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Improving Oral Health in the School Setting Amanda ...
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Running head: IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 1
Improving Oral Health in the School Setting
Amanda Hollingsworth
Touro University, Nevada
October 20, 2018
In partial fulfillment of the requirements for the
Doctor of Nursing Practice
DNP Project Team: Dr. Nadia Luna, DNP, MBA, RN, CNE
Dr. Denise Zabriskie, DNP, RN, CWOCN, WCC
DNP Project Member(s): Dr. Juanita Rosales, DNP, RN, PHN
Date of Submission: October 20, 2018
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 2
Table of Contents
Abstract ......................................................................................................................................... 3
Background ................................................................................................................................... 5
Problem Statement ....................................................................................................................... 8
Objectives .................................................................................................................................... 10
Review of Literature ................................................................................................................... 11
Theoretical Model ....................................................................................................................... 20
Project Design.............................................................................................................................. 27
Implementation ........................................................................................................................... 28
Project Timeline ........................................................................................................................ 32
Ethics of Human Subjects ........................................................................................................ 33
Evaluation ................................................................................................................................... 34
Analysis ..................................................................................................................................... 35
Significance and Implications in Nursing ................................................................................. 38
Limitations of the Project ......................................................................................................... 39
Project Sustainability ................................................................................................................ 41
Conclusion ................................................................................................................................... 42
References .................................................................................................................................... 43
Appendix ...................................................................................................................................... 48
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 3
Abstract
Tooth decay is the most chronic common condition in childhood in the United States (Centers
for Disease Control and Prevention [CDC], 2017). One in five children ages five to 11 have had
a least one untreated decayed tooth (CDC, 2017). The state of California has recognized the
importance of oral health of school age children. On September 22, 2006, the California
Governor signed Assembly Bill [AB] 1433 stating that schools must send notification of the new
oral assessment requirement to parents or legal guardians (California Dental Association [CDA],
2017). Effective January 2007, children attending public school must submit proof of an oral
assessment performed by a licensed or registered dental health professional by May 31, before
entering the first grade (CDA, 2017). The purpose of this project was to increase oral health of
schoolchildren through assessment compliance among kindergarten students in a Southern
California school district. The school nurse plays an essential role in providing support,
education, and referral for children and their families. Thirteen school nurses received an oral
health education toolkit to reinforce oral health hygiene and the requirements of California law
AB-1433. Eighty five percent of the participants answered the 20 multiple choice questions with
a score greater than 75%. A school-based dental clinic was implemented at one elementary site
with approximately 165 enrolled kindergarten students. At the start of the 2018-2019 school
year at this project site, 160 kindergarten students (N=160) were enrolled and one hundred
percent of kindergarten students were missing the oral health screening. By August 31, 2018,
86% of students turned in a completed oral health assessment form. The results of this project
provide support for the establishment of school-based programs within school nursing and in
outside school districts.
Keywords: oral health, school health, students, school nurse, kindergarten
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Improving Oral Health in the School Setting
Dental decay is the most common chronic disease in children and teens affecting nearly
two-thirds of California’s children by the time they reach third grade (CDA, 2017). Dental
decay is the result of acid breakdown of tooth enamel produced by bacteria found in a film that
gathers on the teeth (CDC, 2017). If left untreated, the child may develop infection severe
enough for emergency treatment resulting in permanent damage (CDC, 2017). Although cavities
are preventable in the United States, 21% of children between the ages of 6 to 11 years old had at
least one cavity in their permanent teeth in 2011-2012 (CDC, 2017). Children with oral decay
stop smiling, eat poorly, and have difficulty in the learning environment (CDA, 2017).
Invasive treatment to address disease can be avoided with prevention. Low-cost oral
health decay can be prevented by providing education to caregivers on preventing caries,
effective oral hygiene, a healthy diet, and low-cost fluoride (Hummel, Phillips, Holt, & Hayes,
2015). With early intervention, cavities can be detected and treated. The state of California has
recognized the importance of oral health of school age children. On September 22, 2006, the
California Governor signed Assembly Bill [AB] 1433 stating that schools must send notification
of the new oral assessment requirement to parents or legal guardians (CDA, 2017). Effective
January 2007, children attending public school must submit proof of an oral assessment
performed by a licensed or registered dental health professional by May 31, before entering the
first grade (CDA, 2017). Parents may opt to waive this requirement if the parent cannot afford to
pay for it, if the child’s insurance is not accepted, or if the parent simply chooses not to have the
child’s oral health evaluated (CDA, 2017). This form provides the school nurse information
needed to identify barriers to care and need for follow-up.
Childhood decay often goes unrecognized and untreated resulting in serious health
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 5
problems that may lead to surgical extraction or crown placement (Hummel et al., 2015). These
late-stage interventions, waste healthcare dollars and introduce patients to risks such as increased
risk for disabilities in language acquisition and abstract reasoning from a single exposure to
general anesthesia before age three (Hummel et al., 2015). Implementation of an oral health
program within the school setting will provide added preventative oral health care to reduce the
burden of oral disease in the kindergarten student.
Background
In 2006, a Healthy People 2020 survey revealed nearly 54% of California kindergarten
children had a history of tooth decay in comparison to the United States baseline prevalence of
33.3% for children aged 3-5 years old (California Department of Public Health [CDPH], 2017).
The underserved population face challenges to oral health care access including transportation
problems, health literacy challenges, and social and cultural factors (CDPH, 2017).
Socioeconomic status is a strong determinant of oral health and outcomes (CDPH, 2017).
Children of all ages who live below the federal poverty level (FPL) are more likely to have
untreated dental decay than the children living above the FPL. Students who receive free or
reduced lunch in California schools are more likely to have a history of tooth decay, untreated
decay, or needed urgency dental care more than the children who does not qualify for the free or
reduced lunch program (CDPH, 2017).
In compliance with AB 1433, this school district provides the oral health assessment form
included in the kindergarten registration packet of the public-school child prior to the start of
kindergarten. The parent has until May 31, before the student enters first grade, to complete the
oral assessment. On the form, the parent has the right to waive the oral assessment. This data is
then reported to the County Office of Education (CDA, 2017). If the parent returns the form to
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the school site indicating they choose to waive oral care, this identifies the student as entering
school with possibly untreated decay and more specifically, the follow up may reveal barriers
the child faces in receiving proper oral health care in the community (CDA, 2017).
Significance
Tooth decay is the most chronic common condition in childhood in the United States
(CDC, 2017). One in five children ages five to 11 have had a least one untreated decayed tooth
(CDC, 2017). By kindergarten, more than 50% of children in California have already
experienced tooth decay, 28% untreated tooth decay, and 19% accounting for extensive decay
(California Dental Association [CDA] & California Society of Pediatric Dentistry [CSPD],
2014). Children age five to 11 from low-income families are twice as likely to have untreated
tooth decay (CDC, 2017). Tooth decay is painful and the consequences of untreated tooth decay
are expensive with negative consequences such as teeth, gum, and tooth loss (CDA & CSPD,
2014). Dental disease is infectious and progressive yet largely preventable with early
examination and intervention. California Dental Association and California Society of Pediatric
Dentistry recognize the importance of preventative programs and the need to implement oral
health policy at the local, state, and national levels (CDA & CSPD, 2014).
Needs Assessment
The purpose of this project is to improve oral health assessment compliance in the regard
to AB 1433. An initial self-study conducted by the school nurse found that 155 out of 163
kindergarten children currently enrolled at an elementary school in a public school district in
Southern California have not returned the oral assessment form in the 2017-2018 school year.
The school nurse has found that the methods of holding the parent accountable in obtaining the
school entrance oral health evaluation form varies from school to school, district-wide. At the
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end of every school year, each school site’s unlicensed assistive personnel [UAP] gathers and
reports the oral health assessment data to the district office Student Records Technician. The
oral health assessment data includes the total number of kindergarteners and those who
presented proof of a dental exam, and those found with untreated tooth decay at initial
evaluation. Additional information, the total number of students who could not complete an
assessment due to lack of access to a licensed dentist or registered dental health professional,
those who did not consent to their child receiving the assessment and the total number of
students who did not return either the assessment form or the waiver form is included in this
data collection. The Student Record Technician inputs the district wide total oral health
assessment/waiver data through Student Oral Health Assessment System ([SCOHR], 2012).
SCOHR (2012) tracks the status of all oral health assessment/ waiver request forms through an
online database. Tooth decay is the most chronic yet preventable heath care need among
children in California (California Department of Education, 2017). Tooth decay is the cause of
874,000 school days missed each year, costing school districts $29 to $32 million annually in
average daily attendance funding (California Department of Education, 2017). The goal of the
Kindergarten Oral Health Assessment Requirement (AB 1433) is a way for schools to play an
active role in reducing dental disease in children through oral education, awareness, and
connecting families to a source of regular dental care (California Department of Education,
2017). This program will identify children in need of further examination and dental treatment
and with help in the identification of barriers to the delivery of oral care (CDC, 2017). The low
compliance rates in receiving the completed evaluation/waiver form reveals the need for a
district-wide action plan and the implementation of interventions. A school district located in
Southern California is meeting the very minimum standards of California law by simply sending
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 8
the oral assessment form in the kindergarten registration packet then reporting the compliance
rates through the online database SCOHR.
Problem Statement
An understanding of oral health in school-aged children is an important step in examining
the patterns of delivery and the barriers that the student may face in obtaining care (Reed et al.,
2016). Tooth decay is significant, although preventable (Reed et al., 2016). Refocusing the
school and the school nurse role of improving oral health compliance enables to student to
function at the most optimal level in the classroom (Reed et al., 2016).
The school nurse plays an essential role in providing support, education, and referral for
children and their families. In this Southern California School District, the school nurse is held
to the minimum requirement of California law to gather the end-of-year data of oral health
assessment compliance from the UAP after it has been reported to the Student Records
Technician. Recognizing the oral health status of the kindergarten student allows the nurse to
examine the patterns in the delivery of care, the impact of contributing factors, and the use of
oral health services by these children (Reed et al., 2016). Dental diseases are preventable and
the implementation of activities will improve oral care by carrying out school-wide
interventions, referral to local dentists, and follow up (Voogd, 2014).
Purpose Statement
The purpose of this project is to increase oral health of schoolchildren through
assessment compliance among kindergarten students in the public-school setting. At this time,
there are 3,435 kindergarten students enrolled in the project school district. At one school, 95%
of the enrolled kindergartens did not return the oral assessment form in the 2017-2018 school
year by August 31, 2017. In compliance with California Law (Education Code Section
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49452.8), this school district includes the Oral Health Assessment Form in kindergarten
registrations packets to be returned by May 31, prior to the start of first grade. Whether or not
the oral health assessment form is returned to the school site, the kindergarten child will
continue on to the first grade; no child is excluded from school due to lack of an oral health
evaluation.
The aim of this project is to increase the oral health assessment return compliance rates in
the 2018-2019 school year. Providing oral health education supports the importance of
compliance with California State Law to decrease the number of students entering school with
possible untreated decay while increasing the return of the oral health evaluation among
kindergarten students. If the parent opts to waive the oral health examination, the school nurse
must be aware to follow up with the parent. Documenting this information will allow the school
to know the reason behind the decision to waive care.
The National Association of School Nurses [NASN] recognizes the importance of the
school nurse in identifying social determinants of health in the school community, deliver health
care to all students, support school staff, and create partnerships with local community members
to decrease health disparities (National Association of School Nurses [NASN], 2016).
Vulnerable and underserved populations include racial and ethnic minorities, including
immigrants and non-English speakers, uninsured and publicly insured individuals, children, and
populations of lower socioeconomic status (National Academy of Sciences, 2011). In the
project school district, there were 53,147 students enrolled in the 2016-2017 school year
(Education Data Partnership [Ed Data], 2017). The demographics of this school district in 2016-
2017 school year include 28,074 enrolled as Hispanic and 24,646 students who qualified for the
free or reduced meal program (Ed Data, 2017). The National Academy of Sciences identifies
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 10
the child, ethnic and minority groups, and poor and minority children are substantially less
likely to have access to oral health care (National Academy of Sciences, 2011).
Project Question
The purpose of this project is to examine the oral health assessment compliance rates and
the improvement of compliance rates prior to the start of 1st grade after implementation of an
oral health program using the research question: In the kindergarten student, does
implementation of a school-wide oral health program improve the compliance of completing the
oral health evaluation form by the start of 1st grade?
Project Objectives
• Develop a school-dental office partnership to provide free or low cost dental services to
uninsured or underinsured kindergarten students by April 2018
• Design an evidence-based practice (EVP) oral health education toolkit program
throughout school district by May 2018
• Improve oral health assessment compliance to 65% by the end of August 2018
Search Terms
A comprehensive literature review was performed using multiple databases including
CINAHL Complete, Academic Search Premier, Alt Health Watch, and Health Source: Nursing
Edition, MEDLINE, PubMed, Cochrane Database, and EBSCOhost. The studies were selected
based on oral health in the school-aged child. Key terms included oral health, school health,
school nurse, school nursing, oral health assessment, and school-aged children. The original
search yielded 5,886 search results. The results were narrowed by date of publication, to include
articles published from 2011 to the present, full text, peer-reviewed scholarly articles in the
United States. The final 10 studies were selected included qualitative, quantitative, cross-
sectional, randomized control trials, and comparative data analysis.
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Review of Literature
The purpose of this review of literature is to examine current research pertaining to oral
health in the school-aged child. Key concepts will recognize the school-aged child as a
vulnerable population, the oral health effects on school performance, parental literacy of oral
health education, and the collaboration between organizations in providing an additional access
to dental care. The goal of this review of literature is to identify common themes and potential
gaps, and identify the relationships among the studies found.
Impact of the Problem
Poor, minority children, younger than five years are at a high risk to dental caries (Beil,
2014; Biordi, 2015; DeMattei, 2012; Mahat, 2017; Matsuo, 2015; Seirawan, 2012). Matsuo,
Rozier, & Kranz (2015) revealed that more than 51.7% of Hispanic children and 39% of Black
children had dental caries at the time of enrollment in comparison with 30.4% of White children
(Matsuo et al., 2015). Hispanic and Black children were more likely to have experienced dental
caries then White children, regardless of poverty status (Matsuo et al., 2015). This study
magnified the disparities that an individual of lower socioeconomic status faces that can affect
the child’s oral health indirectly and directly (Matsuo et al., 2015). Families of higher
socioeconomic status are more likely to have access to healthy food and a quality dentist,
perhaps, due to transportation and location of neighborhood (Matsuo et al., 2015).
Bell, Huebner, & Reed (2012) revealed 47% of children and youth were in excellent oral
health, 24% in very good oral health, and 8% in fair/poor oral health. Most children rated in
excellent oral health were younger, white, had health insurance, two married or cohabiting
parents, higher family income, no special health care needs, and a usual source of medical care,
received regular preventive medical care, and resided outside a metropolitan statistical area (Bell
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et al., 2012). Overall, 78% of children and youth received a preventative dental visit (Bell et al.,
2012). Only 24% of children ages 1 to 2 years old and 73% of those ages 3 to 5 years received
preventative visit (Bell et al., 2012). Children without special health care needs had lower rate of
receiving preventive dental care services (Bell et al., 2012).
Simmer-Beck et al. (2015) evaluated the effectiveness of an alternative dental workforce
program—Kansas’s Extended Care Permit (ECP) program—as a function of changes in oral
health. Low income children attending a Title 1 elementary school (defined as exceeding 40%
poverty based upon the number of students that qualify free or reduced-price lunches) located in
a Midwestern suburb participated in this intervention (Simmer-Beck et al., 2015). This study
revealed 64% of participating children in this program had decayed teeth (Simmer-Beck et al.,
2015). This rate is significantly higher than that reported in the state, county, and school district
where the program was located (Simmer-Beck et al., 2015). This rate also exceeded the Healthy
People 2020 baseline (23.8%) and target (21.4%) decay rates (Simmer-Beck et al., 2015).
Children of parents who had low knowledge of oral hygiene were more likely to
experience dental decay in comparison to those with more knowledge (Bell, 2012; Mahat 2017).
Mahat & Bowen (2017) found that the parents who participated in this study were
knowledgeable about some aspects of children’s oral health risk factors however; they lacked
knowledge of certain aspects in oral care. For example, 97.7% of parents knew baby teeth were
important and that baby teeth (92%) and permanent teeth (98.9%) needed to be brushed twice
daily (Mahat & Bowen, 2017). Only a few parents (28.7%) recognized that cavities in baby
teeth could cause long lasting problems (Mahat & Bowen, 2017). Bell, Huebner, and Reed
(2012) examined the associations between parent’s report of their children’s oral health and
receipt of a dental visit for preventative care. The findings of this study revealed 47% of
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children and youth were in excellent oral health, 24% in very good oral health, and 8% in
fair/poor oral health (Bell, Huebner, & Reed, 2012).
Addressing the Problem with Current Evidence
In this section, the impact of the problem will be discussed. The articles collected are
analyzed and the recommendations of prevention, current management, current
recommendations for managing the issues, issues still under investigation, and issues that have
not been addressed.
Prevention. There are significant differences in the families with greater access and use
of services; those with poor access may be at higher risk for poor oral health status (Bell et al.,
2012). Preventative oral health services and receipt of care is disproportionate by age, race and
ethnicity, and the presence of special health care needs (Bell et al., 2012). Matsuo et al. (2015)
recognized the importance of public health strategies to reach high-risk students in low-risk
schools who do not usually benefit from most school-based oral health intervention because their
schools are not targeted (Matsuo et al., 2015). The findings of this study support the need to
implement public health interventions to reduce racial and ethnic oral health disparities (Matsuo
et al., 2015).
Primary prevention. Encounters with alternative providers play a large role in the oral
health status of children (Biordi, 2015; DeMattei, 2012, Simmer-Beck, 2015). School nurse
involvement in school-based dental centers improves access for many children without special
health care needs (DeMattei, Allen, & Goss, 2012). DeMattei et al. (2012) support the benefits of
partnerships between schools and local dental organizations. School-based dentist programs
provide an alternative, easy access to the school-aged child in a familiar environment that
supports academic performance (DeMattei et al, 2012). Similar to California State Law, Illinois
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 14
requires mandatory dental exams for kindergarten, second and sixth grade students (DeMattei et
al., 2012). DeMattei et al. (2012) recognizes the importance of providing oral health care in the
school environment as an additional access to meet this requirement.
Secondary prevention. Beil, Rozier, Preisser, Stearns, and Lee (2014) found that children
who had a dental visit by age 24 months had similar numbers of teeth affected with dental caries
at the time they were examined in kindergarten as the children who had a visit at age 24 to 36
months. The children who had a dental visit by age 24 months were at higher rates of disease
than those who had a visit at 37 to 60 months (Beil et al., 2014). Children who had two or more
visits before 24 months had the same rate of disease as children who had visits with two or more
treatments at older ages (Beil et al., 2014). Children who received two or more restorative
treatments by age 24 months had the same amount of disease as children who had their first visit
at older age, which suggests that early visits may have been effective in treating disease for the
high-risk children (Beil et al., 2014). This study supports early screening and intervention as an
effective way to detect and reduce chronic oral health problems in children.
Tertiary prevention. Dental problems affect quality of life, school performance, and
school attendance (Guarnizo, 2012; Jackson, 2011; Seirwan, 2012; and Simmer-Beck, 2015).
Seirawan, Faust, and Mulligan (2012) measured the impact of dental disease on academic
performance of disadvantaged children by sociodemographic characteristics and access to care
determinants. The results indicate that 6.4% of parents miss workdays and 5.5% of elementary
and high school students miss school due to their children’s dental problems (Seirawan et al.,
2012). In this sample of children, almost 169 days were missed by students because of dental
problems and 218 days lost by parents because of their children’s dental issues. In Los Angeles
Unified School District (136,873 students), this translates to 16,431 school days missed annually
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 15
(Seirawan et al. 2012). Students with toothaches in the past six months were almost four times
more likely to have a grade point average lower than the median of 2.8 compared with students
without recent toothache (Seirawan et al. 2012).
Guarnizo-Herreno and Wehby (2012) found that children ages 6 to 11 years old with
dental problems are more likely to have problems in school (30.22%) and miss school (78.51%).
Guarnizo-Herreno & Wehby, 2012). This study shows dental health is positively associated with
all psychosocial outcomes (Guarnizo-Herreno & Wehby, 2012). Children with dental problems
are more likely to feel worthless/inferior (1.47%), unhappy/sad/depressed (0.79%), and are less
likely to be friendly (55.41%) (Guarnizo-Herreno & Wehby, 2012). Good dental health is
associated with less shyness and more friendliness in contrast to poor or fair dental health
associated with more shyness and feeling worthless, unhappy, sad, and/or depressed (Guarnizo-
Herreno & Wehby, 2012).
DeMattei et al. (2012) implemented service-learning project to eliminate barriers to oral
care for children with special health care needs. Of the sample size, approximately 15 % of the
children presented with severe restraint behavior and no treatment was provided (DeMattei et al.,
2012. The findings of this study detected dental decay in 85 children with 10% urgent need for
restorative care, root canals, and extractions (DeMattei et al., 2014). Implementing alternative
access to care will improve the quality of life for the school-aged child. This project was a
collaboration between a school district’s special education population and a local dental
hygienist program. This project not only proved beneficial to the special needs children but for
the student dental hygienists who learned tactics on performing oral care on this population.
Furthermore, the studies support that dental disease directly affects school performance, school
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 16
attendance, and the psychosocial aspect of the school-aged student (Guarnizo, 2012; Jackson,
2011; Seirwan, 2012; and Simmer-Beck, 2015).
Current management.
In the project school district in Southern California, there is currently no oral health
policy in place. Assembly Bill [AB] 1433 states that schools must send notification of the new
oral assessment requirement to parents or legal guardians (CDA, 2017). The project district
office has instructed school sites to include the oral health assessment form to be included in all
kindergarten registration packets. The return data of the completed oral health assessment
forms are collected and then reported to the district office at the end of every school year. This
school district has site-specific partnerships that the UAP or school nurse has organized.
Currently, there is no standardized process regarding what partnerships or school-based oral
health care should be in place for the kindergarten students.
Current recommendations.
The literature supports the implementation of school-based oral health care and the
collaboration with dentists within the community to increase the child’s quality of life, increase
school performance, and reduce absenteeism (Guarnizo, 2012; Jackson, 2011; Seirwan, 2012;
and Simmer-Beck, 2015).
Biordi et al. (2015) recognized fluoride varnish as a routine tool in dental caries
prevention as it is easy to apply, efficient, and safe in young children. Fluoride varnish remains
an evidence-based practice method in decreasing incidence of early dental caries in high-risk
students. Implementing a school-based project to increase the parent’s knowledge and recognize
the benefits of preventive measures will aid in preventing oral health problems especially for
high-risk students.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 17
Issues still under investigation.
An objective of Healthy People 2020 is to reduce the proportion of children who have
dental caries and untreated decay (as cited in Mahat & Bowen, 2017). The American Academy
of Pediatric Dentists (2014) recommends that parents receive better oral health education about
children’s baby teeth and oral hygiene to minimize and eliminate dental disease (as cited in
Mahat & Bowen, 2017). Bell et al. (2012) recommended future qualitative research to explore
parent perceptions of the young child’s preventive dental health needs and the best ways to
promote this awareness at a population level. Bell et al. (2012) recommended utilizing public
health in an effort to educate parents on preventative screenings and early treatment rather than
seeking services in the response of problems. Bandura’s Social Cognitive Theory (1986)
signifies a central source of social influence (as cited in Mahat & Bowen, 2017). This theory
makes sense that if parents are well informed about oral health, they can influence their child’s
oral health behaviors (Mahat & Bowen, 2017). Ongoing research to identify public health efforts
in prevention and early treatment is beneficial to this target population.
Issues not yet addressed.
Jackson, Vann Jr, Kotch, Pahel, & Lee (2011), examined school days missed for routine
dental care versus dental pain or infection to determine the relationship between children’s oral
health status and school attendance and performance. The study found that children with good,
fair, or poor reported oral health were nearly three times more likely than were children with
very good or excellent oral health to miss school because of dental pain (Jackson et al., 2011).
Black children were less likely than white children to miss school for routine dental care
(Jackson et al., 2011). Although a relatively small percentage (4%) missed school because of
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 18
dental issues, further evidence is needed to identify school performance of children who are
experiencing dental pain or infection (Jackson et al., 2011).
Seirawan et al. (2012) measured the impact of dental disease on academic performance of
disadvantaged children by sociodemographic characteristics and access to care determinants.
This study supports oral disease affects individuals contributing to lower academic achievement,
compromising the parent’s ability to maintain a job, and the need for high-quality outcome
measures to promote oral health programs. Future study implications include the evaluation of
socioeconomic, cultural, and clinical challenges in children with dental issues (Seirawan et al.
2012).
Controversies.
Biordi et al. (2015) created a nurse practitioner-dietician collaboration to provide oral
health services and of the 4,360 children who received at least one fluoride varnish, 1,832
children returned for a second visit, and 728 received three or more fluoride varnishes within the
project span (Biordi et al., 2015). At the first visit, 17.1% of the children had dental caries, with
a greater proportion in the urban site compared to the rural site (Biordi et al., 2015). The number
of dental caries declined with the increase of visits (Biordi et al., 2015). Preventative dental
services include examination, education on diet and home hygiene, topical fluoride, and dental
sealants (Bell; 2012, Biordi, 2015). In contrary, Simmer-Beck et al. (2015) found that the
number of fluoride varnish applications did not affect decay, which is inconsistent with the
literature. This finding may have been due to the lack of baseline measurement at the start of
decay-free teeth. Furthermore, Simmer-Beck (2015) recognized that encounters with alternative
providers decrease decay, increased restorations, and decreased treatment urgency significantly
for the children who may not have received oral health care services.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 19
Implications for nursing practice.
The results of this literature review could help to promote the importance of oral health
assessment in the kindergarten student prior to 1st grade entry. The school-aged child is at risk
for tooth decay that lead to lower school performance, absenteeism, and if left untreated, the
student faces risk of permanent dental damage. Best-practice guidelines will result in increased
student wellness, oral health knowledge, and oral health assessment compliance rates. School
nurses serve as a catalyst for the school district and the students regarding school health. It is
essential for the school nurse to understand the factors associated with tooth decay. As
healthcare providers, the school nurse serves as the frontline to prevent and reduce tooth decay in
students entering school.
Recommendations for practice change.
Dental caries lead to a variety of problems such as oral pain, excessive school absences,
difficulty concentrating, poor appearance and poor oral health as an adult (Mahat & Bowen,
2017). Better parental education about children’s primary teeth and oral hygiene minimize or
eliminate dental disease in support of Healthy People 2020 objective: to reduce the proportion of
children who have dental caries and untreated decay (Mahat & Bowen, 2017). Understanding
this information is supportive in the implementation of oral health evidence-based practice
guidelines for school nurses caring for students in the school district. The recommended changes
include proving oral health protocol for school nurses. A written policy would serve as a tool for
the school nurse in addressing oral health at each school site. The best practice guidelines should
include oral health education and materials to present to the kindergarten parents by explaining
the procedure in the language of the learner, providing pamphlets with appropriate literacy and
age-appropriate care. Matsuo et al. (2015) recognizes racial and ethnic disparities that exist
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 20
among children with dental caries signifying the need to close the gap and improve oral health in
the entire community. The oral health assessment form should be included in registration
packets with extra copies in the classrooms, especially during parent events. Referral and follow
up methods, and the development of collaboration with a local dentist should also be addressed,
as the lack of dental insurance is a contributing factor to waiving the dental assessment.
DeMattei et al. (2012) found that enlisting a practicing public health dentist who had
access to federally qualified health centers was beneficial in referring clients to appointments on
an as needed basis. The importance of follow-up care with parents and guardians may have
accounted for low number of children who received treatment for dental care through a school-
based oral health program (DeMattei et al., 2012). This literature supports the sharing of results
and recommendations through face-to-face interaction rather than handwritten notification
(DeMattei et al., 2012).
Theoretical Model
Oral health is an essential part of overall health with complex interaction from many
influences such as nurses, healthcare providers, dental providers, parents, and teachers. To
improve and promote oral care practice in the public-school setting to enhance the kindergarten
child’s health and wellness, the 21st Century School Nursing Practice developed by the
National Association of School Nurses (NASN) best addressed the clinical issue and PICOT
question. The framework for 21st Century School Nursing Practice is designed to guide
evidence-based standards of practice of each unique school community, with the goal of
professional development (Allen-Johnson, 2017). This framework creates a solid foundation
for public health interventions where the nurse motivates the client to make everlasting life
choices to improve health and wellness.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 21
Historical Development of Theory
The development of this framework began with an assessment of current health needs
and healthcare issues of the school-aged child, evidence-based literature, and the skills needed
to meet various student health challenges (NASN, 2016b). Outside consultation experts,
individuals from the NASN’s 2015 annual conference during three feedback sessions, and
individuals from state and local meetings, explored the framework and the initial draft was
published in July 2015 NASN School Nurse with a link to identify the school nurse’s
information (NASN, 2016b). The NASN Board of Directors reviewed and finalized the
framework in 2016.
Major Tenets of Theory
The framework for 21st century school nursing practice is aligned with the whole school,
whole community, whole child model (WSCC), which calls for the integration of health-
promoting practices in the school setting (CDC, 2015; NASN, 2016). Central to the model is
student-centered care that occurs within the perspective of the student’s family and school
community (NASN, 2016b). Surrounding the student, family, and school community, are the
elements of intersecting key principles: (1) care coordination, (2) leadership, (3) quality
improvement, and (4) community/public health (NASN, 2016b). The fifth principle, standards
of practice, encompasses the key principles as a foundation for evidence-based quality of care
(NASN, 2016b). Practice components of each principle are outlined in Figure 1B.
Care Coordination
Care coordination is based on an assessment of the student and family needs (NASN,
2016b). The school nurse initiates the process of identifying children who are not achieving
their optimal level of health or academic success due to oral health issues based on assessment
(NASN, 2016b). The nurse works as the case manager, which directly affects the child, parent,
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 22
teacher, and care providers in determining interventions that are goal oriented (NASN, 2016b).
Motivational interviewing and counseling can serve as an opportunity to educate parents and
children on self-care behaviors and health care needs (NASN, 2016b). Motivational
interviewing empowers the family to identify their own concerns and solutions, rather than the
nurse providing solutions (NASN, 2016b). Due to the large student population, the school
nurse relies on collaboration and delegation. Nursing delegation will require the assignment of
specific tasks during this project such as ongoing documentation of specific health issues by
other members of the school health team. For example, the UAP will need to indicate
complaints of tooth pain, foul mouth odor, constant chewing on pencils, and cracked teeth.
This information is vital to the nurse, as electronic reports will identify oral health issues.
Leadership
Leadership requires the ability to lead policy development and procedures.
Implementing an oral health care policy within the district is an example of performing
advocacy, change, and health care reform. School nurses are viewed as change agents who
participate in the multidisciplinary team to coordinate policy development and implementation
to address the school-aged child’s health concerns within the school and community (NASN,
2016b). The school nurse shows commitment to be a lifelong learner when engaging in
professional practice and development (NASN, 2016b).
Quality Improvement
Electronic collection and management of data overlaps with the quality improvement
(QI) principle, as data collection is a major practice component (NASN, 2016b). QI is the
continuous and systematic process that leads to measurable improvements and outcomes
(NASN, 2016b). The nurse integrates the QI process daily in an effort to identify the greatest
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 23
impact on student health and outcomes (NASN, 2016b). QI changes practice and builds on
current evidence in school nursing. Evaluation of the outcomes identifies the appropriateness
of the process and interventions in place. Collecting the project’s compliance rates will reveal
the effectiveness of the oral health program.
Community/Public Health
School health is grounded in the framework principle community/public health as the
school nurse focuses on the student and the school community (NASN, 2016b). Healthy
People 2020 recognizes the need for oral health promotion and disease prevention, which
supports the need for school nurses to prioritize health assessments and interventions (NASN,
2016b). Recognizing the levels of prevention is a key in addressing issues through health
education, risk reduction, disease prevention, screening, referrals, and follow up activities.
Outreach to kindergarten families will remain key to the success of this oral health program.
Standards of Practice
The principle, standards of practice guides the WCSS framework and incorporates the
practice and performance standards (NASN, 2016b). The school nurse serves this population
with the specialized skill and knowledge to provide the best possible health care. Clinical
competence, clinical guidelines, NASN’s code of ethics, critical thinking, evidence-based
practice, position statements from NASN, Nurse Practice Acts (NPAs), and scope and
standards of practice will guide the school nurse in providing the school community with the
most current and effective oral health care program. The school nurse leader uses the skills
outlined in the practice components of each principle to promote and support the health and
wellness of the student. See Appendix A for 21st Century School Nursing Practice Framework.
Applicability of Theory to Current Practice
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 24
Although the concept of the school nurse has existed since the early 1900’s, uniformity
among states and school districts regarding the school nurse role in schools and the laws
governing are lacking (Holmes & Sheetz, 2016). The credentialed school nurse benefits the
community in surveillance, chronic disease management, emergency preparedness, behavior
health assessment, ongoing health education, and case management (Holmes & Sheetz, 2016).
With an increase in the student population with chronic health care issues, which affects the
ability to learn, safety, and quality of life, the school nurse plays a vital role in disease
management by working in coordination with parents and healthcare providers (Holmes &
Sheetz, 2016). The 21st Century School Nursing Practice framework supports the
communication between school community and health care community. The school nurse is in
the best position to coordinate care through early identification, data collection, treatment,
management/follow-up, and continued communication with the healthcare provider. A growing
amount of evidence indicates the school nurse role can improve attendance by reducing illness
rates through preventative education, early recognition of infection, and chronic health disease
management (Holmes & Sheetz, 2016).
Application of Theory to DNP Project
There are immediate and long-term effects from oral health decay. A school nurse is able
to take the necessary steps to prevent and intervene on health care issues by: (1) implementing
oral health risk assessment screenings and referrals to local dentists, (2) collaborating with a
local dentist office to provide free school-based oral health exams, (3) working with school staff
to promote opportunities for oral health education, (4) educating parents on oral health and
healthy food choices, and (5) involving community providers and organizations in these efforts.
The nurse can play a pivotal role in to monitoring and recognizing the effects of interventions by
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 25
asking questions about classroom and home response, side effects to care, follow-up issues, and
family counseling. The process of care coordination improves the response to students with
unmet health care issues. The role of the school nurse supports the teachers, staff, parents, and
family providers concerns for the students by distinguishing what is medically necessary from
what is educationally necessary.
Care Coordination
School nurses play an essential role in the implementation of care coordination by
conducting a needs-assessment. The goal of the nurse is to improve student health and wellness
with the support of the school community. In this project, the aim is to intentionally organize
and share information on oral health in the kindergarten child by collaborating with
administration and nursing staff to increase the compliance rates of the kindergarten school
entrance oral health exam. The school nurse will work to delegate tasks to the UAP such as
nursing office visit input to be sure that all oral health data is retrievable in current data software.
Educating the UAP on the different symptoms of oral health problems will aid the UAP in being
a key contributor in this project. Reaching out to the parents will be essential in the success of
this program by telephone and letter templates to remind the family of the upcoming deadline to
complete the dental exam.
Leadership
In this project, the school nurse is in the position to advocate for this vulnerable
population. Section three of the oral health exam allows the parent the option to waive care.
This alerts the nurse to reach out to the parent and understand why the care was waived. In the
event that the student does not have dental insurance, the nurse can advocate for this student and
coordinate with the district’s insurance program to get the student the care needed. Health fairs
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 26
are excellent ways to help entire families seek oral health care. Advertising the health fairs in
print and electronic means targeting mobile home parks and other low-income areas will reach
various crowds. The nurse advocates for the vulnerable populations and they become change
agents (NASN, 2016b). Coordinating health promotion, disease prevention, and care
coordination for students bring the possibility to create and implement the oral health policy
districtwide (NASN, 2016b).
Quality Improvement
Quality improvement is the ongoing process to seek change. One example of this is to
ensure the success of the oral health policy by ongoing follow-up with school nurses, oral health
activities, and identifying trends in data. Training the other school nurses to implement specific
activities will enable to school nurse to become more involved in increasing oral health
awareness. The success of this program will rely on other school nurses to continue their
involvement to decrease absence and increase wellness. Recognizing an increase in dental
activities in the school setting provides an alternative to care outside of a dental office.
Community/Public Health
The levels of prevention will aid in the development of interventions. The oral health
exam is an excellent way to gather data of current oral health status. When this information is
not returned, the student is at risk for entering school with oral health problems. Literature
proves that tooth decay is the cause of 874,000 school days missed each year, costing school
districts $29 to $32 million annually in average daily attendance funding (California Department
of Education, 2017). Recognizing this information, the nurse is the leader to organize an
education program to inform parents on the importance of oral health. Health promotion
programs geared towards kindergarten students with an incentive such as a tooth pillow or a
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 27
tooth stuffed animal in exchange for the oral health exam will increase the likeliness of the return
of the form to the school site. A school-based exam opportunity will aid in the screening and
referral process. Follow-up activities with the school nurse will promote the most optimal
functioning in school (NASN, 2016b).
Standards of Practice
The school nurse maintains the high level of competency and professional knowledge and
skills (NASN, 2016b). Collaborating with peers and community healthcare professionals
enriches the school with the best practice and academic outcomes (NASN, 2016b). Reaching out
to families in need, collecting data with honesty and integrity, and understanding the
confidentiality within the California Department of Education and our healthcare system enables
the nurse to perform to the best of one’s ability.
Project Design
The following project will incorporate a quality improvement (QI) design to develop,
implement, and evaluate an oral health education toolkit (OHET). This project will address
school nurses’ self-awareness of oral health education, staff knowledge of California law AB
1433, and activities to improve oral health assessment compliance rates districtwide. Descriptive
analysis will be utilized post implementation of the oral health presentation to identify the school
nurses’ characteristics and measure of the outcome variables. The overall purpose of this project
is to increase the knowledge of the school nurses’ as well as to utilize school-based activities to
increase the oral health compliance rates among kindergarten students in this school district.
Setting
This project will take place at a school district located in Southern California. The
current population within this district is about 56,000 students. As of May 2018, there are 3,518
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 28
enrolled kindergarteners in this school district. This school district is one of the largest in
California. A school-based dental clinic will be implemented at one elementary site with
approximately 165 enrolled kindergarten students. This elementary school site encompasses
52.8% Hispanic or Latino and 26.0% white students, furthermore, 6,638 students received
special education services, 14.1% students are English learners, and 43.1% students receive free
or reduced lunch. There are currently 19 Title I schools within this school district who receive
supplemental funding based on the percentage of students who qualify for the National School
Lunch Program (NSLP).
Implementation
Description of Population
The health staff working within this school district during dates of data collection will be
invited to participate in the presentation of the OHET. Inclusion criteria for this project are as
follows: the age of 18, currently employed registered nurses, and currently employed at this
school district. There will be 11 nursing staff who will participate in the implementation of this
project. The average years of practice for this group of nurses is 22 years with 12 years
dedicated to school nursing. Demographic information can be found in Appendix B. Data will
be collected from July 2018 to September 2018. An unlicensed assistive personnel (UAP) who
works within one elementary school site is of the age 18, employed in this position for two years,
and has not had previous training on oral health education in the school setting.
Stakeholder Support
This school district supports and recognizes the value of this project to improve the
educational experience for the students. The school district superintendent authorized the
following DNP project. The administrative director provided ongoing collaboration to ensure
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 29
this project is in alliance with district goals and objectives. The 10 school nurses will participate
in a presentation on OHET at the district office during a monthly staff meeting.
In June 2017, an agreement between the dental office and the school district was obtained
to provide in-district, free preventative dental services at school sites. This agreement is in place
for health camps that take place in March of every year. With permission from the school
district, this agreement will be used for this project and the agreement for services can be found
in Appendix C. The partnership with this local dentist will provide a school-based dental
screening for the kindergarten students at one elementary school site at no cost. In collaboration,
the dental office and the DNP student will adapt the oral health assessment form for this school-
based dental clinic service.
A school administrator supports the implementation of a school-based dental clinic to
take place in August 2018. The school administrator will coordinate with the DNP student to set
a date and create a phone and electronic message to all kindergarten student’s parents for the oral
health assessment requirement. The UAP who works at this school site’s health office will be
directly involved in communicating with parents, collaborating with the school nurse to execute
a school-based oral health clinic, and the collecting and documenting of the completed oral
health assessment from parents.
Recruitment
Staff
The school nurse is the population of interest as they play a role in ensuring ongoing
surveillance of school district oral health compliance rates as well as guidance for school-based
dental activities to provide all students with oral health support. Mandatory participation is
required of the school nurses in this practice change initiative to ensure that all the RNs
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 30
understand the new protocol. The ten school nurses are considered a convenience sample as they
are required to attend this monthly staff meeting. No financial incentives will be offered.
Confidentiality will be assured in writing to all participants and no identifiable information will
be used. No consent from the nurses is needed because this is a new standard for managing oral
health screenings. The UAP who works within this project site’s health office is required to
participate in this practice change initiative to adopt the process of implementing the school-
based dental clinic, communication to parents, documentation of data, and inputting data in to
current tracking software.
Oral Health Documentation
The Oral Health Assessment form was adopted from the California Department of
Education (CDE) template. This form will be ordered through the district’s print shop. The oral
health assessment form includes three sections: (1) child’s information to be filled out by parent,
(2) oral health data collection to be filled out by licensed California dental professional, or (3)
waiver of oral health assessment requirement to be filled out by the parent or guardian to be
excused from this requirement. The oral health assessment form, an introduction letter to
California law AB 1433 provided by this school district and the consent form will be provided to
every parent or guardian with an enrolled kindergarten student at this elementary school site with
a goal to participate in the school-based dental clinic provided in partnership with a local dentist
(see Appendix D).
All services offered by Tran’s Dental are free and meet the requirements of California
law AB 1433 and the school district policy. Once the oral health assessment screening is
completed at the school site, the dentist will document the information on the oral health
assessment form and return the completed form to the project lead. The school nurse will review
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 31
the information, follow up with the parent/guardian, record the information electronically, and
file the form to the child’s health record for auditing purposes.
Tools and Instruments
Participants Knowledge
The tools utilized within the OHET will include a PowerPoint and a handout of local
dental home resources (see Appendix E). In order to measure the outcomes of this DNP project,
the following instruments will be used: posttest only design (See Appendix F). The
administration of the posttest will be in a handout form on the same day of the toolkit
presentation. The posttest blueprint describes the participants and the 23 oral health knowledge
questions in multiple-choice, true/false, yes/no, select all that apply, and open-ended question
and the three content experts completed the CVI with a score of 3.95 (Appendix G).
Oral Health Compliance Rate
A retrospective audit will be conducted to compare compliance rates of the kindergarten
students enrolled pre-implementation in the 2017-2018 school year—August 2017 and after
implementation in the 2018-2019 school year-- August 2018, pre and post implementation of the
school-based dental clinic (see Appendix H.).
Data Collection Procedures
Data will be collected two weeks before the presentation of the OHET using Survey
Monkey to collect the school nurse participants’ demographic data, to include the highest level
of education, years of nursing experience, years of school nursing experience, length of
employment in current school district, receipt of oral health training, and confidence in providing
oral health education to school staff, students and parents (See Appendix J).
Oral Health Compliance Rate
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 32
Prior to the school-based dental clinic, the project lead will conduct an electronic report
of the missing oral health screening using the school site’s Q software to identify the non-
compliant enrolled kindergarten students at this school site for the 2017-2018 school year as of
August 2018. Following the school-based dental clinic, the oral health assessment non-
compliance rates, pre and post implementation will be described using descriptive statistics. The
results of the oral health screening will be entered in to the electronic record on Q software then
filed to the child’s health record to provide ongoing compliance data throughout the school year.
At the end of the school day on August 31, 2018, the project lead will conduct a final audit to
conclude the final compliance rate post-implementation of the school-based dental clinic (See
Appendix K). At the end of the day on May 31, the UAP will submit a final step outside of this
project in compliance with California Department of Education data reporting (see Appendix L).
Project Timeline
A detailed timeline for this project can be found in Appendix O. using the Gantt chart.
• Week 1- Parent consent form and letter on AB- 1433 requirement will be distributed to
kindergarten parents at the project site.
• Week 2- Finalize OHET presentation. Send reminders for school-based dental clinic
education to the participants.
• Week 3- Conduct 1st school-based dental clinic at project site.
• Week 4- Conduct school nurse pre-implementation survey via Survey Monkey. Analyze
the data.
• Week 5- Conduct 2nd school-based dental screening at project site.
• Week 6- Present OHET to school nurse participants. Administer same day posttest.
• Week 7- Conduct School Nurse follow up. Gather post-implementation data.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 33
• Week 8- Evaluation of project effectiveness. Analyze data.
• Week 10- Disseminate results of the project to school board.
• Week 12- Disseminate project findings to DNP instructors and student colleagues.
Ethics of Human Subjects
The DNP project is deemed a QI project according to the DNP faculty project team
therefore, review by the institutional review board (IRB) is not necessary (Appendix M). This
DNP project focuses on implementing existing knowledge to improve practice rather than
developing new knowledge, therefore, the project lead is not required to submit a project
proposal to the IRB for the protection of human subjects. The Collaborative Institutional
Training Initiative (CITI) program modules on human subjects’ research were also completed to
educate the project lead in upholding the standards of practice related to protection, policies and
procedures.
This QI project upholds the American Nurses Association (ANA) position statement on
privacy and confidentiality. The ethical principles associated with this QI project include justice
and beneficence. This project will not require informed consent as this is a new standard of care
and QI. No financial incentives will be offered to participants. Data collected will be stored and
locked in a filing cabinet. All computerized data will be stored through a computer secured by a
password. All personal identifying data will not be used or coded in the analysis and evaluation
of data.
The risk for participation to the school nurse are as followed: (1) misinterpretation of
information provided, (2) experience of stress due to significance of presentation, (3) being
inconvenienced by the need to implement activities to increase oral health within their school
sites, and (4) burden of time for participation in educational presentation.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 34
The benefits to the school nurse participants include acquiring the knowledge to improve
oral health within the school setting for every kindergarten student within this school district by
implementing activities to increase compliance rates of the oral health assessment.
Evaluation
Participants Knowledge
Data collected throughout this project will highlight the training and assessment of the
school nurses’ current knowledge in oral health and oral health problems, hygiene, and screening
requirements regarding California law AB-1433. The posttest will assess the degree of
understanding of the material presented. The CVI is a guide used to create the test and the
descriptors of the nurse population. Three content experts completed the CVI with a score of
3.95. The McNemar test for this tool and use of a 2x2 table will be used to show percent correct
for each question along with an average percent correct for the entire test with 95% confidence
interval. Cronbach’s alpha is not needed because the concept of internal consistency is not
useful in this instance. This empirical test will identify the improvement by item. The construct
validity is not needed as it relates to latent constructs, which is not present in this case.
Oral Health Compliance Rate
The project lead will compare oral health assessment compliance rates before and after
the implementation of the school-based dental screening. The independent variable is time,
before implementation in August 2017 and after implementation in the 2018-2019 school year--
August 2018. The dependent variable is the compliance percentage of the oral health assessment
forms returned. A proportion test will be used to determine the mean scores.
Analysis
Participant Knowledge
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 35
An email link via SurveyMonkey as well as a paper version of the school nurse posttest
was offered immediately after post implementation of the OHET. Paper surveys were important
to deliver at this time to gather immediate responses from the school nurses. McMaster,
LeardMann, Speigle, and Dillman (2017) recognize that although online surveys have an
advantage including less time and cost associated with data collection and processing, previous
evidence supports a choice of survey response modes offered via paper as it leads to the most
responses. Eighty five percent (N=11) chose to fill out paper surveys immediately following the
OHET presentation and fifteen percent (N=2) chose to use the SurveyMonkey link within two
weeks of the OHET presentation.
The breakdown of responses of the registered, credentialed school nurses (N=13)
employed in this Southern California School District were as follows: Appendix N. One school
nurse retired during the pre-implementation of this project and was not included in the post-
implementation data collection process. Fifty four (N=7) percent of survey responders reported
“no” to having previous dental education in the school settings. Of the respondents, fifteen
percent (N=2) felt extremely confident, fifteen percent felt very confident (N=2), over fifty three
percent (N=7) reported feeling somewhat confident, and fifteen percent feeling not so confident
(N=2) in providing oral health education in the school settings. Fifty four percent (N=7) agreed
to take part in a future fluoride varnish with the director of the oral health program to take place
at the public health department.
The school nurse posttest highlighted oral health, oral hygiene, and the oral health
assessment requirement to meet the objectives of the OHET. Eighty five percent of the
participants answered the 20 multiple choice questions with a score greater than 75%. Sixty two
percent of the participants answered the “select all that apply” question correctly. The last two
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 36
narrative questions asked participants to identify the action of a scenario and how the role of the
school nurse can aid in the ongoing dental care within the school setting. Suggested local
resources were highlighted by the participants in the narrative questions answered. In this
posttest only design, the participants answered the 23 questions with a mean average of 85%.
The standard deviation is 0.18. With 95% confidence, the average questions answered correctly
in this entire posttest is between 75% and 95%, based on this sample data.
Oral Health Compliance Rate
At the start of the 2017-2018 school year at this project site, 163 kindergarten students
(N=163) were enrolled and by August 31, 2017, 95% of kindergarten students were missing the
oral health screening requirement with a compliance rate of 5%. At the start of the 2018-2019
school year at this project site, 160 kindergarten students (N=160) were enrolled and one
hundred percent of kindergarten students were missing the oral health screening. Post-
implementation of the first school-based dental clinics held on August 1, 2018, 64% of students
were missing the oral health assessment requirement. After the second school-based dental
clinics was held on August 15, 2018, 36% of students were missing the oral health assessment
requirement. By August 31, 2018, 86% of students turned in a completed oral health assessment
form. The McNemar test was used to find the non-compliance rates pre and post
implementation, with the first sample with ninety five percent and sample size of 163, and the
second sample with thirty six percent and sample size of 160. The results of the McNemar test
was a difference of 59% with a significance of P<0.0001.
Discussion
Summary
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 37
The outcome results of this project were congruent with those found in literature.
Kindergarten children, ages five to six years old, are at high risk for dental caries (Beil, 2014;
Bell, 2012; Biordi; 2015; DeMattei, 2012; Guarnizo-Herreno, 2012; Jackson, 2011; Seirawan,
2011; Simmer-Beck, 2015). The school-based dental clinic intervention proved to be
successfully implemented during school hours at the elementary school site. The dental office
staff provided an oral health screening, averaging less than two minutes per student. DeMattei et
al. (2012) support the benefits of partnerships between schools and local dental organizations as
an additional resource to access oral care. Schools play a large role in the oral health care status
as they provide additional access to care (Biordi, 2015; DeMattei, 2012, Simmer-Beck, 2015).
Effective interprofessional teaching-learning strategies is necessary for school nurses to
take part in reducing oral health disparities in America (Dolce, 2014). The oral health education
toolkit (OHET) allows school nurses to recognize oral health, hygiene, and the requirements of
California law AB 1433. Findings from this project add to the growing body of evidence that
interprofessional education improves oral health in the school setting. A study found that school
nurse involvement in school-based dental centers improves access for many children without
special health care needs (DeMattei, Allen, & Goss, 2012). This evidence supports the Healthy
People 2020 goals to reduce oral health problems and increase access to preventative oral health
care through public health interventions.
Significance and Implications in Nursing
Good oral health is recognized as an essential component for a child’s healthy life. The
traditional dental workforce model is unable to reach every child needing oral care (Carpino et
al., 2017). In California, nearly two-thirds of children are affected by dental decay by the time
they reach third grade (CDA, 2017). School nurses are in the perfect position to work with
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 38
administrators and school staff to meet the needs of the family and student in a culturally
sensitive manner (Carpino et al., 2017). Dental decay is preventable; however, progressive
infection does not heal without treatment (CDA, 2017). Children need their teeth to eat, speak,
and smile with confidence (CDA, 2017). Educating school nurses on the oral health assessment
requirement increases awareness and maximizes student access to oral health activities within the
school setting. Moving forward with an improved system of care delivery, a school-based dental
clinic provides access to high quality, cost effective oral health care (Carpino et al., 2017). This
project lays the foundation for a comprehensive oral health toolkit that can be implemented into
school nurse practice of school health. This DNP project aided in raising awareness of the
importance of oral health, connect children with dental professionals, assist in enrolling children
in government benefit programs, and maximize access to care (CDA, 2017). Future projects
should address the impact of the collaboration of school nurses in oral health care as well as the
long-term sustainability of integrating school-based dental health initiatives. Policy development
is recommended to outline oral health procedures for this intervention. Addressing
parent/guardian knowledge would be effective to improve oral health behaviors, as the caregiver
is the exclusive domain during the first years of life (Mahat & Bowen, 2017). A qualitative
study would address self-care, diet, and oral health knowledge to identify the influences, norms,
beliefs, and barriers in achieving oral health behaviors in the school-aged child. Beyond the
requirements of the law, the school plays an essential role in ensuring children are healthy and
ready to learn (CDA, 2017). This project is significant to the nursing profession because it
provides insight on the leadership role of the nurse within a school district and the steps to
implement a school-based dental partnership to increase the oral health assessment compliance
rates by reaching students in an effort to screen, triage, and refer children whose families may be
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 39
experiencing barriers to dental care (CDA, 2017). The creation of an OHET will guide nurses in
outside school districts with the most current evidence-based practice in support of the
requirements of California law AB-1433.
Future Research Recommendations
This DNP project serves to provide school nurses a tool on the importance of oral health,
connecting children with dental professionals, assistance in enrolling children in government
benefit programs, and maximizing access to care in the school setting (CDA, 2017). Future
projects should address the impact of collaboration with school nurses on oral health care as well
as the long-term sustainability of integrating school-based dental health initiatives. Policy
development is recommended to outline oral health procedures for this intervention. The
director of the local oral health program offered to train the school nurses in this school district
on fluoride varnish application, where an additional study could examine school nurse
application rates of fluoride varnish in the school setting.
Limitations of the Project
There were several limitations to this project. The project implementation and data
collection was within a short time period. Quality improvement takes time, continuous
monitoring, evaluating, and the need to revise in an effort to maintain the program. The time
frame for implementation was limited because of the DNP program constraints as well as the
school-based dental clinics in the immediate start of the new 2018-2019 school year. Data
collection was tracked using paper then entered in to the school district’s electronic record (Q
software). This was a strength as it was easily accessible but a drawback because of possible
human error. Staff training may be needed throughout the school district on how to accurately
enter the data for each student and run a report to capture the data-type per each school site to
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 40
avoid inconsistent documentation methods. Another limitation of this project was the need to
translate materials sent home during the implementation phase of the school-based dental clinic.
Project lead bias must be considered as a limitation due to the oral health screening results and
the interpretation of this data. The follow-up and referral processes were challenging as some of
the students received a recommendation on the screening form that urgent/emergent care is
needed. This required the school nurses to follow up with parents, some on more than one
occasion. This caused limitations since the DNP project was to be completed in a specific length
of time. Although the referral process may not be feasible within this project, the school nurse
must work with the school site to ensure the parent has the resources to obtain dental care for the
student.
Dissemination
The OHET was presented to the school nurses at the district office at the monthly staff
meeting. This being the first staff meeting for the 2018-2019 school year in August 2018, the
nurses had much to share in addition to this project. This could be considered a limitation due to
minimal time and the priority over education and health promotion. All staff attended the OHET
presentation and the posttest scores showed increase knowledge. Asking the school nurses at
specific future dates if they have implemented the recommended oral health activities within
their school site assignment would provide real-time data as to whether there is an increase in
oral health compliance rates. An oral health workgroup was recommended in this group of
school nurses to continue monitoring the outcomes of this project.
Areas for Future Dissemination
A vital part of the DNP QI project is to disseminate the project outcomes to the
organization and within the academic community. There are various ways that this project’s
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 41
results will be shared among others. The project lead presented the project results to the OHET
school nurse participants and the school-based dental clinic school staff participants.
Additionally, the project lead presented the project outcomes and recommendations to the district
administrator and the school site administrator. The project lead will seek to disseminate project
outcomes by presenting the project at a districtwide administrator meeting held at the district
office at the request of the administrative director of student services. Further opportunities to
disseminate this project’s outcomes would be to present this project at school nurse conferences
and the submission of the project summary to appropriate journals for publication. The
dissemination of this quality improvement program outcomes to the organization and the
academic community fulfill the purpose of the DNP project.
Project Sustainability
After the completion of this project, it was necessary to recognize a sustainability plan to
continue the processes established during the project. The OHET will be distributed to new
school nurse hires to ensure continuation of the project processes. The OHET will be adapted
and presented at the annual districtwide unlicensed assistive personnel (UAP) training in August
2019. The school site administrators and district school nurses could collaborate and require the
UAP to review the OHET prior to August 2019 and keep an ongoing log of those who completed
the training. The school-based dental clinic schedule process will take place at the beginning of
each school year in collaboration with the UAP and school nurse. The school nurse may need to
seek additional dental partnerships as there are over 23 elementary school sites in this school
district. The school nurse oral health advisory group can serve as a resource for the school sites
to disseminate an additional partnership agreement process. The school nurse oral health
advisory will continue to monitor oral health assessment compliance rates using site specific
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 42
reports generated through Q software. This information will be shared at each monthly district
nurse meeting. One member of the school nurse oral health advisory group will attend the
monthly local public health oral health advisory board meeting and share meeting notes with the
district school nurses via email.
Conclusion
School nurses are in the perfect position to work with administrators and school staff to
meet the needs of the family and student in a culturally sensitive manner (Carpino et al., 2017).
Educating school nurses on the oral health assessment requirement increases awareness and
maximizes student access to oral health activities within the school setting. The results of this
project confirm that implementation of a school-based dental program can lead to an increase in
oral health assessment rates in compliance with California law AB-1433. Results of this project
provide support for the establishment of school-based programs within school nursing and in
outside school districts.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 43
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IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 47
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IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 48
Appendix A.
Figure 1A. Framework for 21st Century School Nursing Practice from NASN (2016).
Figure 1B. Practice Components of the 21st Century School Nursing Practice Principles from NASN (2016b).
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 49
Appendix B.
Pre-Implementation School Nurse Survey
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 50
Appendix C.
School-Based Dental Partnership Agreement
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 51
Appendix D.
Parent Notification of AB 1433
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 52
Figure 1.
Oral Health Assessment
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 53
Figure 2.
Parent Consent Form
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 54
Appendix E.
OHET Powerpoint
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 55
Figure 1.
OHET Resources
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 56
Figure 2.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 57
Appendix F.
School Nurse Posttest
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 58
Appendix G.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 59
Table 1.
CVI Expert Rating Score
Item
Expert 1
Expert 2
Expert 3
Mean
1 4 4 4 4.0 2 4 4 4 4.0 3 4 4 4 4.0 4 4 4 4 4.0 5 4 4 4 4.0 6 4 4 4 4.0 7 3 4 4 3.67 8 4 4 4 4.0 9 4 4 4 4.0 10 4 4 4 4.0 11 4 4 4 4.0 12 4 4 4 4.0 13 3 4 4 3.67 14 3 4 4 3.67 15 4 4 4 4.0 16 4 4 4 4.0 17 4 4 4 4.0 18 4 4 4 4.0 19 4 4 4 4.0 20 4 4 4 4.0 21 4 4 4 4.0 22 4 4 4 4.0 23 4 4 4 4.0
Results: The mean total of all of the means was 3.95 indicating that all of the questions were moderately/highly relevant.
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 60
Appendix H.
Pre-Implementation Audit Tool
Enrolled Kindergartners _____ Pre-Implementation of School-Based Dental Clinic _____ Number of kindergarten students who presented proof of dental exam/waiver _____ Number of kindergarten students who could not complete assessment due to financial burden _____ Number of kindergarten students who could not complete assessment due to lack of access to licensed/registered dental professional _____ Number of kindergarten students who could not complete assessment because their parent/guardian did not consent to receiving assessment _____ Number of kindergarten students who were assessed and found to have untreated tooth decay _____ Number of kindergarten students who did not return the assessment or waiver_____
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 61
Appendix I.
Pre-Implementation School Nurse Survey Results
Participant
Highest Level of Education
Years of Nursing
Experience
Years of School Nurse
Experience
Length of Employment in Current
School District
Previous Oral
Health Education in School Setting
Confidence in proving Oral
Health Education to
School, Students, Parents
1 Master 36 30 30 No Very Confident
2 Master 30 6 6 Yes Very Confident
3 Master 20 10 10 Yes Very Confident
4 Master 13 11 11 No Very Confident
5 Baccalaureate 6 3 3 Yes Somewhat Confident
6 Master 22 17 17 No Very Confident
7 Master 39 19 14 Yes Somewhat Confident
8 Master 34 15 15 Yes Somewhat Confident
9 Master 21 7 7 No Somewhat Confident
10 Baccalaureate 6 4 2 No Very Confident
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 62
Appendix J.
Oral Health Project Audit Form
School NameAug-17 Aug-18
Enrolled KindergartnersPre-Implementation of School-Based Dental ClinicNumber of kindergarten students who presented proof of dental exam/waiver Number of kindergarten students who could not complete assessment due to financial bur Number of kindergarten students who could not complete assessment due to lack of acces Number of kindergarten students who could not complete assessment because their paren Number of kindergarten students who were assessed and found to have untreated tooth dNumber of kindergarten students who did not return the assessment or waiverInformed Consent for School-Based Dental ClinicNumber of forms distributedNumber of forms returned to participate in school-based dental clinicSchool-Based Dental Clinic Number of kindergarten students screened at school-based dental clinicNumber of kindergarten students who were assessed and no obvious problems were foun Number of kindergarten students who were assessed and early dental care was recommenNumber of kindergarten students who were assessed and urgent was neededPost-Implementation of School-Based Dental Clinic Number of kindergarten students who presented proof of dental exam/waiver Number of kindergarten students who were assessed and found to have untreated tooth d
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 63
Appendix K.
SCHOOL ORAL HEALTH ASSESSMENT DATA FORM
Send to Students Services, Bld. E, Attn: M. Mitchell by the end of May
School Name: ____________________________________ Date: _________ Person completing form: __________________________________________
1. The total number of students in kindergarten: ________
2. The total number of students in kindergarten who presented proof of a dental exam: ________
3. The total number of students in kindergarten who could not complete an assessment due to financial burden: ________
4. The total number of students in kindergarten who could not complete an assessment due to lack of access to a licensed dentist or other licensed or registered dental health professional: ________
5. The total number of students in kindergarten who could not complete an assessment because their parent or legal guardian did not consent to their child receiving the assessment: ________
6. The total number of students in kindergarten who were assessed and found to have untreated tooth decay: ________
7. The total number of students in kindergarten who did not return either the assessment form or the waiver request: ________
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 64
Appendix L.
Project Timeline
2017 2018 Action
Nov
embe
r
Dec
embe
r
Janu
ary
Febr
uary
Mar
ch
Apr
il
May
June
July
Aug
ust
Sept
embe
r
Oct
ober
DNP 761 Literature Search Project Mentor Approval Advisor Approval Project Proposal Approval Network with Potential Project Site DNP 763 Site Approval Participant Recruitment Craft Toolkit DNP 767 Present OHET School Based Dental Clinic Gather Implementation Data Analyze Findings Evaluate Project Effectiveness Complete Project Report Final Presentation
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 65
Appendix M.
Project Classification Decision
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 66
Appendix N.
Post-Implementation School Nurse Survey Results Participant
Highest Level of Education
Years of Nursing
Experience
Years of School Nurse Experience
Length of Employment in Current
School District
Previous Oral Health Education in
School Setting
Confidence in proving Oral
Health Education to
School, Students, Parents
Interest in fluoride varnish training
with Public Health
Department
1 Master 35 31 31 No Somewhat confident
No
2 Master 30 6 6 Yes Extremely confident
No
3 DNP 20 10 10 Yes Extremely confident
Yes
4 Master 15 11 11 Yes Somewhat confident
No
5 Baccalaureate
7 4 4 Yes Very confident
No
6 Master 40 20 15 Yes Somewhat confident
Yes
7 Master 35 15 15 No Somewhat confident
No
8 Master 21 7 7 No Somewhat confident
Yes
9
Baccalaureate
7 4 2 No Very confident
Yes
10 Master 7 7 7 No Somewhat Confident
Yes
11 Baccalaureate
25 <1 year <6 months
No Somewhat confident
No
12 Master 40 23 22 Yes Not so confident
No
13 Baccalaureate
5 2 1.5 No Not so confident
Yes
What is the most common chronic childhood disease
among US children?
Response Percent Response Count
Answer Options Response Percent Response Count Asthma 8% 1 Tooth Decay 92% 12 Obesity Diabetes Mellitus Answered Question 13
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 67
Answered Correctly 92%
Dental caries is: Response Percent Answer Options Response Percent Response Count A type of gum disease
A bacterial infection of the tooth structure
62% 8
The same as cavities
38% 5
A viral infection Answered Question 13 Answered Correctly 62%
How can bacteria that causes tooth decay transmit from parent to child?
Response Percent
Answer Options Response Percent Response Count Through germs caused by illness
7.5% 1
Through contact such as sharing spoons or forks
85% 11
Through the air Through cuts and open sores
7.5% 1
Answered Question 13 Answered Correctly 85%
Which of the following is a potential outcome of oral health problems in young children?
Response Percent
Answer Options Response Percent Response Count Impaired speech development
Inability to concentrate
Failure to thrive All of the above 100% 13 Answered Question 13 Answered Correctly 100%
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 68
What does tooth decay in the primary teeth often lead to?
Response Percent
Answer Options Response Percent Response Count Tooth decay in the permanent teeth
92% 12
Difficulty swallowing
Fluorosis Not a usual long-term problem because primary teeth fall out
8% 1
Answered Question 13 Answered Correctly 92%
What typically happens when tooth decay is not treated?
Response Percent
Answer Options Response Percent Response Count The tooth will fall out
7.5% 1
Decay will proceed through the enamel and into the dentin
54% 7
Depends on the extent of decay
31% 4
Decay will enter the bloodstream
7.5% 1
Answered Question 13 Answered Correctly 54%
When should the first oral health examination performed by a dentist take place?
Response Percent
Answer Options Response Percent Response Count When the child is developmentally ready
7.5% 1
No later than age 1 77% 10 No later than age 3 7.5% 1 When the child can sit without support
7.5% 1
Answered Question 13 Answered Correctly 77%
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 69
How often should a child receive an oral examination performed by a dentist?
Response Percent
Answer Options Response Percent Response Count Every 6 months 92% 12 Every year 8% 1 Every 2 years It depends on the child’s age
Answered Question 13 Answered Correctly 92%
What is the purpose of an oral health screening?
Response Percent
Answer Options Response Percent Response Count It helps the health professional determine whether signs of oral disease are present
15% 2
It helps infant and young children become comfortable with having their mouths examined
It helps the health professional become familiar with different manifestations of oral disease
All of the above 85% 11 Answered Question 13 Answered Correctly 85%
How long does an oral health screening take to complete?
Response Percent
Answer Options Response Percent Response Count Approximately 15 minutes
8% 1
Approximately 2 to 3 minutes
92% 12
Approximately 1 hour
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 70
Approximately several hours
Answered Question 13 Answered Correctly 92%
How should an infant or young child’s healthy lips and tongue appear?
Response Percent
Answer Options Response Percent Response Count Soft, pink, & moist 100% 13 Dry & warm Smooth & free of bumps
Appearance depends on skin color
Answered Question 13 Answered Correctly 100%
How should a child’s primary teeth appear?
Response Percent
Answer Options Response Percent Response Count White & opaque 85% 11 Straight 7.5% 1 Cream colored & translucent
Smooth & bright 7.5% 1 Answered Question 13 Answered Correctly 85%
When should parents begin cleaning their infant’s teeth?
Response Percent
Answer Options Response Percent Response Count At birth 8% 1 When an infant or child is able to sit still & cooperate
When an infant or child is developmentally ready
As soon as the first tooth erupts
92% 12
Answered Question 13
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 71
Answered Correctly 92%
When should a child begin using fluoride toothpaste?
Response Percent
Answer Options Response Percent Response Count As soon as the first tooth erupts
At around age 2 years
92% 12
At around age 5 years
8% 1
Children should not use fluorinated toothpaste
Answered Question 13 Answered Correctly 92%
When is the oral health assessment requirement due in California public schools?
Response Percent
Answer Options Response Percent Response Count March 31 of the first year of public school
7.5% 1
May 31 of the first year of public school
69% 9
March 15 of the first year of public school
May 15 of the first year of public school
23% 3
Answered Question 13 Answered Correctly 69%
Can a dental provider outside of California perform the oral health assessment requirement?
Response Percent
Answer Options Response Percent Response Count Yes 15% 2 No 85% 11 Answered Question 13
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 72
Answered Correctly 85%
An oral health assessment meets the requirement of AB 1433 if the form was completed prior to entry of kindergarten, as early as:
Response Percent
Answer Options Response Percent Response Count 12 weeks 12 months 100% 13 24 weeks 24 months Answered Question 13 Answered Correctly 100%
If a student enters public school in 1st grade, the oral health requirement does not apply:
Response Percent
Answer Options Response Percent Response Count True 23% 3 False 77% 10 Answered Question 13 Answered Correctly 77%
The parent may indicate on the oral health assessment form to waive the oral health assessment requirement:
Response Percent
Answer Options Response Percent Response Count True 92% 12 False 8% 1 Answered Question 13 Answered Correctly 92%
Verbal communication of obtaining an oral health assessment
Response Percent
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 73
for a child by the parent or legal guardian is acceptable documentation. Answer Options Response Percent Response Count True 8% 1 False 92% 12 Answered Question 13 Answered Correctly 92%
Who can perform an oral health assessment to meet California law AB 1433? (Select all that apply)
Response Percent
Answer Options Response Percent Response Count Registered Nurse (RN)
7.5% 1
Licensed Dentist 85% 11 Licensed Vocational Nurse (LVN)
School Health Clerk
Registered Dental Hygienist (RDH) under Dentist Supervision
92% 12
Pediatric Medical Doctor
15% 2
Registered Dental Assistant under Dentist Supervision
62% 8
Answered Question 13 Answered Correctly 62%
A school nurse receives notice that the oral health assessment form was returned although the parent requested to be excused from this requirement and the box is checked “I cannot afford a dental check-up for my child.”
Participant
What next action should the nurse take? How can the nurse aid in the ongoing management of a student’s oral health?
1 Refer to medi-cal/denti-cal Distribute toothbrush 2 Talk to parent & look at resources
available Screening program at school
3 Refer to community resources Prevent missed school days & improve oral health
IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 74
4 Contact parent, refer to denti-cal, connect to dental home
Follow-up with oral health assessments when needed, educate families & students, connect to dental home
5 Contact parent & offer to refer to ProjectKind
Follow-up every 6 months to remind parent that students needs care, provide fliers for dental fairs
6 Retired
7 Consult health department Provide outside resources & education materials
8 Oral health assessment of child & call to parent
More time & staffing
9 Find resources for parent Find dental home 10 Resources for parents Refer to dental home 11 Refer to free/reduced cost services Cooperate with a dental home for the
child 12 Refer to community dental service Educate students & parents 13 Provide resources including denti-cal Education 14 Provide resources, refer to
ProjectKind Follow up with parent
Table 1. Participant’s Final Score
Participant
Score
1 83% 2 91% 3 74% 4 96% 5 74% 6 Retired at Project Implementation 7 87% 8 97% 9 92% 10 87% 11 70% 12 96% 13 70% 14 100% Average Mean
86%