

Concerns

o Possible dental cavities / o Missing tooth-space holder needed
o Abscessed tooth/teeth / o Traumatized tooth/teeth
o Crowding: Mild, Moderate, Severe / o Other
o Unusual eruption pattern

Needs to be seen

o For regular check-ups / o Before regular check-up / o As soon as possible

Reason:

______

Our next visit to the school will be in ______.

If you need help finding a dentist or have questions

visit www.PlaistowSmiles.com or call us at 603-974-1150

Angela Estes, Registered Dental Hygienist

Pollard Dental Screening Program Director

Appendix C: Pollard Dental Screening Program Consent to Treat

Pollard Dental Screening Program Permission Slip

Student Name ______Date of Birth______

Teacher______Grade ______

Parent or Guardian ______Email______

Home Phone ______Cell Phone______

Child’s Dentist ______Last Visit ______

Reason for last visit ______

How did he or she react ______

1. I hereby o give o do not give permission for my child to have the free dental screening.

2. Please check additional services you would like your child to receive:

o Free Fluoride Varnish

o Free Decay-stopping fluoride (applied twice during the school year to help stop a moderately sized cavity from getting bigger and to make it feel better. You can tell it worked if the cavity becomes hard and black. Limited to molars.)

3. Does your child have a congenital heart defect requiring pre-medication with antibiotics before dental treatment? o Yes -Explain______o No

4. Does your child have any allergies? o Yes -Explain______o No

5. Has your child ever had any serious health problems? o Yes - Explain o No ______

6. Is your child unable to receive dental treatment in a dental office? o Yes o No

If unable to do so, please check all that apply.

o Can’t find a dentist who accepts our insurance o Cost o Transportation o Fear

o Can’t afford insurance co-pays o Can’t take time off from work

o Other______

7. Does your child have Dental insurance? o Yes o No

If yes, which kind of dental insurance? o Private insurance o Medicaid

8. Does your child have Medical Insurance? o Yes o No

I understand that by signing this form I am consenting for the child named above to receive a basic oral health assessment and fluoride if requested. I understand this screening is only a very simple evaluation and does not take the place of a thorough dental examination. I understand my child’s dental assessment for treatment may be shared with the school nurse and in the event of a referral for treatment, with the dental office treating your child.

I understand that a copy of Pollard Dental Screening Program Privacy Practices can be obtained by contacting Plaistow Pediatric Dentistry and Orthodontics at (603) 974-1150 or visiting the website at www.Plaistowsmiles.com and clicking on the school screening program link.

______

Signature of Parent or Guardian Date

Appendix D: Parent Letters

The Pollard Dental Screening Program at

Pollard Elementary School

August 2, 2017

Dear Parent/Guardian,

A healthy mouth is part of total health and wellness. When a child is healthy he/she is able to focus and learn better. Therefore, Plaistow Pediatric Dentistry & Orthodontics (PPDO) has partnered with Timberlane Regional School District to offer a free in-school dental screening program for all children in kindergarten through the fifth grade. The services offered include classroom education, dental screenings, fluoride varnish, and silver diamine fluoride application. (Which is a decay-stopping fluoride applied to moderately sized cavities twice during the school year to help slow the progression of a cavity.)

The purpose of this screening is to help identify children with unmet dental needs and assist parents in getting the care their child requires. We will provide each family with a written synopsis of their child’s oral health noting any obvious issues that need to be addressed.

The Pollard Dental Screening Program will be providing referrals to local pediatric and/or family dentists for children who do not have a “dental home” and will also assist children with urgent dental needs in obtaining appointments.

For a copy of our Privacy Practices or parents with questions about this program call PPDO at (603) 974-1150 or visit our web site www.Plaistowsmiles.com and click on the Pollard Dental Screening Program link.

We will be performing the dental screenings at Pollard Elementary School on November 3, November 17 & December 1, 2017.

To allow your child to be included in the free in-school dental screening please Complete, sign and return the form to your child’s teacher.

Sincerely,

Angela Estes, Registered Dental Hygienist

Pollard Dental Screening Program Director

Appendix D: Parent Letters

The Pollard Dental Screening Program at

Atkinson Academy

August 2, 2017

Dear Parent/Guardian,

We will be performing the dental screenings at Atkinson Academy on September 19 & September 29, 2017.

To allow your child to be included in the free in-school dental screening please Complete, sign and return the form to your child’s teacher.

Sincerely,

Angela Estes, Registered Dental Hygienist

Pollard Dental Screening Program Director

Appendix D: Parent Letters

The Pollard Dental Screening Program at