A REVIEW OF SCHOOL-BASED DENTAL SEALANT PROGRAMS AND THE
DEVEOPMENT OF A STATEWIDE SCHOOL-BASED DENTAL SEALANT
PROGRAM MANUAL IN PENNSLVANIA
by
Kaitlyn Burgess
BA, BS, University of Florida, 2011
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Kaitlyn Burgess
on
April 20, 2015
and approved by
Essay Advisor:
David Finegold, MD
Professor of Human Genetics
Director, Multidisciplinary MPH Program
Graduate School of Public Health
University of Pittsburgh
_________________________________
Essay Reader:
Richard Rubin, DDS, MPH
________________________________
Assistant Professor
School of Dental Medicine Liaison for Multidisciplinary MPH Program
School of Dental Medicine
University of Pittsburgh
ii
Copyright © by Kaitlyn Burgess
2015
iii
David Finegold, MD
A REVIEW OF SCHOOL-BASED DENTAL SEALANT PROGRAMS AND THE
DEVEOPMENT OF A STATEWIDE SCHOOL-BASED DENTAL SEALANT
PROGRAM MANUAL IN PENNSLVANIA
Kaitlyn Burgess, MPH
University of Pittsburgh, 2015
ABSTRACT
Background: Dental caries is the single most common chronic childhood disease. There
is a disproportionately high level of dental caries experience in children from low-income
families.
Dental sealants have been proven to be effective at preventing caries development.
Access to care is an enormous obstacle preventing necessary dental treatment such as dental
sealants in school-aged children; school-based dental sealant programs (SBSPs) have been
shown to minimize barriers to dental care, increase sealant use and decrease caries incidence.
Although Pennsylvania has indicated the need to create dental public health interventions, no
such statewide program has been developed for a SBSP.
Public Health Relevance: Due to the high prevalence of untreated dental decay in schoolaged children in Pennsylvania, a school-based sealant program is a feasible and needed way to
increase sealant use and reduce dental caries incidence in children. This goal is in accordance
with the benchmarks set out by Health People 2020.
Proposed Intervention: This essay proposes developing a statewide school-based dental
sealant program manual for use by counties across Pennsylvania.
iv
TABLE OF CONTENTS
1.0
INTRODUCTION ........................................................................................................ 1
2.0
PUBLIC HEALTH SIGNIFICANCE OF DENTAL CARIES IN SCHOOL-AGED
CHILDREN ................................................................................................................................... 2
2.1
CAUSES AND EFFECTS OF DENTAL CARIES IN CHILDREN .............. 2
2.2
PREVENTION, TREATMENT AND COST OF DENTAL CARIES ........... 3
2.3
INTRODUCTION TO SBSPS ............................................................................ 5
2.4
NEEDS ASSESSMENT FOR A SBSP IN PENNSYLVANIA ........................ 5
3.0
DETAILED REVIEW OTEMPERATURES AT 1 HOUR OF LIFEF SBSPS ...... 7
3.1
REVIEW OF EXISTING SBSPS ....................................................................... 7
3.1.1
Literature Search of SBSPs ............................................................................ 7
3.1.2
Best Practice Examples of SBSPs ................................................................... 8
3.1.3
Existing SBSPs in Pennsylvania .................................................................... 11
3.2
AVAILABLE RESOURCES TO CREATE A STATEWIDE SBSP
MANUAL ............................................................................................................................ 12
3.3
4.0
DISCUSSION AND APPLICATIONS FOR PENNSYLVANIA .................. 14
PROPOSAL FOR STATEWIDE SBSP MANUAL IN PENNSYLVANIA .......... 15
4.1
GOALS AND AIMS .......................................................................................... 15
4.2
MANUAL OUTLINE ........................................................................................ 15
v
4.2.1
Strategic Partners ......................................................................................... 15
4.2.2
Participants ................................................................................................... 16
4.2.3
Personnel ....................................................................................................... 17
4.2.4
Equipment and Supplies ................................................................................ 18
4.2.5
Timeline ......................................................................................................... 19
4.2.6
Forms............................................................................................................. 20
4.2.7
Evaluation ..................................................................................................... 20
4.3
5.0
DISCUSSION ..................................................................................................... 21
4.3.1
Intended Public Health Outcomes ................................................................. 21
4.3.2
Anticipated Obstacles .................................................................................... 21
4.3.3
Sustainability ................................................................................................. 22
4.3.4
Funding Sources ............................................................................................ 23
CONCLUSION ........................................................................................................... 23
BIBLIOGRAPHY ....................................................................................................................... 24
vi
LIST OF TABLES
Table 1. Pennsylvania Medical Assistance Dental Fee Schedule for Children Under 21 .............. 4
Table 2. Summary of Successful Statewide SBSPs ........................................................................ 9
Table 3. Tentative Program Timeline ........................................................................................... 19
vii
1.0
INTRODUCTION
The public health significance of dental caries is well documented. Epidemiological
studies show that caries can affect people of all ages, races, genders and socioeconomic statuses;
however people of low SES are at a higher risk for developing dental caries1.
Thus,
interventions aimed at reducing dental caries in low SES populations are advantageous from a
public health standpoint2. Reducing the prevalence of caries in a population is cost effective and
reduces the risk of future dental disease. Caries is a preventable disease and its occurrence can
be reduced through a variety of ways. Early intervention, increased public awareness, patient
education, nutritional counseling, frequent dental screenings, use of fluoride and application of
dental sealants can all help to prevent caries3.
For children specifically, school-based interventions have been shown to be effective at
reducing the burden of oral disease4. Many states have instituted school-based sealant programs
(SBSPs) that have improved access to dental care and ultimately lead to the reduction of caries.
The states that will be profiled in this essay are Arizona, Georgia, Illinois, Kansas, Maryland,
Michigan, Minnesota, New Mexico, Nevada, Ohio, Oregon and Wisconsin4-16.
Pennsylvania has a documented need for a statewide school-based sealant program, but
no such program has yet been devised. This essay will propose to develop a statewide schoolbased dental sealant manual for use by counties across Pennsylvania.
1
2.0
PUBLIC HEALTH SIGNIFICANCE OF DENTAL CARIES IN SCHOOL-AGED
CHILDREN
This section of the essay will explore the causes, effects, prevention methods, treatment
options and cost implications of dental caries. School-based dental sealant programs will be
introduced and basic needs assessment for a statewide SBSP in Pennsylvania will be discussed.
2.1
CAUSES AND EFFECTS OF DENTAL CARIES IN CHILDREN
Dental caries is a chronic, multifactorial disease that has many adverse consequences.
Genetics, diet, oral hygiene habits, SES, oral microflora, health beliefs, education level and
access to dental treatment all affect the development and progression of dental caries.
In
children, other important factors affecting caries development in permanent teeth include
maternal oral health habits, maternal oral microflora, existence of early childhood caries, food
security and parental income17.
Children are susceptible to dental caries in both primary and permanent teeth, and those
who have carious lesions in the primary teeth are more likely to develop carious lesions in the
permanent teeth18. Caries can have numerous unfavorable consequences for children such as
possible dental pain, negative experiences at the dental office, need for future dental treatment,
2
missed time from school for dental appointments, increased cost for dental care, and other
psychosocial effects19.
2.2
PREVENTION, TREATMENT AND COST OF DENTAL CARIES
As with most diseases, there are two primary avenues to address dental caries: prevention
before the onset of caries or intervention after the initiation of caries. Prevention methods
include nutritional counseling, oral hygiene instructions, regular dental visits, use of dental
sealants, and application of fluoride dentifrices at home and at the dental office. Preventative
interventions such as these have been shown to be effective at the population level to improve
public health outcomes20.
Once caries have begun to demineralize tooth structure to the point of surface cavitation,
professional intervention is required. Prior to tooth surface cavitation, non-surgical methods
such as application of fluoride, placement of a dental sealant over the incipient lesion, and diet
modification can be effective at stopping the progression of caries21. At this stage, registered
dental hygienists or dental assistants in many states can administer treatment and counseling.
However, once the lesion has cavitated, surgical treatment is required. A licensed dentist must
perform this treatment. Such treatment may initially include amalgam or composite restorations
and could ultimately progress to involve endodontic and prosthodontic procedures if recurrent
caries develops. Thus, there are different caries management pathways that dental providers
should choose from in an attempt to preserve dental tissues22.
Comparing a detailed cost effectiveness analysis of prevention strategies versus
intervention strategies is multifaceted and beyond the scope of this essay. For simple comparison
3
purposes, the Pennsylvania medical assistance dental fee schedule for children under 21 (last
updated Oct 13, 2014)23 is included in Table 1.
Table 1. Pennsylvania Medical Assistance Dental Fee Schedule for Children under 2123
Procedure Code
Terminology
MA Fee
D1351
Sealant- per tooth
$25.00
D2140
Amalgam- one surface
$45.00
D2391
Resin-based composite- one surface, posterior
$50.00
D2751
Crown- porcelain fused to metal
$500.00
D3330
Endodontic therapy- molar
$500.00
In general, dental public health preventative methods have been proven to be cost
effective24-26.
One program rising in popularity is the non-operative caries treatment and
prevention program (NOCTP). NOCTP is a conservative program that advocates the institution
of preventative methods such as fluoride and sealants in high-risk populations due to their
efficacy and cost-effectiveness27-28.
In 2001, the National Institutes of Health released a
consensus statement in support of early detection of incipient dental caries and subsequent nonsurgical treatment such as dental sealants29. Operative dentistry does not cure the disease of
caries; it only treats the resulting lesion. Instituting preventative methods is highly encouraged
because it helps to address the underlying causes of dental caries. Thus, treatment planning
should include a focus on preventative measures30.
The dental community has recently
undergone a paradigm shift concerning dental treatment of pit and fissure carious lesions;
4
minimally invasive procedures are encouraged over surgical interventions from both a technical
and financial standpoint31.
2.3
INTRODUCTION TO SBSPS
Dental sealants have been show to reduce up to 81% of caries in sealed teeth as compared
to non-sealed teeth after 2 years32. The Surgeon General and National Institute of Health
advocate the use of school-based sealant programs to address oral health issues in America33.
SBSPs have been show to be more cost effective than other universal, publically funded private
practice models34. It has been estimated that instituting school sealant programs can more than
double sealant prevalence in a given population35. The CDC along with the independent Task
Force on Community Preventive Services recommended community water fluoridation and
school sealant preventive programs as the most effective public health means to prevent tooth
decay36-37. SBSPs are a proven and highly recommended strategy to prevent dental caries,
particularly in low-income populations38-39.
2.4
NEEDS ASSESSMENT FOR A SBSP IN PENNSYLVANIA
Healthy People 2020 outlined several measureable objectives in order to address the high
rate of dental caries in children.
A key goal is increasing access to dental care through
implementing school-based dental sealant programs. Objectives concerning SBSPs are OH-9.1
“increase the proportion of school-based health centers with an oral health component that
includes dental sealants from 24.1% to 26.5%”, OH-12.2: “increase the proportion of children
5
aged 6 to 9 years who have received dental sealants on one or more of their permanent first
molar teeth from 25.5% to 28.1%”40.
The Pennsylvania Department of Health created an Oral Health Program under Act 87 in
1996. The Oral Health Program advocates the creation of school linked sealant programs for
low-income populations41. Additionally, the Pennsylvania Department of Health released an
Oral Health Strategic Plan in 2002 that included the creation of school-linked sealant programs
as a primary way to improve the state of oral health in Pennsylvania42.
Although Pennsylvania has a demonstrated need to create dental public health
interventions, no such program has been developed for a statewide SBSP.
As of 2013,
Pennsylvania was one of only seven states to have no report of a SBSP in practice 43.
Additionally, the Pew Center on the States issued Pennsylvania a grade of “D” in terms of dental
sealant utilization44. The most recent data from the CDC indicate that only 26.1% of third
graders in Pennsylvania have dental sealants and that 27.3% of third graders have untreated
dental decay45. There are over twenty school districts in Allegheny County alone with greater
than 50% of students on free or reduced lunch, indicating there is substantial need for
intervention in just the greater Pittsburgh area46.
Developing a manual for a statewide SBSP in Pennsylvania is an appropriate and
necessary step towards meeting the Healthy People 2020 goals to increase dental sealant
utilization and reduce dental decay.
6
3.0
DETAILED REVIEW OF SBSPS
As of 2013, there are 43 states reporting at least one existing SBSP44. The structure of
SBSPs can vary widely based on funding, available dental providers, state government
infrastructure, regional differences, economic climate, and many other factors. Some SBSPs
have been in practice since the early 1970s and many have shown profound success47. This
section of the essay will highlight some existing SBSPs and examine the available resources for
creating a SBSP.
3.1
3.1.1
REVIEW OF EXISTING SBSPS
Literature Search of SBSPs
A PubMed search was conducted using the search query “school based sealant program
in America” for articles published in English. The search yielded 22 results. Article topics
varied widely and included issues such as improving access to care, cost-effectiveness of
sealants, retention rates of sealants, change in academic performance among students receiving
sealants, and utilizing mid-level providers to staff SBSPs. One article detailed the effectiveness
of a New York State Department of Health SBSP; after five years the number of decayed,
missing and filled surfaces was 6.8 in the control group and only 2.2 in the sealant group. Best
results seen in the lowest income schools. The sealant group experienced a 44% net cost savings
as compared to the control group48. Another article described a SBSP managed by a Boston
dental school; through this intervention the Healthy People 2010 objective of 50% of all children
aged 8 years to have at least 1 dental sealant was realized for study participants49. One study
examined retention rates for sealants placed at a SBSP in Alabama and found that 71% of
sealants were retained after 1.6 years. Children with sealants were also found to have significant
7
protection from occlusal decay50. Another article examined how the state of Texas was able to
create a SBSP and serve over 28,300 students in the first year alone51.
3.1.2 Best Practice Examples of SBSPs
Due to the varied nature of journal articles published on SBSPs, it is perhaps more
pertinent to examine current best practice examples for SBSPs. The Association of State and
Territorial Dental Directors (ASTDD) released a report profiling eleven successful SBSPs4.
Similarly, the Children’s Dental Health Project (CDHP) also released a Sealant Report that
included a description of five selected states with sustainable and substantial SBSPs5. After
reviewing the ASTDD and CDHP documents, twelve states were selected to profile in depth in
Table 2. The twelve states were selected based on the potential for the state’s SBSP to be
modified and applied to Pennsylvania. Knowledge gleaned from studying these twelve programs
combined and adapted to create a statewide SBSP manual that is customized for Pennsylvania.
The successful programs that will aid in creation of a statewide SBSP for Pennsylvania
shared many commonalities such as funding sources, school selection criteria, student selection
criteria and resources utilized. Many successful programs used the Basic Screening Survey
(BSS)52 for the initial dental exam and the Sealant Efficiency Assessment for Locals and States
(SEALS)53 for data analysis. The most variable elements among different states were recruiting
and funding of dental providers. Some programs contracted outside dental providers, others
directly employed dental providers, and several provided grants to a third party to then hire
dental providers at their discretion. Additionally, some states attempted to calibrate providers by
instituting mandatory training modules while others had minimal standardization.
details the similarities and differences between programs.
8
Table 2
Table 2 Summary of Successful Statewide SBSPs
State
Program
AZ6
Est. 1987
GA7
Funding
Admin
Organization
Arizona Dept of
Health Services
Office of Oral
Health
School Selection
Georgia Oral
Health
Prevention
Program
(GOHPP)
Illinois
Department of
Public Health
(IDPH)
Bureau of Oral
Health
>50% students
on free/reduced
lunch
-CDC
-CDC
Cooperative
Agreement
-MCHBG
-Delta Dental
-HRSA
-CDC
-HRSA
-MCHBG
-AZ Medicaid
-Private donors
Est. 1984
-MCHBG
-State general
funds
IL8
-MCHBG
Est. 1985
KS9
Est. 2010
MD10
-HRSA
-CDC
-State grants
-KS Medicaid
-Delta Dental
Foundation of
Kansas
Est. 2009
MI11
Est. 2007
MN12
Est. 2011
High proportion
of students on
free/reduced
lunch program
Student
Selection
Second and
sixth grade
students
Dental Providers
Resources
Results
Individually
contracted and must
complete training
course
-BSS
In 2011-2012:
-11,411 students screened
-6,412 students received sealants
-70% sealant retention rate
Second grade
students
Dental sealant team
employed by GOHPP
-BSS
-SEALS
In 2011-2012:
-71 schools visited
-5337 screenings
-7461 sealants
>50% students
on free/reduced
lunch
Second and
sixth grade
students
Schools
identified from
online Screening
Program “Smiles
Across Kansas”
as having unmet
dental needs
Not specified
Individually
contracted by
applying for direct
grant from IDPH
Individually
contracted and must
complete calibration
course
-“Healthy Smiles”
(oral health survey)
-BSS
-SEALs
-“Smiles Across
Kansas” (online
screening program)
Since inception:
-72 counties served
-1 million children screened
-2 million sealants placed
In 2011-2012:
-46% of all KS public schools had
participated with “Smiles Across
Kansas”
-355 schools visited
-21,914 sealants placed
-86.5% sealant retention rate
Maryland
Department of
Health Office of
Oral Health
Known sealant
rate, response
rate free meal
rate, caries rate
Third grade
students
University of
Maryland School of
Dentistry students
and faculty
In 2009-2010:
-Conducted state dental sealant
demonstration project
Michigan
Department of
Community
Health
>50% students
on free/reduced
lunch
Third grade
students
Registered Dental
Hygienists
-Maryland public
school children
survey (oral health
survey)
-Released SBSP
manual
-SEALS
Minnesota
Department of
Health (MDH)
Oral Health
Program
>50% students
on free/reduced
lunch
Not specified
Individually
contracted by
applying for direct
grant from MDH
-BSS
-SEALS
-MN Oral health
Statistics System
-Released SBSP
manual
As of 2013:
-64% of MN children estimated to
have dental sealants
-29% of high-risk schools in MN
have SBSP
9
9
In 2012-2013:
-138 schools visited
-4724 students screened
-16,731 sealants placed
Table 2 continued: Summary of Successful Statewide SBSPs
NM
-State of New
Mexico
New Mexico
Department of
Health
>50% students
on free/reduced
lunch
Grades 1-3 in
urban areas,
Grades 1-6 in
rural areas
Dental Sealant
Program State Staff
-Oral Health
America
-HRSA
-Private donors
-NV Medicaid
-MCHBG
-HRSA Oral
Health
Workforce
grant
Future Smiles
Southern
Nevada Dental
Hygiene
Initiative
Ohio
Department of
Health
>50% students
on free/reduced
lunch
Not specified
Public Health Dental
Hygienists; work on
school premises or
on mobile dental site
-BSS
-SEALS
In 2012-2013:
-3199 sealants placed
-80% sealant retention rate
-Improved academic performance
High proportion
of students on
free/reduced
lunch program
Second and
sixth graders
-Released SBSP
Manual
-Funds 18 SBSPs across Ohio
-State of Oregon
Oregon Health
Authority
>50% students
on free/reduced
lunch
First and
second
graders
Grants awarded to
local health
departments, school
systems, not-forprofit agencies and
hospitals who hire
dental staff
Dental team
employed by OHA
-“Oregon Smile”
(oral health survey)
-SEALS
In 2013-2014:
-76.8% of eligible schools have
active SBSP
-7387 students screened
-16,184 sealants placed
-87% sealant retention rate
-Wisconsin
Department of
Health Services
-Delta Dental of
Wisconsin
Wisconsin
Department of
Health Services
and Children’s
Health Alliance
of Wisconsin
At the discretion
of grant recipient
At the
discretion of
grant
recipient
Grants awarded to
local public health
departments,
community health
centers, hospitals,
school districts,
dental schools and
independent dentists
-BSS
-SEALs
In 2012-2013:
-60 counties served
-42 SBSPs funded
-33,000 children screened
-92% sealant retention rate
Est. 1978
NV13
Est. 2009
OH14
Est. 1984
OR15
Est. 2006
WI16
Est. 1999
In 2012-2013:
-6254 students screened
-19,075 sealants placed
-85% sealant retention rate
MCHBG: Maternal and Child Health Block Grant
HRSA: Health Resources and Services Administration
CDC: Centers for Disease Control and Prevention
*Information in Table 2 was summarized from Association of State and Territorial Dental Directors Best Practices Report4, Children’s Dental Health Project (CDHP) Sealant
Report5 and state specific administrative organization websites 6-16.
10
3.1.3
Existing SBSPs in Pennsylvania
While Pennsylvania does not have a statewide SBSP, there are some existing SBSPs at
the county level. Two such programs are in Allegheny County and Chester County.
Allegheny County Health Department created a SBSP in 1996. From 1997-2000, the
SBSP was in the pilot program phase and served 14 schools and 897 first grade students. Data
analysis of the pilot program revealed that the program was successful and self-sustainable, so
the program was expanded. Since its creation, over 60 elementary schools have been visited,
30,000 children have received oral health education, and 9,000 students have received dental
sealants. The program consists of two parts: (1) oral health education to first and second grade
students given by hygiene students from the University of Pittsburgh Dental Hygiene Program
and (2) initial exam and sealant application done on-site at the qualified school by a dental team.
The program has since been expanded to include fluoride varnish and now allows for the
treatment of sixth grade students in addition to first grade students. Schools in Allegheny
County are eligible to participate if at least 50% of students are on the free school lunch
program54-56.
Chester County Health Department also has an existing SBSP.
In the fiscal year
2011/2012, 396 children aged 6-8 and 12-14 received dental sealants through the school
program. The program is sponsored and funded by the PA Department of Health Oral Health
Program. The program is run by the CCHD in partnership with the Coatesville Area School
District57. A thorough dental sealant form was created for the program that includes information
for parents about dental sealants and oral hygiene. Sealants and fluoride are applied at no cost to
the parents. However, parents of students without insurance can be connected with resources
such as medical assistance, CHIP and private insurers for other dental and medical issues58.
11
3.2
AVAILABLE RESOURCES TO CREATE A STATEWIDE SBSP
MANUAL
There are numerous resources available to aid in creating a statewide SBSP manual.
Some of these resources are outlined below.
Seal America: The Prevention Intervention59: The National Maternal and Child Oral
Health Resource Center published an online guide to creating a school-based dental sealant
program. This guide includes 10 key steps: (1) getting started, (2) gaining and maintaining
community support (3) staffing (4) purchasing dental equipment and supplies (5) funding (6)
developing forms and records, tracking students, and collecting and analyzing data (7) preparing
to launch (8) implementing the program (9) referral and follow-up (10) program evaluation. The
guide is very general and can be applied to SBSPs of any size and in any state. The CDC, ADA,
CDHP and ASTDD all reference Seal America as a thorough, useful tool for the creation of
SBSPs.
Promoting Oral Health in Schools: A Resource Guide60: This comprehensive manual
was also released by the National Maternal and Child Oral Health Resource Center; it outlines
school-based interventions such as basic dental screenings, placing dental sealants, topical
fluoride application, injury prevention and community education. There is also a comprehensive
list of existing programs and resources concerning school programs. This resource provides an
extensive summary and contact list for public health interventions across America.
Ohio Department of Health SBSP Manual61: In this comprehensive manual, the Ohio
Department of Health (ODH) describes all pertinent details to their successful SBSP programs.
12
Important issues such as regulatory compliance, clinical methods, Medicaid billing and
collection, health professional enrollment and reporting are explained in detail. The manual is
intended for agencies applying for a SBSP grant from the ODH. The information base is
extensive and helps ODH SBSP grant recipients in Ohio to meet all requirements and
expectations of the program. While targeted at providers and agencies within Ohio, the manual
has a wealth of useful information about creating a comprehensive SBSP that can be used as a
beginning template for other states to create their own SBSP manual.
Ohio Dental Clinics Online Module62: As an adjunct to the SBSP Manual, the ODH
released a mandatory online training module for all ODH SBSP grant recipients. The five-part
module is targeted at calibrating SBSP staff to the basic procedures involved in sealant
placement. The technical knowledge should be purely review for dental providers, but the
modules allow for standardization and continuity within the program. Similar to the ODH SBSP
Manual, this resource is aimed at ODH SBSP grant recipients, but can be generalized to
providers in all states. The module was created by ODH in conjunction with the National
Maternal and Child Oral Health Resource Center, the creators of Seal America.
Minnesota Department of Health SBSP Manual63: This manual is published for programs
interested in starting or standardizing SBSPs in Minnesota. This may include local public health
departments, public schools, community health centers, safety net dental providers, dental
schools and non-profit organizations. The manual is thorough and outlines how to create,
execute, analyze and sustain a SBSP.
Maryland Office of Oral Health Dental Sealant Guidelines and Operations Manual64:
This manual analyzes the current state of SBSPs in Maryland and provides a framework to
modify and standardize programs. The manual discusses all relevant information about SBSPs
13
including but not limited to protocols, community needs assessment, staffing, reports and site
reviews. The manual also contains suggestions for health education programs, information about
technical assistance, and offers flexible ideas for SBSPs such as mobile dental programs and
hybrid programs.
3.3
DISCUSSION AND APPLICATIONS FOR PENNSYLVANIA
The existing resources on creating statewide SBSPs have some variability, but there is
also a significant amount of overlap of necessary information. Universal elements include
creating a purpose statement, conducting a needs assessment, discussing strategic partners,
securing adequate funding, identifying qualified schools, selecting patients, acquiring informed
consent from parents, recruiting dental personnel, purchasing equipment, establishing technical
protocols for sealant application, assuring regulatory compliance and infection control, creating a
referral network for patients needing more advanced treatment, involving school personnel,
filing insurance claims, conducting retention checks and/or quality assurance site visits,
analyzing program data and discussing program sustainability.
These elements must be
incorporated into even the simplest SBSP to assure the proper standard of care is maintained.
Creation of a statewide SBSP requires a thorough analysis of numerous economic,
political, legal and environmental factors. There is a wealth of information available concerning
SBSPs such as published case studies, best practice examples, and state specific SBSP manuals.
Pennsylvania has no such state specific SBSP manual or guide published. Publishing a SBSP
manual for Pennsylvania would help facilitate the implementation of SBSPs across the state by
eliminating guesswork and streamlining the creation of local programs.
14
4.0
PROPOSAL FOR STATEWIDE SBSP MANUAL IN PENNSYLVANIA
The following proposal is for the creation of a statewide SBSP manual in Pennsylvania.
The program goals, program outline, strategic partners, program participants, program personnel,
necessary supplies, program timeline, and program evaluation will be described.
4.1
GOALS AND AIMS
Program manual design will be centered on best practice criteria for existing SBSPs. The
primary goals will be to create a program with (1) demonstrated impact and effectiveness (2)
maximum efficiency with both time and finances (3) sustainability (4) collaboration and
integration with other existing SPSPs (5) adaptable objectives4.
4.2
MANUAL OUTLINE
The outline for this manual is intended to serve as a framework for future SBSPs in
Pennsylvania and can be adapted to meet the needs of many different populations.
4.2.1 Strategic Partners
There are several important organizations that will be crucial to the development and
execution of a functional statewide SBSP manual. The Allegheny County Health Department
will be an important resource concerning state specific demographic information, integration
15
with existing school health programs, state funding opportunities and administrative experience.
The Chester County Health Department will be similarly helpful by describing their existing
SBSP, evaluating strengths and weaknesses and determining potential obstacles to expanding
and integrating the program to other counties. The Pennsylvania Department of Health could
provide important information about health departments across the state and give valuable
administrative advice concerning public health programs. The Pennsylvania Dental Association
could be helpful in identifying different possible dental providers. The officials at the school
districts and elementary schools in Pennsylvania will be key to the implementation of SBSPs.
The school officials will serve as an intermediary between SBSP program personnel and the
parents of program participants, so qualifying schools must have administrative staff that is
willing and able to support the SBSP.
4.2.2 Participants
Elementary schools in Pennsylvania will be eligible to participate with the SBSP if
greater than 50% of students are eligible for free or reduced lunch. This information can be
found via the National health and Nutrition Examination Survey65 for each county in
Pennsylvania.
All students enrolled in the second grade at schools participating with the SBSP will be
screened for dental sealants, regardless of insurance status. If funds and personnel are available,
then students enrolled in the sixth grade can also be screened. Students with an established
dental home will be encouraged to pursue treatment with their personal dentist in an effort to
maintain professional decorum.
16
Inclusion criteria for sealant placement include fully erupted first permanent molars
without caries or with incipient caries on second grade students and fully erupted second
permanent molars without caries or with incipient caries on sixth grade students. Exclusion
criteria for sealant placement includes non-erupted or partially erupted permanent molars or fully
erupted permanent molars with cavitated lesions.
4.2.3 Personnel
A program director for the statewide SBSP must be recruited and hired to organize and
facilitate the administrative aspects of the pilot program. A program assistant would also be
valuable for completing miscellaneous tasks. Staffing to provide the dental treatment at various
schools can be secured in different ways.
Dental personnel can be recruited through the
Pennsylvania Dental Association, Pennsylvania Dental Hygienists’ Association and Public
Health Council, Public Health Dental Hygiene Practitioners’ Association, Expanded Function
Dental Assistants’ Association, local health departments, community health clinics, federally
qualified health centers, dental schools, dental hygiene schools and private dental offices.
A minimum of two providers should be present at each SBSP. These providers can be
licensed dentists, public health dental hygiene practitioners (PHDHP), expanded function dental
assistants (EFDA), dental hygienists, dental students and dental hygiene students. PHDHPs
would be ideal providers since they can place dental sealants without direct supervision from a
dentist66. EFDAs, dental hygienists, dental students and dental hygiene students all require direct
supervision from a dentist in Pennsylvania67.
In order to standardize the providers, all clinical program personnel will be required to
complete the Ohio Dental Clinics Online Module62 prior to performing dental treatment.
17
4.2.4 Equipment and Supplies
Equipment and supplies may be purchased by each individual health department or
SBSP. Alternatively, equipment and supplies may be purchased by the Program Director and
then loaned to health departments of SBSP.
Final decisions on procuring equipment and
supplies will depend heavily on funding.
Start-up Costs: Starting a SBSP requires the purchase of portable dental equipment. This
equipment includes a portable dental unit, air compressor, dental chair, dental light, dental
hygienist stool, assistant stool, sterilizer, ultrasonic cleaner and dental tools. Seal America
estimates that start-up costs for this equipment can range from $7,621.00 to $17,746.00 for the
initial operatory. Each additional operatory can cost from $4,811.00 to $11,92059.
Operating Costs: Other supplies will also be necessary such as gowns, masks, gloves,
bibs, disposable plastic covers, air-and-water syringe tips, high-volume suction tips, low-volume
suction tips, cotton rolls, dry angles, gauze, disposable bite blocks, incentives for students,
toothbrushes, etch gel, prime and bond, resin-based sealant material, dental trays, antibacterial
gel, sterilizer backs, sterilizer cleaner, surface disinfectant, ultrasonic cleaner solution, vacuum
system cleaner, trash cans, trash can liners, light bulbs, first aid kit, electrical equipment, tool kit
and general office supplies59. These costs will recur throughout the duration of the SBSP.
Salary and Wages: Additional costs include a salary for the Program Director, hourly
compensation for the Program Assistant, transportation to and from school sites, fee to access the
Basic Screening Survey, cost of SEALS software, purchase of two laptops for Program Director
and Program Assistant. Consultant fees may also be required for project design and/or data
analysis.
18
4.2.5 Timeline
Table 3: Tentative Program Timeline
Prior to
1st visit
to school
Tentative
Timeline
12 months
prior
7-11
months
prior
 Identify and hire program director
 Create appropriate forms to be distributed to parents, schools, and
dental personnel
 Formalize agreement with dental providers
 Introduce program to school officials
 Secure additional project funding
 Purchase equipment and supplies
6 months
prior
 Determine school’s eligibility (>50% free/reduced lunch)
 Contact school to determine interest level in SBSP
3 months
prior
 Discuss details of program with school officials
 Establish date of 1st visit
2 months
prior
 Distribute permission forms for students to give to parents
 Identify student’s insurance status (uninsured, Medicaid, private)
1 month
prior







1st visit
to school
1 month
2nd visit
after
initial
to school
school visit
rd
3
visit 1 year after
initial
to school
school visit
Program
analysis
Description of Activities
12-18
months
after initial
school visit
Collect permission forms from students
Determine final estimate of student participants
Order necessary dental materials
Schedule dental personnel for school visits
Initial exam using Basic Screening Survey
Sealant placement
Short-term retention check to verify sealant application was
satisfactory
 Long-term retention check to verify sealants are still properly sealed
 Limited dental exam to check for development of caries on teeth
where dental sealants were placed




Data analysis using SEALS
Create report on pilot program
Evaluate successes and failures of pilot program
Adapt and expand program where necessary
19
4.2.6 Forms
There are several forms that are crucial to the SBSP:
1) Interest letter for qualified elementary schools
2) Informed consent letter to parents of second grade students
3) Information on dental sealants and SBSP for distribution to parents and teachers
4) Certification of completion of online training module for dental providers
5) Basic Screening Survey for initial dental exam
6) Reimbursement form for Medicaid, CHIP and private dental insurance
7) Referral form to UPSDM for more advanced dental treatment
4.2.7 Evaluation
The CDC’s Sealant Efficiency Assessment for Locals and States (SEALS) will be used to
evaluate program inputs, dental treatment administered, outputs and outcomes. Key indicators
will be the number of students treated, prevalence of one or more dental sealants before and after
pilot program, DMFS/DMFT scores of students before and after pilot program. Data will be
used to determine if program goals and Healthy People 2020 goals were achieved. It will also
serve to analyze the total costs of the program and ultimate treatment benefits. Information may
then be submitted to the National Oral Health Surveillance System, if appropriate. If necessary,
site visits could be helpful to evaluate the program, determine the level of standardization of
dental providers and to assess quality control.
20
4.3
DISCUSSION
4.3.1 Intended Public Health Outcomes
The intent of creating a statewide SBSP manual is to increase the number functioning
SBSPs in Pennsylvania. A comprehensive manual will facilitate the creation of local programs
and ensure standard of care is maintained. Each SBSP aims to increase the number of children in
Pennsylvania with dental sealants, decrease the number of children with untreated dental decay,
and improve access to dental care for children from low-income families by eliminating some
barriers to care. Community preventative services such as SBSPs are an attempt to connect
people with health care resources, particularly in at-risk populations.
There are numerous
potential benefits on the population and individual level. Effectively implemented SBSPs with
the guidance of a statewide SBSP manual can ultimately be cost saving for government agencies.
4.3.2 Anticipated Obstacles
Creating a statewide SBSP manual also comes with many potential obstacles. The first
and largest obstacle is funding. The documented success of other statewide SBSP manual helps
to justify the cost. Once the SBSP manual is created, disseminating that information could also
be challenging. Sending the manual to all county health departments in Pennsylvania would be a
good first step to raising awareness about the manual and for ultimately creating SBSPs.
Other obstacles include challenges specific to SBSPs. One potential issue is recruiting
elementary schools that are willing and able to support a SBSP. In an attempt to overcome this
issue, interest letters will be sent to all qualified elementary schools. Officials that are motivated
to respond to the inquiry are more likely to be helpful in facilitating the SBSP. Another
documented issue is the return rate of consent forms from parents of qualified students. To
21
combat this issue, the Program Director can opt to hold an evening meeting for parents of
students for the SBSP. However, parents that are not compliant in returning consent forms are
unlikely to attend an evening meeting, so the effect may be minimal. Another potential obstacle
will be recruiting dental providers. Targeting PHDHPs, EFDAs, and dental staff at health
departments, community health clinics and federally qualified health centers may be a good
starting point. In Pennsylvania, PHDHPs are the only mid-level dental provider that can apply
dental sealants without direct supervision from a licensed dentist. Thus, PHDHPs are the ideal
provider for SBSPs in Pennsylvania since they are able to work independently. Providing
financial incentives may also help to attract providers if necessary. Further complications may
arise from utilizing a large number of different dental providers to administer treatment. Thus,
standardization through a free online training module56 will be required prior to administering
treatment. There are many other potential issues that may arise throughout the planning and
execution of the SBSP.
The program director, health department, school district officials,
elementary school administration and attending dentists should work together to resolve any
obstacles affiliated with the SBSP.
4.3.3 Sustainability
In order for a SBSP to be sustainable, one primary goal is to secure substantial funding.
Billing Medicaid, CHIP and private insurance companies for services rendered will also be a
necessity. Another critical goal is the establishment of a permanent position at a state agency for
development of the program. The Pennsylvania Department of Health Oral Health Program
could be approached about creating this position.
22
4.3.4
Funding Sources
There is a wealth of potential funding for SBSPs. The first and most substantial is the
Title V Maternal and Child Health Services Block Grant.
This grant funds a majority of
successful statewide SBSPs in excess of $300,000.00 annually, per state. Delta Dental has also
provided grants for SBSPs in many different states. HRSA currently funds SBSPs through the
Bureau of Health Profession’s State Oral Health Workforce Grants. The CDC sponsors StateBased Oral Disease Prevention Program grants for oral health community programs. Oral Health
America’s National Sealant Alliance donates dental sealant materials to qualified SBSPs.
Additionally, the Pennsylvania Department of Health Oral Health Program may allocate some
funds for SBSPs.
5.0
CONCLUSION
School based-sealant programs are an effective means of preventing dental caries in highrisk populations. There are many states with successful programs in place and a vast array of
available resources for designing SBSPs. Pennsylvania would greatly benefit from the creation
of a statewide SBSP manual.
By developing a clear and useful manual, counties across
Pennsylvania could begin to institute SBSPs and ultimately reduce the burden of oral disease for
children in Pennsylvania.
23
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