Children in school: School-based sealant programs enhance access to care

By Jamie Collins, RDH, CDA

Many of our country's smallest citizens are the ones most in need of care, and have the least control over the situation in seeking dental care, even when something hurts. Whether it is due to the family socioeconomic status or access to care, many factors can inhibit a child from receiving a screening and treatment.

According to the Centers for Disease Control and Prevention, 23% of children ages 2 to 5 have experienced caries in primary teeth, and the incidence of caries is twice as high in groups that are not classified as non-Hispanic white children. Statistically, according to the CDC, 27% of Hispanic children ages 6-11 have had caries in permanent teeth compared to non-Hispanic white and Asian children of the same age (18% caries rate). The incidence of caries has greatly reduced over decades with the use of pit-and-fissure sealants, especially in high-risk socioeconomic groups due to the access of community outreach programs. As dental clinicians, we are able to make the difference if the oral health of these children.

Over 90% of the decay affecting children and teens begins in the pit and fissures of the occlusal surface of the teeth, where it often deep and narrow, trapping food and allowing bacteria to decay the teeth. By placing sealants in the grooves of teeth prior to decay forming, it can reduce the incidence of decay greatly. A school-based sealant program is especially helpful in reaching low-income students who may not seek private dental care and provide care free of charge either in a school or clinical setting. Volunteers in the dental community often host these programs, providing screening and placement of dental sealants.

If decay is noted, the child may be referred to a low-cost community clinic for treatment. Children experiencing tooth pain may have impaired learning due to the pain and discomfort and have time away from school due to the same reason. Often, the parents may not be aware of a problem or need for treatment including sealants until a screening has been done and brought to the parents' attention.

School-Based Programs

The primary focus of school-based sealant programs is on second and sixth grades since it reflects the ages of children most likely to have newly erupted molars. The hope is to screen and seal those teeth before decay has a chance to develop. Studies show only about one in five, or 20%, of children ages six to 11 from low-income families have received dental sealants.

School-based sealant programs are now in effect in the majority of states in the United States, and the numbers are growing every year. Based on the individual states' dental practice acts, these services may be performed by dentists, hygienists, and dental assistants. Regulations in some states require a supervising dentist to be on site, while other states allow the hygienist to evaluate, diagnose, and place sealants. A program may be initiated by individuals or groups of people such as a local dental hygiene chapter that sees the need to help the community, or may be initiated by a school system. In planning for a sealant program, one important element is to define the target population often by grade most likely to benefit in addition to the general income level of the area.

Often, the income information can be found by percentage of students that qualify for free or reduced meal programs through the school system, as it is often a reflection of the economic status of the families in the school. As we know, often the students with a smaller family income are often the ones who are not able to seek private practice dental care.

In the development of a sealant program, a committee may decide which children are eligible to receive treatment, whether it allows all students or just those who are considered low income and qualify for the reduced lunch programs. One thing to consider depending on the areas served is whether to allow the criteria to include students that may be family of migrant workers, who often don't qualify for the reduced lunch programs due to the citizen status but are often the children in the most need of dental care. For some of these families, the cultural differences in the knowledge of preventive care can be just as inhibitive as the financial status.

Gaining the support of the school and community is the key to a successful community service program. In turn, it creates a bond with all parties involved in the planning and implementing of the community based sealant programs. Strong communication with the school nurse, administrators, principal, and the community of dental providers create a bond that can be carried on for years to the benefit of hundreds and even thousands of children.

In many cases, the clinician is working a paid position in the public health sector, including the school-based sealant programs. This person can be responsible for organizing, implementing, and staffing the events, as well as ensuring the funding, equipment, and materials needed are available. Many times these programs are operated and staffed with volunteers from the dental community. The volunteers range from dental students and hygiene students to those who have been practicing for years. Depending on the state, volunteer hours may be counted toward continuing education requirements.

If you are interested in volunteering and not sure where to turn for information contact the local hygiene association or board of dentistry for direction. Having the ability to give back-especially to those little members of society who need it the most-can be extremely rewarding at the end of a hard day.

Going to School

One challenge in a school-based program is how to administer the treatment in the available setting. There are options from an outfitted van or bus that is able to move from site to site, using portable equipment within the school, or, when available, a more permanent setup can be established within a medical clinic in the school. Most clinics are operated off a mobile unit, van, or bus, or by using mobile equipment to be set up within the school and removed once the clinic is completed.

However, a dental van is costly to start, and upkeep and insurance are among the additional expenses. The mobile unit, though, allows for a fully functional operatory on wheels, able to provide a range of treatment if needed.

Portable equipment allows the staff or volunteers to provide treatment within the school. But it is time consuming to set up and break down equipment. Many times a sealant clinic may be operated within a classroom, gymnasium, or any other available room.

Portable dental units need to have a self-contained unit with a high-speed evacuation, air-water unit, and a self-contained water source. An air compressor is necessary to operate in addition to some sort of a dental chair, which should be light weight and easily mobile. An exterior light source is necessary for treatment-you can't work with what you can't see. A great alternative is using a personal illumination light that attaches to your glasses or loupes. If this is used, an overhead dental light may not be needed. Any sealant clinic must have the ability to sterilize the necessary equipment, and this includes an ultrasonic and autoclave. All standards of care must be followed, including the ability to disinfect accordingly.

The cost of dental equipment and supplies can be daunting, especially in a nonprofit organization. There are ways to help alleviate the financial burden that may inhibit the operation of a school-based clinic. Many dental supply companies will offer a reduced rate on equipment and supplies for government or nonprofit programs, which adds up to huge savings. Soliciting area dental offices for donations of everything from money to dental products and equipment that may no longer be of use can provide the necessary items for school-based clinics at no charge.

Calling the manufacturer or supply representative can lead to great results when in search of donations for a nonprofit community clinic. State and local dental organizations, such as the local chapter of the hygiene association, are fantastic resources finding volunteers or funding to allow the opportunity to see more children for screening and sealants. Government agencies can provide funding through grants in certain circumstances. Check with the local health department for guidance. In my experience, people are willing to help either with products or funding especially when it benefits children in need.

Documenting the participation rates, number of children treated, number of decayed teeth noted, number of sealants placed, and retention rates is imperative to justify the need for the school-based sealant programs to continue. Armed with this information, the group may be able to apply for increased funding in relation to the need for screening and sealant placement for the benefits of children.

Developing and operating a school-based sealant program is a huge undertaking and requires the cooperative efforts of a variety of individuals and organizations to make it happen. Whether you want to bring a clinic to a local school, or find a volunteer opportunity to donate your time, it may be the thing that make the difference in the life of a child. RDH

Treatment Tips for School-Based Clinics

The recommended placement of sealants in a school-based program doesn't always provide for the use of a handpiece to clean the tooth prior to placement. It is recommended to do a toothbrush prophylaxis to clean the grooves of the occlusal surfaces prior to placing etchant on non-carious posterior teeth.

Radiographs are not deemed necessary prior to placement of sealants in this type of setting. A benefit of school-based programs is that they can help identify those young patients who are in need of more extensive treatment, and can guide the family or advocates to other government resources such as Medicaid or community programs that will provide care for those in need.

After each patient, document treatment provided with any information that would be charted in a traditional clinical setting. Entries should include information about screening and treatment, decay noted, and referrals given. As when treating any child, a written consent from the parent and guardian must be obtained prior to seeing the patient.

Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected].