Implementing Public Health Interventions to Reduce Caries Prevalence

Dental caries, although highly preventable, remains one of the most prevalent chronic childhood diseases in children in the United States.¹ Currently, 20% of children between the ages of 5 and 11, and 13% of adolescents have at least one tooth with active dental decay.¹ Although caries is preventable with education and access to dental care, these solutions are widely unavailable because children residing in low-income families, who most often face access-to-care barriers, are twice as likely to experience decay.¹ Evidence also shows that racial minorities experience the greatest burden of oral diseases.² Performing assessments, adopting policies, and assuring access to care are core public health measures to help combat dental decay.

Oral Health Surveillance: Basic Screening Survey

In 1999, the Association of State and Territorial Dental Directors released the Basic Screening Survey (BSS) tool to provide states with a consistent model for monitoring oral disease in a timely fashion. The BSS is part of the National Oral Health Surveillance System, which is designed to measure and monitor the burden of oral disease in a simple and consistent manner.³ Caries rates by individual states have long been tracked by the BSS and the BSS can be conducted on a variety of populations, such as students in Head Start programs, third grade students, and individuals ages 65 and older.

Third grade students are often used to determine decay rates in children because they usually exhibit a mixed dentition. Their first molars also have erupted long enough to have sealants placed or to have developed caries; these children are easy to access in the public school system. The BSS is a statistically sound study with a random selection of public schools that is further weighted by population within the state. The BSS can look different from state-to-state but, ultimately, the survey is able to provide a benchmark of how the state has done on preventing caries in children.

BSS survey results can differ by state due to the funding available for the survey, state legislation surrounding the scope of practice for oral health professionals, and laws regarding data collection methods. If the BSS is completed every 5 years, trends can be noted, and a story told on who exactly is at the highest risk of dental disease within the state.

The BSS collects geographic distribution, race, and age in addition to performing an open mouth screening to collect data on untreated caries, treated decay, caries experience, dental sealants, and silver diamine fluoride. As a result of collecting these data, the following is revealed regarding children in each region of the state:

1. Percentage of those who have experienced caries
2. Percentage of those who have had treatment for tooth decay
3. Percentage of those who have had dental sealants placed

The BSS represents one of the core public health measures of assessment. This information aids the next two core functions of policy and assurance. It helps community oral health programs to develop targeted prevention programs based on the BSS results.

Oral Health and Racial Inequities

A conversation on access-to-care issues would be deficient without addressing the following factors:²

1. Racial minorities bear more of the burden of oral diseases
2. Notable differences exist between racial groups with more advantages compared to those with fewer advantages
3. Racial inequities have existed over time and across spaces

Jamieson² further explains that evidence demonstrates this is not an individual provider prejudice, but that laws, rules, and practices implemented across numerous levels of government entities support inequalities in the US oral healthcare system. Mitchell and Lassiter⁴ cite the Sullivan Commission’s Report that states Black patients are significantly more likely to seek oral healthcare from Black dentists, and that Black dentists treat 62% of Black patients while white dentists treat about 11% of Black patients. In addition, the US lacks a diverse oral healthcare workforce, with minorities comprising just 5% of dentists.⁵

Michigan conducted the “Third Grade BSS” during the 2015-2016 school year. Results demonstrated that higher proportions of untreated dental disease were seen in children with government insurance or no dental insurance, minority children, and children attending schools in the city of Detroit.⁶ More than 31% of Detroit’s children experienced primary or permanent untreated dental decay. Sixty percent of Black/African American children experienced primary or permanent caries experience and 69% of Hispanic/Latino children experienced primary or permanent caries experience.⁶ Approximately 38% of Black/African American children presented with untreated decay with more than 21% requiring immediate dental care.⁶ Overall for the state of Michigan, 21% of white children presented with untreated decay with 9% requiring immediate dental care.⁶ The definition of the need for immediate dental care corresponded to signs and symptoms of pain, infection, or swelling.

Policy Development and Prevention

Once a state completes the BSS, oral health partners, such as oral health coalitions, local health departments, dental organizations, and oral health advocates, will have the evidence needed to determine where community health programs are best placed to make the most significant impact. If a BSS is completed on students in a Head Start Program and results demonstrate a high rate of caries, this suggests that the region may be in a health professional shortage area with limited access to dental care and may lack community water fluoridation. The results may mobilize community partners to encourage medical-dental integration, another core public health function. Implementing a fluoride varnish program, as a part of the government-funded Women Infant and Children’s Program might be a way to help prevent decay in infants and young children. This would also provide health professionals time with parents/caregivers to offer oral health education on self-care and nutrition information to assist in caries prevention.

Mobile Dentistry

Mobile dentistry may be used in high-risk areas. Currently, many states are able to use public health dental hygienists to work in alternative settings, such as daycare centers, Head Start Programs, and K-12 schools, to bring prevention and education directly to patients. Mobile dentistry services can be completed by using portable dental units in which a dental operatory is temporarily set up in a location, or it can be provided on a bus that is a fully equipped dental office. The mobile teams may consist of coordinators, dental assistants, dental hygienists, and/or dentists, determined by state law and practice acts, program design, and funding allocated to the public health program.

School-Based Health Centers

School-based health centers are an effective and efficient way to provide healthcare and preventive services to students, as they enable the provision of consistent, high-level, interprofessional care.⁵ Schools with health centers may encounter many students with dental-related complaints, leaving the school-nurse/medical provider(s) to navigate an unfamiliar landscape of dentistry, dental clinics, and complicated payment systems.⁵ Incorporating a dental provider into the school-based health center ensures the presence of a provider who is educated in dentistry and provides the opportunity to transition the student into the appropriate setting for care and offer follow-up to make sure care was received. This level of care coordination can provide a cost-effective method of treatment that can be timelier, thus, relieving students of pain faster. Incorporating a dental provider into a school-based program can allow ample opportunity for prevention to take place via classroom presentations and one-on-one education, the application of fluoride varnish, and placement of dental sealants and silver diamine fluoride when applicable.

Role of Teledentistry

Teledentistry, similar to telehealth, can play a vital role in community-based programs. Due to the COVID-19 pandemic, many states were able to continue to safely treat patients via telehealth measures. Teledentistry as a part of telehealth “is the use of electronic information, imaging, and communication technologies, including interactive audio, video, data communications, as well as store and forward technologies, to provide and support dental care delivery, diagnosis, consultation, treatment, transfer of dental information, and education.”⁷

Teledentistry has been used to reduce costs and increase efficiency in dentistry via reduced travel and fewer in-person appointments.⁷ It has a place in community health programs to make the visits even more meaningful. For example, in school-based care, a dental hygienist working in a prevention program might come across a student with pain, swelling, and infection and utilize teledentistry. The student could have a synchronous (live) visit with a dentist on the day of the preventive program visit to address the urgent need. The appointment with the dentist could use video conferencing between the student and dentist while the dental hygienist uses sophisticated technology software systems and intraoral cameras to show the dentist the area of concern. The dentist could order a radiograph that could be taken by the dental hygienist and electronically read by the dentist, an abscess could be diagnosed, and an antibiotic electronically prescribed that day. The prescription would be waiting at the pharmacy for the parent/caregiver to pick up, and an appointment for further treatment could be made for the student to be seen at the dental office. This level of teledentistry would eliminate the need for an in-person appointment and decrease out-of-school time for the child and missed work for a parent/caregiver. It would have the infection treated in a timely manner, which would provide pain relief for the student and enable him or her to sleep, eat well, and learn while in school.

Mobile dentistry, school-based health centers, and teledentistry can reduce barriers to care, assure utilization of oral health services, and support an adequate and competent workforce.

Addressing Dental Decay in Public School Students

The Michigan Department of Health and Human Services Oral Health Program (OHP) has responded to the dental decay epidemic in several ways. The OHP has conducted three Third Grade BSS surveys and one Head Start BSS over the past 15 years. For the 2021–2022 school year, the OHP initiated a combined Head Start and Third Grade BSS to monitor the caries rate among young children and students. There have been many reports published over the past 2 years that demonstrate children have foregone preventive care, including dental care, due to the COVID-19 pandemic. The BSS survey results shall help determine possible policies and shape future community health programs.

Results of the 2015–2016 Third Grade BSS demonstrated the high amount of dental decay found in students living in Detroit. Based on these findings, the OHP was able to partner with the Detroit Public School Community District (DPSCD) and, in 2020, developed an oral health coordinator position within the DPSCD Office of School Health and Wellness. The coordinator works with school nurses, principals, and the DPSCD-contracted mobile dental providers to provide dental services, including dental sealants, to the students in all 105 DPSCD schools. By using the core function of assessment, the OHP was able to leverage resources and implement the core function of assurance by reducing barriers to care and assure utilization of oral health services.

Conclusion

Dental caries remains the most common chronic childhood disease and the public health approach to address this disease is multifaceted, with the approaches grounded in the evidence collected via the BSS. State oral health programs use the BSS as a tool to measure and monitor trends in the burden of disease. The BSS also helps guide the planning, promotion, and implementation of programs to prevent and control dental decay. The BSS can also help with detecting changes in health practices and promoting change. Those changes can include the expansion of the workforce and dental service delivery models. The BSS can assist state oral health programs in the provision of essential public health services to promote oral health and decrease dental disease. These strategies represent other core public health functions of policy development and assurance.

References

1. United States Centers for Disease Control and Prevention. Children’s Oral Health. Available at: cdc.gov/​oralhealth/​basics/​childrens-oral-health/​index.html. Accessed October 19, 2022.
2. Jamieson LM. Racism and oral health inequalities: an introduction. Community Dent Health. 2021;38:131.
3. Association of State and Territorial Dental Directors. ASTDD Basic Screening Surveys. Available at: astdd.org/​basic-screening-survey-tool. Accessed October 19, 2022.
4. Mitchell DA, Lassiter SL. Addressing health care disparities and increasing workforce diversity: The next step for the dental, medical, and public health professions. Am J Public Health. 2011;96:2093–2097.
5. Moore J. Oral health in school-based health care clinics. J Mich Dent Assoc. 2013;95:42, 44, 65.
6. Michigan Department of Health and Human Services. 2016 Count Your Smiles Report. Available at: michigan.gov/​-/​media/​Project/​Websites/​mdhhs/​Folder3/​Folder27/​Folder2/​Folder127/​Folder1/​Folder227/​Count_​Your_​Smiles_떐_​Report-FINAL.pdf?rev=6833c91743f44dbca63e09b494f17495. Accessed October 19, 2022.
7. American TeleDentistry Association. Facts About Teledentistry. Available at: americanteledentistry.org/​facts-about-teledentistry. Accessed October 19, 2022.

From Dimensions of Dental Hygiene. November/December 2022;20(11)21-23.