Session
Building Sustainable, Effective School-Based Oral Health Programs
APHA 2022 Annual Meeting and Expo
Abstract
CariedAway: one solution to one global disease
APHA 2022 Annual Meeting and Expo
Background: Dental caries is childhood’s most prevalent, preventable disease, affecting more than 50% of all children and exceeding 70% in low income and minority children. Efforts to address this problem have seen substantial increases in Medicaid budgets for child oral health; a 20% increase in dentists and hygienists; and multiple federal and state organizations recommending school-based caries prevention.
Problem: Despite these efforts, less than 40% of U.S. dentists provide sealants, approximately 16% of children accessing care receive sealants or fluoride, and school-based prevention typically fail to implement evidence-based protocols with outcome assessments. Additionally, Medicaid misspends 25% of its oral health budget on ineffective care. To address these deficiencies, we posited that a comprehensive, evidence-based caries prevention program quantitatively reduces caries prevalence and incidence. We present a guiding framework for evidence-based school caries prevention.
Boundary conditions: The CariedAway program was developed under the conditions specified by the Institute of Medicine’s quality aims, the Institute for Healthcare Improvement’s Triple Aim, HealthyPeople 2020 goals, and UN Sustainable Development Goal #3. The evolution of CariedAway further saw the incorporation of HealthyPeople 2030 goals, the American Dental Association guidelines for non-restorative care, the AHRQ National Quality Strategy, the CMS Framework for Health Equity, the WHO Essential Dental Medicines, and COVID-19 requirements for aerosol-free dental care.
Conclusions: School-based prevention, framed by external conditions from governmental and clinical practice organizations, increases care effectiveness. This framework for school-based caries prevention results in an adaptive, flexible model that provides essential oral health care even in pandemic areas and positively impacts child development.
Abstract
School-based caries prevention with minimally invasive treatments: results from phase one of the CariedAway cluster randomized pragmatic trial
APHA 2022 Annual Meeting and Expo
Background and Objectives: Dental caries is the world’s most prevalent noncommunicable disease, and children from low-income and minority populations face profound oral health inequities. Our objective was to evaluate a school-based caries prevention program that uses WHO essential medicines.
Methods: CariedAway is a longitudinal, cluster-randomized, non-inferiority trial of minimally invasive treatments for oral diseases. Phase 1 of CariedAway assessed the two-year caries arrest and prevention rates of silver diamine fluoride compared to glass ionomer sealants and atraumatic restorations, the short-term impacts on quality of life and academic performance, and the impact of nurses versus dental hygienists on treatment effectiveness. Non-inferiority for study outcomes was assessed using mixed effects multilevel models and two-sample proportion tests with cluster adjustment.
Results: Of the 4718 subjects randomized, 1398 follow-up observations were completed in Phase 1. The baseline sealant prevalence was 11% and untreated decay prevalence was 30%, indicating severe unmet need. Overall caries arrest and prevention rates after two years, regardless of treatment, were 50% and 80%, respectively. The difference in caries arrest between treatment and control groups was -0.11 (95% CI = -0.22, 0.01), and the difference in prevention was 0.01 (-0.04, 0.06). Both demonstrated non-inferiority of SDF.
Conclusions: The sustainability of school-based oral health programs is contingent upon program participation, clinical and cost-effectiveness, diversity in treatment options, and workforce requirements. Findings support the utilization of silver diamine fluoride as an effective, non-restorative caries arresting and preventive agent and suggests a new, sustainable framework for school-based caries prevention.
Abstract
Nurses are non-inferior to dental hygienists in the prevention of caries using silver diamine fluoride: results from the CariedAway school-based clinical trial
APHA 2022 Annual Meeting and Expo
Background and Objectives: Silver diamine fluoride (SDF) is an efficient, economical, minimally invasive arresting and preventive agent for dental caries. In contrast to other nonsurgical methods, SDF can be easily applied by non-dental health professionals including registered nurses, with simple training, but this approach has not been tested.
Methods: The CariedAway study is a longitudinal, school-based, cluster randomized, non-inferiority trial of non-surgical interventions for dental caries. A secondary objective of CariedAway was to test the effectiveness of SDF when applied by registered nurses compared to dental hygienists in the two-year prevention of dental caries in a school-based pragmatic setting. Non-inferiority for nurses versus dental hygienists was assessed using two-sample proportion tests with adjustment for clustering.
Results: Of the 417 subjects treated with silver diamine fluoride that did not have caries at baseline, 298 were treated by dental hygienists and 119 were treated by registered nurses. The prevention rate after two years was 0.812 and 0.798 for dental hygienists and nurses, respectively, for a difference of 0.014 (95% CI = -0.07, 0.098), indicating non-inferiority in the effectiveness of SDF.
Conclusions: The effective prevention of dental caries in schools can improve health and overall child development, and the National Association of School Nurses advocates for oral health prevention and education to be included as part of their professional practice. State practice acts can authorize registered nurses, including school nurses, to treat children with silver diamine fluoride with substantial impacts on the efficiency and reach of care.
Abstract
Robust implementation of school-based health centers: engagement approaches for improved participation, evaluation, and dissemination
APHA 2022 Annual Meeting and Expo
Background and Objectives: Community engagement and program promotion are critical and frequently overlooked components in the design and sustainability of school-based health centers. Our objective was to develop a comprehensive engagement approach to cultivate strong partnerships with schools. Our engagement model provides participating school communities with meaningful opportunities and resources for community engagement and strengthens the ability to assess and improve partnerships and overall programmatic functioning.
Methods: A multilevel community engagement model was developed that includes frequent engagement with partnered school communities, including school administration, teachers, and students/families. Our community engagement toolkit included collaborative operations planning with partnered school leadership, program awareness presentations for all school administration, teachers, and staff, interactive oral health education presentation for students, oral health resource distribution, and post-treatment quality improvement feedback surveys disseminated to school leadership.
Results: The community engagement model for the CariedAway school-based oral health program allowed for the strengthening of partnerships, effective planning prior to treatment visits, improved overall functioning during designated treatment periods, improved informed consent retention across all schools, increased program awareness, and increased oral health education. Overall participant retention was 80% and demonstrated a 20% increase in new subject recruitment.
Conclusions: Active involvement with school partners and continuous evaluation of the implementation process allows the school-based health center to better understand barriers and facilitators to overall program functioning, and in turn, better connects students with the preventative dental services available.