Association of State and Territorial Dental Directors - ASTDD
Date of Report: September 23, 2009
A Best Practice Approach is defined as a public health strategy that is supported by evidence for its impact and effectiveness. This Best Practice Approach Report describes a public health strategy, summarizes the strength of evidence of the effectiveness of the strategy, and uses current practice examples to illustrate successful and/or innovative implementation of the strategy. This report serves as a resource to share ideas and promote best practices for state and community oral health programs.
Table of Contents:
I. Best Practice Approach (page 1)
II. Description (page 1)
III. Guidelines and Recommendations from Authoritative Sources (page 11)
IV. Research Evidence (page 13)
V. Best Practice Criteria (page 15)
VI. State Practice Examples (page 17)
VII. References (page 20)
VIII. Attachments (page 25)
Suggested citation: Association of State and Territorial Dental Directors (ASTDD), Best Practices Committee, Best Practice Approaches for State and Community Oral Health Programs – Improving Children’s Oral Health through Coordinated School Health Programs, September 23, 2009.
I. Best Practice Approach
Improving Children’s Oral Health
through Coordinated School
Health Programs
II. Description
A. Children’s Oral Health
Richard H. Carmona, M.D., M.P.H., F.A.C.S., the Surgeon General of the United States Public Health Service during 2002-2006, called oral diseases “a silent epidemic” that is “affecting our most vulnerable citizens – children from families with low incomes, children from racial and ethnic minority groups, and children with special health care needs. No child should suffer the stigma of craniofacial birth defects nor be found unable to concentrate because of the pain of untreated oral infections.” 1
For children from families with incomes at or below the federal poverty level:
( The prevalence of tooth decay for children ages 2-5 remained unchanged from the early 1970s to the early 1990s.2
← Nearly 80 percent of decayed primary teeth have not been treated and restored in children ages 2 through 5.3
← Almost 50 percent of decayed primary and permanent teeth have not been restored in children ages 6 through 14.3
The association between tobacco use and oral diseases is well documented. Evidence shows that maternal tobacco use is associated with congenital abnormality such as cleft palate and cleft lips.4 Although the prevalence of tobacco use among students in grades 9 through 12 has decreased since 1999, 28 percent of students in this age group currently use tobacco products (e.g., cigarettes, spit tobacco and cigars). Of this age group, 15 percent of non-Hispanic black students, 18 percent of Hispanic students, and 25 percent of non-Hispanic white students smoke cigarettes.5
Children’s oral health also include being free from injury of the teeth, mouth and face. Thirty-five percent of children and adolescents will have sustained dental trauma at least once by age 16.6 Head, face and neck injuries occur in more than half of the child abuse cases.7
B. Untreated Dental Disease Affects General Health
Dental disease is progressive and can significantly diminish general health and quality of life for children. Tooth decay continues to be the most common chronic disease of childhood. Failure to prevent dental problems has long-term adverse effects.8 Dental disease compromises children’s growth and function including their ability to be attentive for learning, to develop positive self-esteem, to eat, and to speak. The cost of preventive dental care is low compared to alternatives of suffering, dysfunction and expensive repair.9,10
Millions of children in the United States do not have basic dental care. Oral health care is the most prevalent unmet health care need among children.11 Children without health insurance are four times more likely than those with private health insurance to have unmet oral health care needs (20 percent vs. 5 percent, respectively).12 Hispanic children are almost twice as likely as non-Hispanic white children to have had no contact with a dental professional in the past 2 or more years.12 Although more than 90 percent of general dentists provide care to children, very few provide care to children under age 4, children with high levels of dental caries and children covered by Medicaid.13
C. Relationship of Health and Academic Performance
There is a relationship between health and academic performance.14 The fundamental mission of schools is to provide young people with the knowledge and skills they need to become healthy and productive adults. Promoting healthy and safe behaviors among students is an important part of this mission. Improving student health and safety can:
• increase students’ capacity to learn,
• reduce absenteeism, and
• improve physical fitness and mental alertness.
Good health is necessary for academic success. Students at school have difficulty being successful if they are depressed, tired, being bullied, stressed, sick, using alcohol or other drugs, hungry, or abused. Former Surgeon General, Dr. Antonia Novello said that “health and education go hand in hand: one cannot exist without the other.”15 The U.S. Department of Education acknowledged that health problems and unhealthy behaviors have a major effect on students’ success.16
D. Oral Health and Learning
School nurses report oral health problems in children and the problems including tooth decay, gingival (“gum”) disease, malocclusion (poor bite), loose teeth, and oral trauma.17 When children have poor oral health, it affects their ability to learn.18
An estimated 51 million school hours per year are lost because of dental-related illness.19 Students ages 5 to 17 years missed 1,611,000 school days in 1996 due to acute dental problems averaging 3.1 days per 100 students.20 Children from families with low incomes had nearly 12 times as many restricted-activity days (e.g., missed school days) because of dental problems compared to children from families with higher incomes.21,22
A child with a dental problem may have anxiety, fatigue, irritability, and depression; he or she may withdraw from normal activities.23,24 Children distracted by dental pain may be unable to concentrate and learn, complete school work and score well on tests.25 Poor oral health has been related to decreased school performance, poor social relationships and less success later in life.25-28 When children’s acute dental problems are treated and they are no longer experiencing pain, their learning and school-attendance records improve.29
Tooth loss due to dental decay may lead to failure to thrive, impaired speech development and reduced self-esteem.26 Missing teeth also limit food choices due to chewing problems; this may result in inadequate nutrition.30 Nutritional deficiencies could hinder children’s school performance, reduce their ability to concentrate and perform complex tasks, and affect their behavior.31,32
E. Preventing Dental and Oral Disease
Children needlessly suffer from dental and oral disease which can be prevented. Oral health promotion and prevention strategies would reduce the disease burden and increase quality of life. Preventive dental services are cost-effective in reducing this disease burden.33-38 These services include the following:
Preventive Care – Low-income children who have their first preventive dental visit by age one are less likely to have subsequent restorative or emergency room visits and their average costs for dental care over a five year period are almost 40% lower ($263 compared to $447) than children who receive their first preventive visit after age one.34
Water Fluoridation – Water remains the most cost-effective method of delivering fluoride to communities.39 Community water fluoridation decreases tooth decay by 29 to 51 percent in children ages 4 through 17.40 For every $1 invested in fluoridation, $38 in dental treatment costs is saved.35 Medicaid dental programs costs as much as 50% less in fluoridated communities compared to non-fluoridated communities.36
Dental Sealants – Dental sealants are effective in the prevention of tooth decay in the pits and fissures of teeth and are effective over time as long as they are maintained on the teeth.41 Only 12 percent of children ages 6 through 14 living at or below the federal poverty level have at least one dental sealant (one-third of the percentage of children in families with higher incomes).42 Dental sealants have been shown to avert tooth decay over an average of 5-7 years.43,44
Without access to regular preventive dental services, dental care for many children is postponed until symptoms (e.g., a toothache and facial abscess) become so acute that care is sought in hospital emergency rooms.45 This consequence is costly to the health care system. A three-year aggregate comparison of Medicaid reimbursement for inpatient emergency room treatment ($6,498) versus preventive treatment ($660) revealed that on average, the cost to manage symptoms related to dental caries on an in-patient basis is approximately 10 times more than to provide dental care for the same patients in an outpatient dental office.45
Social and demographic factors (e.g., income, race and education) can limit children’s access to preventive dental care.46,47 Low-income children are only half as likely to access preventive dental services as middle or high-income children even though they are two to three times more likely to suffer from untreated dental disease.46,47 Minority children and children whose primary caregivers have less education are less likely to have access to dental services than their white counterparts.46-48
Children with private or public dental insurance coverage are 30 percent more likely than low-income uninsured children to have a preventive dental visit in the previous year.49 Children with Medicaid coverage are more likely to have a usual source of care.49 Parents of children covered by Medicaid are 3.5 times less likely to report that their child has an unmet dental need than uninsured children.50 Among young Medicaid-enrolled children, a cost savings of $66-$73 per tooth surface is projected when the need to repair a tooth is avoided.51 It is also estimated that with regular dental screening and early intervention, there is a 7.3 percent savings.52
School-based oral health services have the advantage of reaching children and enable targeting of preventive services to underserved, low-income children.53 School based oral health programs could include a range of services: oral health education and promotion, dental screening, dental sealants, fluoride mouth rinses or tablets, fluoride varnish, referral, case management, establishment of a dental home, and restorative treatment to ensure timely oral health care for children with unmet oral health needs.
F. The Coordinated School Health Program Model
According to the Centers for Disease Control and Prevention (CDC), Division of Adolescent and School Health, “Schools by themselves cannot, and should not be expected to address the nation’s most serious health and social problems. Families, health care workers, the media, religious organizations, community organizations that serve youth, and young people themselves also must be systematically involved. However, schools could provide a critical facility in which many agencies might work together to maintain the well-being of young people.”54
CDC developed an eight-component model for a Coordinated School Health Program (CSHP). The model is research-based and identifies policies and practices most likely to be effective in improving youth health risk behaviors. A CSHP is a planned, organized set of health-related programs, policies, and services coordinated to meet the health and safety needs of K-12 students at both the school district and individual school building levels. It is comprised of multiple components that can influence health and learning, which include health education; physical education; health services; nutrition services; counseling and psychological services; a healthy school environment; family/community involvement; and health promotion for staff. The following are the eight components of the CSHP model ().54-59
1. Health Education: A planned, sequential, K-12 curriculum that addresses the physical, mental, emotional and social dimensions of health. The curriculum is designed to motivate and assist students to maintain and improve their health, prevent disease, and reduce health-related risk behaviors. It allows students to develop and demonstrate increasingly sophisticated health-related knowledge, attitudes, skills, and practices. The comprehensive health education curriculum includes a variety of topics such as personal health, family health, community health, consumer health, environmental health, sexuality education, mental and emotional health, injury prevention and safety, nutrition, prevention and control of disease, and substance use and abuse. Qualified, trained teachers provide health education.
2. Physical Education: A planned, sequential K-12 curriculum that provides cognitive content and learning experiences in a variety of activity areas such as basic movement skills; physical fitness; rhythms and dance; games; team, dual, and individual sports; tumbling and gymnastics; and aquatics. Quality physical education should promote, through a variety of planned physical activities, each student's optimum physical, mental, emotional, and social development, and should promote activities and sports that all students enjoy and can pursue throughout their lives. Qualified, trained teachers teach physical activity.
3. Health Services: Services provided for students to appraise, protect, and promote health. These services are designed to ensure access or referral to primary health care services or both, foster appropriate use of primary health care services, prevent and control communicable disease and other health problems, provide emergency care for illness or injury, promote and provide optimum sanitary conditions for a safe school facility and school environment, and provide educational and counseling opportunities for promoting and maintaining individual, family, and community health. Qualified professionals such as physicians, nurses, dentists, health educators, and other allied health personnel provide these services.
4. Nutrition Services: Access to a variety of nutritious and appealing meals that accommodate the health and nutrition needs of all students. School nutrition programs reflect the U.S. Dietary Guidelines for Americans and other criteria to achieve nutrition integrity. The school nutrition services offer students a learning laboratory for classroom nutrition and health education, and serve as a resource for linkages with nutrition-related community services. Qualified child nutrition professionals provide these services.
5. Counseling, Psychological, and Social Services: Services provided to improve students' mental, emotional, and social health. These services include individual and group assessments, interventions, and referrals. Organizational assessment and consultation skills of counselors and psychologists contribute not only to the health of students but also to the health of the school environment. Professionals such as certified school counselors, psychologists, and social workers provide these services.
6. Healthy School Environment: The physical and aesthetic surroundings and the psychosocial climate and culture of the school. Factors that influence the physical environment include the school building and the area surrounding it, any biological or chemical agents that are detrimental to health, and physical conditions such as temperature, noise, and lighting. The psychological environment includes the physical, emotional, and social conditions that affect the well-being of students and staff.
7. Health Promotion for Staff: Opportunities for school staff to improve their health status through activities such as health assessments, health education and health-related fitness activities. These opportunities encourage school staff to pursue a healthy lifestyle that contributes to their improved health status, improved morale, and a greater personal commitment to the school's overall coordinated health program. This personal commitment often transfers into greater commitment to the health of students and creates positive role modeling. Health promotion activities have improved productivity, decreased absenteeism, and reduced health insurance costs.
8. Family/Community Involvement: An integrated school, parent, and community approach for enhancing the health and well-being of students. School health advisory councils, coalitions, and broadly based constituencies for school health can build support for school health program efforts. Schools actively solicit parent involvement and engage community resources and services to respond more effectively to the health-related needs of students.
Coordinated school health programs, or CSHPs, aim to improve the health and academic performance of school children. Effective CSHPs actively involve parents, teachers, students, families and communities in their implementation. The programs work toward long-term results and are designed to promote student success. They help students establish and maintain healthy personal and social behaviors improving student knowledge about health and develop personal and social skills that help them make smart choices in school and in life.
There are existing school based or school linked health programs that may have been previously developed and implemented outside of a coordinated school health initiative. These programs are already addressing one or more components of the CSHP model. It’s important to recognize that these programs’ positive impact and a coordinated school health (CSH) initiative should integrate and coordinate with these programs. CSH initiative should ensure continuity for preventive health measures and a CSHP should building upon the success and effectiveness, and leverage off, of existing school health programs.
CDC, Division of Adolescents and School Health, provides funding for state and territorial education agencies and tribal governments to help school districts and schools implement a Coordinated School Health Program (CSHP). Twenty-two state educational agencies and one tribal government receive funding to implement Coordinated School Health Programs: Arizona, Arkansas, California, Colorado, Connecticut, Idaho, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Mississippi, New Jersey, New York, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Washington, West Virginia, Wisconsin, and Nez Pierce (Tribal Government).60 These funded partners are:
• Partnering with health agencies to share decision making and responsibilities for implementing policies and practices.
• Providing tools and training to help schools and school districts implement effective policies and practices to establish and strengthen CSHP, promote physical activity and healthy eating, and reduce tobacco use.
• Developing and disseminating policies to promote and improve
o School health councils and school health coordinators in local school districts.
o Health education curriculum, instruction, and assessment.
o Physical education curriculum, instruction, and assessment.
o Opportunities for physical activity and healthy eating.
o Tobacco use prevention.
• Identifying youth at greatest risk for inactivity, unhealthy dietary patterns, and tobacco use and focusing efforts on implementing strategies to reduce their risk.
• Involving youth in planning, delivering, and evaluating CSHPs and efforts to promote PANT (physical activity, nutrition and tobacco prevention).
• Documenting the impact of program activities by monitoring the percentage of schools that are implementing effective CSHP and PANT policies, programs, and practices.
The CDC School Health Program provides a funding catalyst for collaboration between state education and health agencies to improve students’ health and well-being. The funding assists states to improve the health of children and youth and remove barriers to students’ academic success by improving the high quality and coordination of efforts of school-level programs. States use this funding to maximize efficiency and eliminate duplication by coordinating multiple existing state and community initiatives.
In order to tailor services to needs, schools can use the School Health Index (SHI), a self-assessment and planning tool to improve their health and safety policies and programs. The tool is available online at . The SHI helps schools identify strengths and weaknesses and to develop an action plan for improvement.
Coordinated school health programs contribute to improved health outcomes and academic student achievement in the following ways:
• Schools that offer breakfast programs have increased academic test scores, daily attendance, and class participation.
• Each $1 invested in school-based tobacco prevention, drug and alcohol education and family life education saves $14 in avoided health costs.
• School improvements in currently funded states include healthier food choices, tobacco-free campuses, more effective health education, and increased opportunities for quality physical education. For example, the Life Skills Training program resulted in 44% fewer students using tobacco, alcohol, and marijuana.
• Students who receive mental health services have reduced failures, disciplinary actions and improved grade point averages.
Success stories of coordinated school health programs are being reported across the country from states funded by CDC as well as states that embraced the coordinated school health model without related CDC funding. Examples of reported success stories include:
• CDC Division of Adolescent and School Health, School Health Programs – Success Stories from the Filed 2009
• CDC Division of Adolescent and School Health, 2009 Success Stories – Local, State, and Nongovernmental Organization Examples
• Coordinated School Health in Arkansas – Success Stories
• Hawaii’s State Success Stories in Coordinated School Health
• Michigan’s Healthy Schools, Healthy Students Success Stories
• South Dakota Coordinated School Health Program Success Stories
• Tennessee Department of Education – Coordinated School Health Success Stories
• McComb School District (Mississippi) – Journey to Good Health
One of the success stories, the McComb School District in Mississippi, has documented impressive outcomes with the adoption of the CDC’s Coordinated School Health model. The McComb School District has approximately 3,000 children in seven schools. Eighty percent of the students are minorities and 90% are on free or reduced price school lunch programs. When Dr. Pat Cooper began as McComb’s superintendent in 1997, there were fights at school, a high juvenile arrest rate, a substantial dropout rate and a high teenage pregnancy rate among the students. Children entering school at age 5 were functioning at a three- to four-year-old level. Under Dr. Cooper’s leadership, McComb adopted the CDC’s Coordinated School Health model for a comprehensive school health program (also added a ninth component on “Academic Opportunity”). Guided by Maslow’s hierarchy of needs which holds that people’s most basic needs are physical (e.g., hunger) followed by emotional needs of security, love, self-esteem and self-actualization, the school health program aimed to first meet the students’ basic physical needs in order to help the children achieve their full potential. The entire community was involved in implementing the model. After eight years, McComb’s 8% dropout rate for teenage mothers fell to 3%. Children achieved higher grades. Attendance improved. Juvenile crime arrest rates fell. Graduation rates increased from 77% in 1997 to 92% in 2004. The percent of students performing below grade level decreased from 57% to 45%. The commitment to the health and well-being of the students is captured in the McComb School District Wellness Policy (), which addressed each of the components of the Coordinated School Health model.
G. Integrating Oral Health to the Coordinated School Health Program Model
The coordinated school health program model highlights the importance of including all eight components to fully impact student health behaviors. A strategic approach to improve the oral health of school children is to integrate oral health into the coordinated school health program model.
Each of the eight components of the model should include oral health to achieve a comprehensive and collaborative program that addresses the overall health and safety of school children. Oral health can be integrated into a coordinated school health program as follows:
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1. Health Education: Oral health education is an integral component of school health education classes. The school comprehensive health education curriculum includes prevention and control of oral and dental disease, oral and facial injury prevention, and personal health practices that promote oral health. Assure that oral health education, whenever possible, complies with the Department of Education standards and integrates with teachers’ lesson plans.
2. Physical Education: In promoting quality physical education and planning physical activities for students to enjoy and pursue throughout their lives, prevention and protection from facial and oral injuries in programs devoted to fitness and health should be addressed. Schools can promote the use of personal protective equipment inside and outside school-associated sports and recreation activities. Students could be provided with and required to use personal protective equipment appropriate to the type of physical activity that are well fitted, in good condition and comply with national standards.
3. Health Services: Services provided for students to appraise, protect and promote health should include prevention and treatment of oral and dental diseases. Services assure access or referral to oral health care services and provide emergency care for dental and mouth pain, infection or injury. The school nurse or school-based health center nurse would have oral health information available, provide effective preventive services, and assure students with dental treatment needs access professional care.
4. Nutrition Services: School nutrition programs teach students better choices of foods for oral health. Lunches, snacks and beverages offered by school food services and on school property should be healthy and lower the risk of oral disease such as tooth decay.
5. Counseling and Psychological Services: Services to improve students' mental, emotional, and social health should integrate the impact of oral health to the well-being of the students. These services can help by ensuring that children with oral health needs obtain needed professional care.
6. Healthy School Environment: The physical and aesthetic surroundings and the psychosocial climate and culture of the school can promote oral health, by not using junk food for fundraisers or as choices in vending machines.
7. Health Promotion for Staff: Opportunities for school staff to improve their oral health status through activities often transfers into greater commitment to the health of students and creates positive role modeling. Providing staff with access to oral health information will encourage them to set an example for students by promoting good oral health behaviors.
8. Family/Community Involvement: An integrated school, parent and community approach is needed to enhance the oral health and well-being of students. Building support from school health advisory councils, coalitions and broadly based constituencies can contribute to integrating oral health efforts. Parents can be asked to attend workshops on oral health and to encourage their children to develop good oral hygiene practices at home and school.
School health programs can help children and adolescents attain full educational potential and good health by providing them with the skills, social support and environmental reinforcement they need to adopt long-term oral health behaviors.
H. Oral Health Recommendations for Coordinated School Health Programs
Based on reviews of research literature, CDC in collaboration with other federal agencies, state agencies, universities, voluntary organizations, and professional organizations, have developed guidelines for school health program strategies. Attachment B provides the URLs for selected CDC school health guidelines and recommendations related to oral health (for promotion of healthy eating, prevention of unintentional injuries and violence, and prevention of tobacco use and addiction).
The ASTDD School and Adolescent Oral Health Workgroup and the ASTDD Best Practices Committee developed an initial list of oral health recommendations for integrating oral health to each of the eight component of the coordinated school health programs mode. Attachment C provides a listing of these oral health recommendations.
III. Guidelines & Recommendations from Authoritative Sources
Guidelines and recommendations for improving the oral health of children include the following:
1. Healthy People 2010
Healthy People 201061 () reflects the very best in public health planning. It lays out a series of objectives, created by a broad coalition of experts from many sectors, to improve the health of all people in this country.
• Healthy People 2010, Chapter 21 – Oral Health. Several objectives relate to improving the oral health of children. Tooth decay can be reduced by increasing dental sealant placement, the use of the oral health care system, preventive services for low-income children, school-based health centers with an oral health component, and systems for recording and referring children with craniofacial anomalies.
• Healthy People 2010, Chapter 27 – Tobacco Use. Several objectives focus on promoting the health of children by reducing tobacco use, the initiation of tobacco use, exposure to tobacco smoke, illegal tobacco sales to minors, and eliminating tobacco advertising, while increasing disapproval of smoking, cessation of tobacco use and smoke-free environments.
• Healthy People 2010, Chapter 15 – Injury and Violence Prevention. One objective addresses the health of school children calling for increased use of head, face, eye and mouth protection.
• Healthy People 2010, Chapter 19 – Nutrition and Overweight. One objective addresses the health of school children aimed at increasing students’ dietary quality at school.
2. American Academy of Pediatric Dentistry
The mission of the American Academy of Pediatric Dentistry62 () is to advocate policies, guidelines and programs that promote optimal oral health and oral health care for children. The American Academy of Pediatric Dentistry 2006-2009 Strategic Plan (), includes a goal that promotes optimal health for all children and persons with special health care needs and objectives related to (a) an oral disease-free population and (b) access to appropriate oral health care.
3. Children’s Dental Health Project
The Children's Dental Health Project63 () forges research-driven policies and innovative solutions by engaging a broad base of partners committed to children and oral health. The mission of the Children's Dental Health Project is to advance policies that improve children access to oral health for children. CDHP Areas of Advocacy include (a) financing efforts on public and private insurance and public health funding, (b) prevention efforts for early care, pubic education and research, (c) safety net efforts to advance comprehensive care, and (d) workforce efforts to engage all healthcare providers for oral health.
4. Support of Coordinated School Health by Authoritative Sources
Many influential voices support coordinated school health programs:
• The National Association of State Boards of Education (NASBE) advocated that “Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially.”64
• The National Governors Association (NGA) provided a policy brief on coordinated school health programs and recommended to policymakers that they focus on eliminating barriers that affect readiness to learn among lower-performing students.65
• The U.S. Department of Health and Human Services noted that schools have more influence on young people than any other social institution except the family and highlighted the opportunity that schools offer for improving the health status of children and youth.66
• Superintendents and school administrators nationwide have found benefits from coordinated school health programs. One superintendent, Edward VandenBulke, of the Stow-Munroe Falls City Schools in Ohio, noted that his district has seen first-hand what a well-rounded health program can accomplish for all children, pre-K through 12th grade. He states that there is no question in the minds of the educators in the district that a complete school health program positively affects student achievement.67
• The American Cancer Society (ACS) understood the important links between health and education, and took a leadership role in promoting coordinated school health programs for the nation’s schools.”68
Over 50 leading national health and education organizations participate in a coalition, called the “Friends of School Health,” to promote coordinated school health programs. A partial listing of these organizations is provided in Attachment D. The Friends of School Health testified before the United States House of Representatives Committee on Appropriations Subcommittee on Labor, Health, and Human Services Education and Related Agencies. You can find the oral testimony and written testimony.69
IV. Research Evidence
A. Evidence of Health and Student Achievement
Evidence of health and student achievement over the past two decades has given support that the components of coordinated school health programs have an impact on students’ success in school. For each of the eight components of the coordinated school health program model, research has shown how they contribute to healthy behaviors and improved academic achievement:70
1. Comprehensive School Health Education: Curricula with supporting research evidence as to their effectiveness have been proven to assist students in establishing and maintaining healthy behaviors.71-74 Students receiving comprehensive school health education increase their health knowledge and improve their health-related skills and behaviors.75,76 A study of elementary school students involving a control group of students who did not receive comprehensive school health education and an experimental group that did, showed that students who received the comprehensive school health education scored higher than the control group in reading and math.75
2. Physical Education: Physical education has been shown to improve physical and mental health for students. Physical education contributes to development of skills and behaviors that help young people start an adult life incorporating regular physical activity.77 Studies indicate schools that offered physical education did not experience a harmful effect on standardized test scores; even though less time was available for other academic subjects, physical education is positively associated with enhanced academic performance and improved classroom behavior.78-81
3. School Health Services: Early interventions that include health services can improve later school performance, and they may improve high school completion rates and lower juvenile crime.82 Studies showed that regular access to health services can have a positive impact on student health and the ability of children to succeed in school. Schools with on-site health centers which provide a variety of primary health care services for children and youth have reported increased classroom attendance, decreased drop-outs and suspensions, and higher graduation rates.83-85
4. School Nutrition Services: One study showed that children who reported not having enough food to eat had significantly lower arithmetic scores and were more likely to have repeated a grade, been suspended from school, seen a psychologist, and had difficulty getting along with other children.86 Studies found that students who participated in school breakfast programs demonstrated increased learning and academic achievement outcomes, greater attention to academic tasks, reduced visits to the school nurse, fewer behavior problems, and less tardiness/absenteeism.87,88 Ensuring that schools limit less nutritious snack foods or sodas is an important policy objective for many nutrition programs.71
5. School Counseling, Psychological, and Social Services: In one study, a comprehensive intervention combining teacher training, parent education, and social competency training in children had long-term positive impact showing greater commitment and attachment of students to the school, less social misbehavior, and improved academic achievement.89 Another study showed that a school social services program targeting students at high-risk of dropping out of school produced increased grade point average across all classes taken, increased school bonding, and improved self-esteem of the students.90
6. Healthy School Environment: A healthy school environment involves a positive emotional and social climate and a safe and functional physical facility.71 Several studies have noted the importance of connections to parents and school as the two most important factors in healthy social development for children and youth. Students who develop a positive affiliation with school are also more likely to remain academically engaged and less likely to be involved in misconduct at school.91 One study demonstrated the link between school facilities and academic performance showing students perform better in facilities that are attractive, functional, safe and secure.92
7. School-Site Health Promotion for Staff: School-site health promotion for staff enhance their well-being but also help staff become role models for the students providing reinforcement to sustaining healthy behaviors.71 School-site health promotion programs promoting physical activity for staff result in health benefits that include stress reduction, maintenance of healthy weight, an improved sense of well-being, fewer sick days, and less health insurance cost due to illness.93 Students benefit as their teachers are more energetic and students have more days with their regular teacher when teachers have fewer absent days.94
8. Family/Community Involvement: Studies have shown the critical role families in education providing growing evidence that parental involvement improves student achievements.95,96 Studies have shown that student participation in community activities (e.g., co-curricular, extracurricular and after-school programs related to community initiatives) positively impact academic achievement, reduce school suspensions, and improve school-related behaviors.97,98
B. Preventive Oral Health Services
The Guide to Community Preventive Services99 conducted systematic reviews on the effectiveness of selected population-based interventions that address oral health (). The intervention strategies included the following:
1. Preventing or controlling dental caries (cavities)
2. Preventing or controlling oral and pharyngeal cancers
3. Preventing or controlling sports-related craniofacial injuries
Community Water Fluoridation (CWF) reduces dental caries approximately 30% to 50% for communities with non-fluoridated water. Stopping CWF (where other sources of fluoride are inadequate) can result in increases in dental caries by a median of 18%.100 The median cost per person was $0.40 per year for systems serving populations greater than 20,000. CWF was cost saving in all studies for populations above 20,000.101-105 The Task Force on Community Preventive Services recommends CWF on the basis of strong evidence of effectiveness in reducing dental decay.
Dental sealants in a school-based or school-linked program were associated with a median decrease in dental caries of 60%.106-115 School-based programs showed a higher median decrease (65%) than school-linked programs (37%). Programs in which sealants were re-applied at some point between initial application and follow-up showed a higher median decrease (65%) than programs in which sealants were not re-applied (30%). Among school- based and school-linked sealant programs, the median sealant program costs per child ranged from $18 to $60 with a median cost of $39. The cost saving per surface saved from decay ranged from $0 to $487. The Task Force recommends school-based and school-linked pit and fissure sealant programs on the basis of strong evidence of effectiveness in reducing decay in pits and fissures of children’s teeth.
The Task Force found insufficient evidence to determine the effectiveness of population-based interventions for early detection of pre-cancers and cancers in reducing cancer morbidity or mortality, or in improving the quality of life, because no studies in the review measured effectiveness in terms of those outcomes. The Task Force also found insufficient evidence to determine the effectiveness of population-based interventions to encourage use of helmets, facemasks, and mouthguards in contact sports, because available studies showed inconsistent and small effects. A determination that there is “insufficient evidence to determine effectiveness” does NOT mean that the intervention does not work, but rather indicates that additional research is needed to determine whether or not, as well as the degree to which the intervention is effective.
V. Best Practice Criteria
For the best practice approach of Improving Children’s Oral Health of Children through Coordinated School Health Programs, the following are initial review standards for five best practice criteria. It is understood that these standards may have limited usefulness for state oral health programs that do not have specific activities directed toward coordinated school health or school linked programs, or for programs lacking sufficient staff or data to use the standards. Nevertheless, the standards are provided as resource information for states that are developing programs and/or developing evaluation strategies.
(1) Impact / Effectiveness (Benefits the oral health and well-being of populations or communities)
• Program measures showing oral health benefits achieved. For example:
o The program reduces the number of children who must be treated in the hospital operating room for dental/oral pain or infection.
o Oral health surveillance documents improved oral health status (reduced levels of active tooth decay or need for urgent dental care) as a result of programs reaching school aged children.
• Program measures showing benefits in the processes and systems for improved oral health. For example:
o An increased number of children having a dental home or receiving preventive oral health services.
o New policies promoting oral health as an important component of a healthy school environment.
(2) Efficiency (Shows that costs are appropriate for the benefits and/or staffing and time requirements are reasonable)
• An analysis that demonstrates efficiency in terms of costs vs. benefits. For example:
o An intervention program showing cost savings for averted tooth decay or avoiding the need to treat an advanced stage of dental disease.
o The cost of treating children in an out-patient dental facility is less than the costs of treating school age children in the hospital operating room.
• Demonstration of efficiency in terms of leveraging resources through collaboration with other programs. For example:
o Using Medicaid reimbursement to sustain school-based dental prevention services.
o Collaboration with other chronic disease or MCH programs to improve access to dental care and care coordination for high risk children.
(3) Demonstrated Sustainability (Shows that the program is sustainable and/or the program benefits are sustainable)
• Documentation of the sustainability of the program or a plan to address sustainability. For example:
o Funding devoted to oral health services is part of the budget for a coordinated school health program.
o The oral health component of the coordinated school health program has a long track record of operating successfully.
(4) Collaboration / Integration (Builds effective partnerships and/or integrates oral health with general health)
• Demonstration of partnerships and the benefits that resulted from the partnerships developed through the coordinated school health program. For example:
o Oral health services have expanded through integrated with coordinated school health efforts.
o Having a formal Memorandum of Understanding or an informal relationship with collaborating agencies supporting oral health integration in a coordinated school health program.
(5) Objectives / Rationale (Addresses HP 2010 objectives, relates to the Surgeon General’s Report on Oral Health, and/or builds basic infrastructure and capacity for state/territorial oral health programs)
• The goals and objectives of the coordinated school health program related to oral health are consistent with recommendations and guidelines promoted by authoritative sources, strategies of the state oral health plan, Healthy People 2010 oral health objectives, and/or the National Call to Action to Promote Oral Health.
VI. State Practice Examples
The following practice examples illustrate various elements or dimensions of the best practice approach. These reported success stories should be viewed in the context of the state’s and program’s environment, infrastructure and resources. End-users are encouraged to review the practice descriptions (click on the links of the practice names) and adapt ideas for a better fit to their states and programs.
A. Summary Listing of Practice Examples
Table 1 provides a listing of programs and activities submitted by states illustrating the strategies and interventions that can be used to improve children’s oral health through coordinated school health programs. Although this collection of practices may not be formally structured and fully organized as a coordinated school health effort, the practices and lessons can be adapted or applied for coordinated school health programs. Each practice name is linked to a detailed description.
|Table 1. |
|State Practice Examples Illustrating Strategies and Interventions for |
|Improving Children’s Oral Health through Coordinated School Health Programs |
|Item |Practice Name |State |Practice # |
|Oral Health Assessment |
|1. |Nevada Third Grade Oral Health Screening Survey |NV |31003 |
|Oral Health Training and Education |
|2. |OPEN WIDE |CT |08002 |
|3. |New Jersey Preventive Oral Health Education Program |NJ |33011 |
| | | | |
|4. |Through With Chew – Tools for Educators |WY |57003 |
| | | | |
|School Environment and Policies |
|5. |Rhode Island School Oral Health Legislation, Rules and Regulation | | |
|6. |Illinois’ Law Requiring Dental Examinations for School Children | | |
|7. |Certification of Dental Providers and Services Delivered in New York Public Schools |NY |35008 |
| | | | |
|School-based, School-linked Dental Prevention & Treatment Services |
|8. |The Dental Health Action Team and the Future Smiles Dental Clinic | | |
|9. |The Neighborhood Outreach Action for Health (NOAH) Program: Integrated Medical and |AZ |04007 |
| |Dental Health in Primary Care | | |
|10. |California Children’s Dental Disease Prevention Program |CA |06001 |
| | | | |
|11. |Massachusetts Department of Public Health SEAL (Seal, Educate, Advocate for Learning) |MA |24006 |
| |Program | | |
|12. |Oral Health Across the Commonwealth (OHAC) Portable Dental Program | | |
|13. |Community Oral Health Collaboration |MI |25005 |
|14. |New Hampshire Statewide Sealant Project (NHSSP) |NH |32006 |
|15. |School-Based Dental Sealant Program |NM |34001 |
|16. |Tennessee School Based Dental Prevention Program (SBDPP) |TN |48006 |
|17. |The Methodist Healthcare Ministries School Based Oral Health Program |TX |49003 |
|18. |Tooth Tutor Dental Access Program |VT |51001 |
|19. |Wisconsin Seal-A-Smile |WI |56004 |
B. Highlights of Practice Examples
Highlights of state practice examples are listed below.
1. Oral Health Assessment
NV Nevada Third Grade Oral Health Screening Survey / Practice #31003
In order to have more current assessment data to identify oral health needs and gaps in access to care the Oral Health Program at the Nevada State Health Division utilized the Association of State and Territorial Dental Directors (ASTDD) Basic Screening Survey to conduct a statewide screening of third graders in February of 2003. Nevada repeated the survey of third graders in 2006. This practice supports the building of a state oral health surveillance system by collecting surveillance data on children’s oral health and supports efforts to respond to the Healthy People 2010 Objectives.
2. Oral Health Training and Education
CT OPEN WIDE / Practice #08002
OPEN WIDE is an oral health-training program for non-dental health and human services providers throughout Connecticut, including physicians, nurses, nutritionists, childcare and outreach workers, and others. OPEN WIDE training is designed to: educate health and human service providers about the importance of oral health in early childhood development; build awareness and integrate oral health into existing health systems; and enable non-dental providers to engage in anticipatory guidance and prevention interventions, and make appropriate referral for improved oral health.
NJ New Jersey Preventive Oral Health Education Program / Practice #33011
WY Through With Chew – Tools for Educators / Practice # 57003
3. School Environment and Policies
RI Rhode Island School Oral Health Legislation, Rules and Regulation / Practice #45002
IL Illinois’ Law Requiring Dental Examinations for School Children / Practice #16012
NY Certification of Dental Providers and Services Delivered in New York Public Schools / Practice #35008
4. School-based, School-linked Dental Prevention & Treatment Services
AR The Dental Health Action Team and the Future Smiles Dental Clinic / Practice #05001
AZ The Neighborhood Outreach Action for Health (NOAH) Program: Integrated Medical and Dental Health in Primary Care / Practice #04007
The NOAH Program provides an integrated model for offering primary care services, preventive visits, dental care, obstetric care, and vaccinations for uninsured and underinsured children and their immediate family members. NOAH operates two health centers in Greater Metropolitan Phoenix Area in Arizona. Each health center houses a medical clinic and a dental clinic. The two locations include a school-based clinic and a community-based neighborhood clinic. NOAH health centers consistently serve more than 2,600 children and families delivering more than 6,000 primary care visits annually delivering medical and dental services.
CA California Children’s Dental Disease Prevention Program / Practice #06001
MA Massachusetts Department of Public Health SEAL (Seal, Educate, Advocate for Learning) Program / Practice #24006
The Massachusetts Department of Public Health (MDPH), Office of Oral Health has developed and implements the MDPH-SEAL (Seal, Educate, Advocate for Learning) Program. The goal of the Program is to improve the oral health of high-risk children by increasing their access to preventive dental services. This program assists partners to develop their school-based oral health prevention programs with technical support and financial support for the first year. MDPH-SEAL also provides direct services delivering dental sealants and fluoride varnish applications in schools. The program serves high-risk children and those eligible for or enrolled in MassHealth (state’s Medicaid/SCHIP program).
MA Oral Health Across the Commonwealth (OHAC) Portable Dental Program / Practice #24007
MI Community Oral Health Collaboration / Practice #25005
The Michigan Department of Community Health (MDCH)/Oral Health Program has teamed with the Paula L. Tutman’s Children’s Tooth Fairy Foundation (CTFF)4 and the University of Detroit Mercy School of Dentistry to bridge the gap from school-based/school-linked prevention programs to comprehensive dental care. Through the CTFF, children in need in Wayne, Washtenaw, Macomb and Oakland Counties receive no cost preventive, basic and comprehensive dental care. Through the MDCH Oral Health school-based/school-linked dental sealant program, children who reside in the identified counties are directly referred to the University of Detroit School of Dentistry for restorative services.
NH New Hampshire Statewide Sealant Project (NHSSP) / Practice #32006
The New Hampshire Department of Health and Human Services, Oral Health Program, with the support of a Task Force representing partners and stakeholders, established a demonstration project called the New Hampshire Statewide Sealant Project (NHSSP). A grant from Endowment for Health, a private NH foundation, funded the project for planning and three implementation years. The project: built on the existing infrastructure of New Hampshire’s 21 school-based programs; placed teams consisting of a volunteer dentist, hygienist and dental assistant in schools, which are not served by existing school-based programs; worked with the communities to create sustainable programs; and evaluated and compared the three delivery models set up to deliver dental sealants with regard to clinical efficiencies and sealant retention rates.
NM School-Based Dental Sealant Program / Practice #34001
The Department of Health (DOH), Office of Oral Health (OOH) administers a school-based dental sealant program that provides oral health education, dental sealant screenings and application of a dental sealant on first and second molar. The Dental Sealant Program was developed to answer the need for preventive dental services for school children as many low-income children of New Mexico have limited or no access to preventive dental care. In rural areas all elementary school children are eligible to participate in the dental sealant program. In urban areas, the services are limited to the first, second and third grade students. The program is conducted by state employees and dental provider contractors and offers services at no cost to the parents/guardians and participating schools. Elementary schools qualify for the program if they have at least 50% or more of its student population on the free and reduced school lunch program.
TN Tennessee School Based Dental Prevention Program (SBDPP) / Practice #48006
Since 2001, the Tennessee Department of Health (TDH), Oral Health Services, has administered a statewide school based sealant program that provides dental sealants to high risk children, called Tennessee School Based Dental Prevention Program. The school based program has a multi-million dollar annual budget funded by TennCare (the state’s Medicaid program) to provide adequate access to dental services. The program consists of three service components: screenings and referral for care, oral health education and outreach for TennCare, and full charted dental examination and dental sealant application. Children in grades K-8 are eligible to receive these services. The program has been implemented in the seven rural regions as well as six metropolitan regions. All services are provided in a school setting using portable equipment.
TX The Methodist Healthcare Ministries School Based Oral Health Program / Practice #49003
The Methodist Healthcare Ministries School Based Oral Health Program is a comprehensive model that focuses on oral disease prevention, treatment and education. The program is a collaborative effort of Methodist Healthcare Ministries (a faith-based, non-profit organization), University of Texas Health Science Center San Antonio Department of Dental Hygiene and Dental School, and the Texas Department of State Health Services Oral Health Program. The Program’s prevention component includes annual oral health assessments, sealants, fluoride treatments, mouthguard fabrication for sports, oral hygiene instruction, nutrition, tobacco cessation and early intervention programs. The treatment component includes essential services such as emergency, diagnostic, preventive and restorative care. The education component provides classroom oral health education for children and increases awareness of good oral health among parents and teachers.
VT Tooth Tutor Dental Access Program / Practice #51001
WI Wisconsin Seal-A-Smile / Practice #56004
The Wisconsin Seal-A-Smile (SAS) school based dental sealant program is in its 9th year of providing dental sealants to low-income children across the state of Wisconsin. Children’s Health Alliance of Wisconsin is sub-contracted by the Wisconsin Department of Health Services to administer dental sealant mini-grants to local programs across the state. County public health departments, community health centers, dental hygiene programs and dental clinics are the recipients of these grants that range in size from $2,000 to $30,000. Each local program tailors its dental sealant services to the needs of the community. These local programs are providing dental examinations, oral health education and the placement of dental sealants. In addition, some programs offer additional services such as dental cleanings, fluoride varnishes and in a few cases, restorative services. Many of the programs have been very successful by developing relationships with local dentists.
Acknowledgements
This report is the result of efforts by the ASTDD Best Practices Committee to identify and provide information on developing and successful practices that address the oral health care needs of school age children.
The ASTDD Best Practices Committee extends a special thank you to the ASTDD School and Adolescent Oral Health Workgroup (SAOH) for their contributions to this report. Please visit the ASTDD, SAOH web pages for tools to assist efforts to integrate oral health into Coordinated School Health programs or other school linked health programs .
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B. Preventive Oral Health Services
99. Promoting oral health: interventions for preventing dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. A report on recommendations of the task force on community preventive services. MMWR Recomm Rep. 2001 Nov 30;50(RR-21):1-13.
100. Truman BI, Gooch BF, Sulemana I, et al. Reviews of evidence on interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med 2002;23(1S):21–54.
101. Doessel DP. Cost–benefit analysis of water fluoridation in Townsville, Australia. Community Dent Oral Epidemiol 1985;13(1):19–22.
102. Dowell TB. The economics of fluoridation. Br Dent J 1976;140(3):103–6.
103. Nelson W, Swint JM. Cost-benefit analysis of fluoridation in Houston, Texas. J Public Health Dent 1976;36(2):88–95.
104. Niessen LC, Douglass CW. Theoretical considerations in applying benefit–cost and cost–effectiveness analyses to preventive dental programs. J Public Health Dent 1984;44(4):156– 68.
105. O’Keefe JP. A case study on the cost effectiveness of water fluoridation. Would fluoridation make economic sense in Montreal today? Ont Dent 1994;71(8):33–8.
106. Bagramian RA. A 5-year school-based comprehensive preventive program in Michigan, U.S.A. Community Dent Oral Epidemiol 1982;10(5):234 –7.
107. Bravo M, Baca P, Llodra JC, Osorio E. A 24-month study comparing sealant and fluoride varnish in caries reduction on different permanent first molar surfaces. J Public Health Dent 1997;57(3):184 –6.
108. Burt BA, Berman DS, Silverstone LM. Sealant retention and effects on occlusal caries after 2 years in a public program. Community Dent Oral Epidemiol 1977;5(1):15–21.
109. Horowitz HS, Heifetz SB, Poulsen S. Retention and effectiveness of a single application of an adhesive sealant in preventing occlusal caries: final report after five years of a study in Kalispell, Montana. J Am Dent Assoc 1977;95(6):1133–9.
110. Klein SP, Bohannan HM, Bell RM, Disney JA, Foch CB, Graves RC. The cost and effectiveness of school-based preventive dental care. Am J Public Health 1985;75(4): 382–91.
111. McCune RJ, Bojanini J, Abodeely RA. Effectiveness of a pit and fissure sealant in the prevention of caries: three-year clinical results. J Am Dent Assoc 1979;99(4):619–23.
112. Messer LB, Calache H, Morgan MV. The retention of pit and fissure sealants placed in primary school children by Dental Health Services, Victoria. Aust Dent J 1997; 42(4):233–9.
113. Selwitz RH, Nowjack-Raymer R, Driscoll WS, Li SH. Evaluation after 4 years of the combined use of fluoride and dental sealants. Community Dent Oral Epidemiol 1995;23(1):30–5.
114. Songpaisan Y, Bratthall D, Phantumvanit P, Somridhivej Y. Effects of glass ionomer cement, resin-based pit and fissure sealant and HF applications on occlusal caries in a developing country field trial. Community Dent Oral Epidemiol 1995;23(1): 25–9.
115. Sterritt GR, Frew RA, Rozier RG. Evaluation of Guamanian dental caries preventive programs after 13 years. J Public Health Dent 1994;54(3):153–9.
ATTACHMENT A
ATTACHMENT B
CDC Guidelines for School Health Program Strategies
CDC has published a series of guideline documents that identify the school health program strategies most likely to be effective in promoting healthy behaviors among young people. Based on extensive reviews of research literature, the guidelines were developed by CDC in collaboration with other federal agencies, state agencies, universities, voluntary organizations, and professional organizations.
1. Guidelines for School Health Programs to Promote Lifelong Healthy Eating ()
Centers for Disease Control and Prevention. Guidelines for school health programs to promote lifelong healthy eating. MMWR 1996;45(No. RR-9):1-33.
Recommendations for school health programs for nutrition:
Based on the available scientific literature, national nutrition policy documents, and current practice, these guidelines provide seven recommendations for ensuring a quality nutrition program within a comprehensive school health program.
Recommendation 1. Policy: Adopt a coordinated school nutrition policy that promotes healthy eating through classroom lessons and a supportive school environment.
Recommendation 2. Curriculum for nutrition education: Implement nutrition education from preschool through secondary school as part of a sequential, comprehensive school health education curriculum designed to help students adopt healthy eating behaviors.
Recommendation 3. Instruction for students: Provide nutrition education through developmentally appropriate, culturally relevant, fun, participatory activities that involve social learning strategies.
Recommendation 4. Integration of school food service and nutrition education: Coordinate school food service with nutrition education and with other components of the comprehensive school health program to reinforce messages on healthy eating.
Recommendation 5. Training for school staff: Provide staff involved in nutrition education with adequate preservice and ongoing in-service training that focuses on teaching strategies for behavioral change.
Recommendation 6. Family and community involvement: Involve family members and the community in supporting and reinforcing nutrition education.
Recommendation 7. Program evaluation: Regularly evaluate the effectiveness of the school health program in promoting healthy eating, and change the program as appropriate to increase its effectiveness.
2. School Health Guidelines to Prevent Unintentional Injuries and Violence ()
Centers for Disease Control and Prevention. School health guidelines to prevent unintentional injuries and violence. MMWR 2001;50(No. RR-22):1-74.
Recommendations to prevent unintentional injuries, violence, and suicide:
Recommendation 1. Social environment. Establish a social environment that promotes safety and prevents unintentional injuries, violence, and suicide.
Recommendation 2. Physical environment. Provide a physical environment, inside and outside school buildings, that promotes safety and prevents unintentional injuries and violence.
Recommendation 3. Health education. Implement health and safety education curricula and instruction that help students develop the knowledge, attitudes, behavioral skills, and confidence needed to adopt and maintain safe lifestyles and to advocate for health and safety.
Recommendation 4. Physical education and physical activity programs. Provide safe physical education and extracurricular physical activity programs.
Recommendation 5. Health services. Provide health, counseling, psychological, and social services to meet the physical, mental, emotional, and social health needs of students.
Recommendation 6. Crisis response. Establish mechanisms for short- and long term responses to crises, disasters, and injuries that affect the school community.
Recommendation 7. Family and community. Integrate school, family, and community efforts to prevent unintentional injuries, violence, and suicide.
Recommendation 8. Staff members. For all school personnel, provide staff development services that impart the knowledge, skills, and confidence to effectively promote safety and prevent unintentional injuries, violence, and suicide, and support students in their efforts to do the same.
3. Guidelines for School Health Programs to Prevent Tobacco Use and Addiction ()
Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. MMWR 1994;43(No. RR-2):1-18.
Recommendations for school health programs to prevent tobacco use and addiction:
The seven recommendations below summarize strategies that are effective in preventing tobacco use among youth. To ensure the greatest impact, schools should implement all seven recommendations.
Recommendation 1. Develop and enforce a school policy on tobacco use.
Recommendation 2. Provide instruction about the short- and long-term negative physiologic and social consequences of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills.
Recommendation 3. Provide tobacco-use prevention education in kindergarten through 12th grade; this instruction should be especially intensive in junior high or middle school and should be reinforced in high school.
Recommendation 4. Provide program-specific training for teachers.
Recommendation 5. Involve parents or families in support of school-based programs to prevent tobacco use.
Recommendation 6. Support cessation efforts among students and all school staff who use tobacco.
Recommendation 7. Assess the tobacco-use prevention program at regular intervals.
ATTACHMENT C
|Integrating Oral Health to the Coordinated School Health Programs |
| |Coordinated School Health Components |Oral Health Integration & Recommendations |
|1 |Health Education: |
| |Coordinated School Health: |Oral Health Integration: |
| |A planned, sequential, K-12 curriculum that addresses |Oral health education is an integral component of school health education |
| |the physical, mental, emotional and social dimensions of|classes. The school comprehensive health education curriculum includes |
| |health. The curriculum is designed to motivate and |prevention and control of oral and dental disease, oral and facial injury |
| |assist students to maintain and improve their health, |prevention, and personal health practices that promote oral health. Assure that|
| |prevent disease, and reduce health-related risk |oral health education, whenever possible, complies with the Department of |
| |behaviors. It allows students to develop and demonstrate|Education standards and integrates with teachers’ lesson plans. |
| |increasingly sophisticated health-related knowledge, | |
| |attitudes, skills, and practices. The comprehensive |Oral Health Recommendations: |
| |health education curriculum includes a variety of topics|• Provide oral health education on disease process, risk factors, and behavior |
| |such as personal health, family health, community |to promote oral health. |
| |health, consumer health, environmental health, sexuality|• Provide tobacco-use prevention education in kindergarten through 12th grade |
| |education, mental and emotional health, injury |and link students using tobacco to intervention programs. |
| |prevention and safety, nutrition, prevention and control|• Integrate oral health into nutrition education from preschool through |
| |of disease, and substance use and abuse. Qualified, |secondary school. |
| |trained teachers provide health education. |• Implement health and safety education curricula that help students to adopt |
| | |and maintain safe lifestyles and to advocate for health and safety that include|
| | |prevention of oral and facial injuries and other behaviors impacting oral |
| | |health such as Methamphetamine use. |
| | |• Assess/evaluate oral health education programs at regular intervals. |
|2 |Physical Education |
| |Coordinate School Health: |Oral Health Integration: |
| |A planned, sequential K-12 curriculum that provides |In promoting quality physical education and planning physical activities for |
| |cognitive content and learning experiences in a variety |students to enjoy and pursue throughout their lives, prevention and protection |
| |of activity areas such as basic movement skills; |from facial and oral injuries in programs devoted to fitness and health should |
| |physical fitness; rhythms and dance; games; team, dual, |be addressed. Schools can promote the use of personal protective equipment |
| |and individual sports; tumbling and gymnastics; and |inside and outside school-associated sports and recreation activities. Students|
| |aquatics. Quality physical education should promote, |could be provided with and required to use personal protective equipment |
| |through a variety of planned physical activities, each |appropriate to the type of physical activity that are well fitted, in good |
| |student's optimum physical, mental, emotional, and |condition and comply with national standards. |
| |social development, and should promote activities and | |
| |sports that all students enjoy and can pursue throughout|Oral Health Recommendations: |
| |their lives. Qualified, trained teachers teach physical |• Provide safe physical education and extracurricular physical activity |
| |activity. |programs that include appropriate protection from oral and facial injuries |
| | |including mouth guard use. |
| | |• Provide fabricated mouthguards and headgears when appropriate for physical |
| | |activity programs by engaging local physicians and dentists (e.g., conduct |
| | |clinics for on-site fabrication of mouthguards for students). |
| | |• Develop a promotional program and integrate messages that promote prevention|
| | |and protection from oral and facial injuries (e.g., testimonials and support of|
| | |professional team players). |
| | |• Expand the campaign of promoting prevention and protection from oral and |
| | |facial injuries to community recreation and sports programs. |
| | |• Assess/evaluate oral and facial injury prevention education program and use |
| | |of mouth guard protection at regular intervals. |
|3 |Health Services |
| |Coordinated School Health: |Oral Health Integration: |
| |Services provided for students to appraise, protect, and|Services provided for students to appraise, protect and promote health should |
| |promote health. These services are designed to ensure |include prevention and treatment of oral and dental diseases. Services assure |
| |access or referral to primary health care services or |access or referral to oral health care services and provide emergency care for |
| |both, foster appropriate use of primary health care |dental and mouth pain, infection or injury. The school nurse or school-based |
| |services, prevent and control communicable disease and |health center nurse would have oral health information available, provide |
| |other health problems, provide emergency care for |effective preventive services, and assure students with dental treatment needs |
| |illness or injury, promote and provide optimum sanitary |access professional care. |
| |conditions for a safe school facility and school | |
| |environment, and provide educational and counseling |Oral Health Recommendations: |
| |opportunities for promoting and maintaining individual, |• Assure oral health is included in school health services that meet the |
| |family, and community health. Qualified professionals |physical, mental, emotional, and social health needs of students. |
| |such as physicians, nurses, dentists, health educators, |• Assure students are receiving effective preventive oral health services |
| |and other allied health personnel provide these |including school dental sealant programs and school fluoride programs (e.g., |
| |services. |fluoride mouthrinse programs for schools in communities without optimal |
| | |fluoridated water and fluoride varnish programs for high risk children). |
| | |• Support the establishment of a dental home for students. |
| | |• Develop a referral program or system for students with unmet oral health |
| | |needs. |
| | |• Promote a medical/dental integration model for school based health centers. |
| | |• Provide training program for school nurses in the identification of oral |
| | |health needs. |
| | |• Assess/evaluate oral health prevention and treatment services programs at |
| | |regular intervals. |
|4 |Nutrition Services |
| |Coordinated School Health: |Oral Health Integration: |
| |Access to a variety of nutritious and appealing meals |School nutrition programs teach students better choices of foods for oral |
| |that accommodate the health and nutrition needs of all |health. Lunches, snacks and beverages offered by school food services and on |
| |students. School nutrition programs reflect the U.S. |school property should be healthy and lower the risk of oral disease such as |
| |Dietary Guidelines for Americans and other criteria to |tooth decay. |
| |achieve nutrition integrity. The school nutrition | |
| |services offer students a learning laboratory for |Oral Health Recommendations: |
| |classroom nutrition and health education, and serve as a|• Integrate oral health in school nutrition programs related to obesity, |
| |resource for linkages with nutrition-related community |diabetes and general health. |
| |services. Qualified child nutrition professionals |• Integrate campaigns that stop junk food and other food that increases the |
| |provide these services. |risk of tooth decay into school services (e.g., “Stop the Pop” campaign). |
| | |• Promote healthy oral health self-care habits in the school environment |
| | |(e.g., toothbrush, floss and rinse after school breakfast and lunch). |
| | |• Assess/evaluate effectiveness of the school health program in promoting |
| | |healthy eating at regular intervals. |
|5 |Counseling, Psychological, and Social Services |
| |Coordinated School Health: |Oral Health Integration: |
| |Services provided to improve students' mental, |Services to improve students' mental, emotional, and social health should |
| |emotional, and social health. These services include |integrate the impact of oral health to the well-being of the students. These |
| |individual and group assessments, interventions, and |services can help by ensuring that children with oral health needs obtain |
| |referrals. Organizational assessment and consultation |needed professional care. |
| |skills of counselors and psychologists contribute not | |
| |only to the health of students but also to the health of|Oral Health Recommendations: |
| |the school environment. Professionals such as certified |• Promote awareness that poor oral health impacts self-esteem and ability to |
| |school counselors, psychologists, and social workers |learn among school children. |
| |provide these services. |• Create an educational program to inform school counselors, psychologists and|
| | |social workers regarding issues of oral health related to self-esteem and |
| | |ability to learn. |
| | |• Inform school counselors, psychologists and social workers on options for |
| | |children with unmet oral health needs to access care (e.g., the school dental |
| | |referral program). |
| | |• Assess/evaluate oral health integrated with counseling, psychological and |
| | |social services at regular intervals. |
| | |• Promote awareness that poor oral health impacts school children’s |
| | |self-esteem and ability to learn. |
| | |• Create an educational program to inform school counselors, psychologists and|
| | |social workers regarding issues of oral health related to self-esteem and |
| | |ability to learn. |
| | |• Inform school counselors, psychologists and social workers on options for |
| | |children with unmet oral health needs to access care (e.g., the school dental |
| | |referral program). |
| | |• Assess/evaluate oral health integrated with counseling, psychological and |
| | |social services at regular intervals. |
|6 |Healthy School Environment |
| |Coordinated School Health: |Oral Health Integration: |
| |The physical and aesthetic surroundings and the |The physical and aesthetic surroundings and the psychosocial climate and |
| |psychosocial climate and culture of the school. Factors |culture of the school can promote oral health, by not using junk food for |
| |that influence the physical environment include the |fundraisers or as choices in vending machines. |
| |school building and the area surrounding it, any | |
| |biological or chemical agents that are detrimental to |Oral Health Recommendations: |
| |health, and physical conditions such as temperature, |• Develop and enforce a school policy on tobacco use. |
| |noise, and lighting. The psychological environment |• Establish a social and physical environment that promotes safety and |
| |includes the physical, emotional, and social conditions |prevents unintentional injuries of the face and mouth. |
| |that affect the well-being of students and staff. |• Adopt a coordinated school nutrition policy that promotes healthy eating |
| | |through classroom lessons and promotes a supportive school environment |
| | |including promoting balanced school meals and no junk food in vending machines.|
| | |• Assure “easy” implementation of strategies by school personnel for oral |
| | |health integration that will fit into the daily routine with minimal class time|
| | |and little disruption of class activities. |
| | |• Assess/evaluate school environment for promotion of oral health at regular |
| | |intervals. |
|7 |Health Promotion for Staff |
| |Coordinated School Health: |Oral Health Integration: |
| |Opportunities for school staff to improve their health |Opportunities for school staff to improve their oral health status through |
| |status through activities such as health assessments, |activities often transfers into greater commitment to the health of students |
| |health education and health-related fitness activities. |and creates positive role modeling. Providing staff with access to oral health |
| |These opportunities encourage school staff to pursue a |information will encourage them to set an example for students by promoting |
| |healthy lifestyle that contributes to their improved |good oral health behaviors. |
| |health status, improved morale, and a greater personal | |
| |commitment to the school's overall coordinated health |Oral Health Recommendations: |
| |program. This personal commitment often transfers into |• Provide program-specific in-service training for teachers on oral health. |
| |greater commitment to the health of students and creates|• Support cessation efforts among school staff using tobacco. |
| |positive role modeling. Health promotion activities have|• For all school personnel, provide staff development services that impart the|
| |improved productivity, decreased absenteeism, and |knowledge, skills and confidence to effectively promote safety and prevent |
| |reduced health insurance costs. |unintentional facial and mouth injuries. |
| | |• Provide staff involved in nutrition education with adequate pre-service and |
| | |ongoing in-service training that focuses on teaching strategies for oral health|
| | |behavioral change. |
| | |• Assess/evaluate staff oral health programs at regular intervals. |
|8 |Family/Community Involvement |
| |Coordinated School Health: |Oral Health Integration: |
| |An integrated school, parent, and community approach for|An integrated school, parent and community approach is needed to enhance the |
| |enhancing the health and well-being of students. School |oral health and well-being of students. Building support from school health |
| |health advisory councils, coalitions, and broadly based |advisory councils, coalitions and broadly based constituencies can contribute |
| |constituencies for school health can build support for |to integrating oral health efforts. Parents can be asked to attend workshops on|
| |school health program efforts. Schools actively solicit |oral health and to encourage their children to develop good oral hygiene |
| |parent involvement and engage community resources and |practices at home and school. |
| |services to respond more effectively to the | |
| |health-related needs of students. |Oral Health Recommendations: |
| | |• Integrate school, family and community support of school-based programs to |
| | |prevent tobacco use. |
| | |• Integrate school, family and community efforts to prevent unintentional |
| | |injuries of the face and mouth. |
| | |• Integrate school, family and community efforts in supporting and reinforcing|
| | |nutrition education. |
| | |• Integrate school, family and community support in providing preventive |
| | |dental services and improving access to dental care. |
| | |• Involve school, family and community in integrating oral health into |
| | |school-based health programs. |
| | |• Promote school, family and community support for oral health screenings for |
| | |children entering into first grade, middle school, junior high, and high |
| | |school. |
| | |• Assess/evaluate family and community involvement in promoting oral health at|
| | |regular intervals. |
ATTACHMENT D
Organizations Dedicating in Promoting Coordinated School Health
“Friends of School Health” is a coalition dedicated to promoting coordinated school health programs. Over 50 leading national health and education associations participate in the coalition. Nearly every major health and education organization is involved. The following is a partial listing of these organizations:
• American Academy of Pediatrics
• American Alliance for Health, Physical Education, Recreation and Dance
• American Association for School Administrators
• American Cancer Society
• American College of Preventive Medicine
• American Dietetic Association
• American Heart Association
• American Psychological Association
• American Public Health Association
• American School Food Service Association
• American School Health Association
• Association for Supervision and Curriculum Development
• Association of State and Territorial Chronic Disease Program Directors
• Association of State and Territorial Health Officials
(includes its affiliate, the Association of State and Territorial Dental Directors)
• Council of Chief State School Officers
• Children’s Environmental Health Network
• Girl Scouts of America
• National Assembly on School-Based Health Care
• National Association of State and County Health Officials
• National Association of School Psychologists
• National Association of State Boards of Education
• National Education Association Health Information Network
• National School Boards Association
• Partnership for Prevention
• Society for Public Health Education
• Society of State Directors of Health, Physical Education and Recreation
-----------------------
DRAFT (9/23/09)
Best Practice Approaches
for State and Community Oral Health Programs
Summary of Evidence Supporting
Improving Children’s Oral Health through
Coordinated School Health Programs
Research ++
Expert Opinion +++
Field Lessons ++
Theoretical Rationale +++
See Attachment A for details.
[pic]
Family/Community Involvement
Include: prevent tobacco use; support preventive dental services; encourage oral screenings for first grade, middle, junior and senior schools
Health Promotion
for Staff
Include: provide in-service training; deliver safety and nutrition education; promote cessation of tobacco use among staff
Healthy School Environment
Include: establish school policy on tobacco use; promote safety from injury; adopt school nutrition policy
Counseling, Psychological &
Social Services
Include: increase awareness that oral health impacts self-esteem; inform counselors of unmet oral health needs and treatment problems
Nutrition Services
Include: increase awareness of oral health related to obesity and diabetes; reduce consumption of junk food and sweetened beverages; promote in-school oral health self-care habits
Health Services
Include: provide oral health care; deliver sealants and fluoride varnishes; establish dental homes; make referrals; train school nurses; develop school oral health centers
Physical Education
Include: promote
mouth guards and headgear for injury prevention; expand education to community recreation and sports
Health Education
Include: provide oral health education on oral disease & risk factors; promote cessation of tobacco use; promote nutrition and safety
(for preschool to secondary grades)
Integrating
Oral Health into Coordinated School Health Programs
Strength of Evidence Supporting Best Practice Approaches
The ASTDD Best Practices Committee took a broader view of evidence to support best practice approaches for building effective state and community oral health programs. The Committee evaluated evidence in four categories: research, expert opinion, field lessons and theoretical rationale. Although all best practice approaches reported have a strong theoretical rationale, the strength of evidence from research, expert opinion and field lessons fall within a spectrum. On one end of the spectrum are promising best practice approaches, which may be supported by little research, a beginning of agreement in expert opinion, and very few field lessons evaluating effectiveness. On the other end of the spectrum are proven best practice approaches, ones that are supported by strong research, extensive expert opinion from multiple authoritative sources, and solid field lessons evaluating effectiveness.
Promising Proven
Best Practice Approaches Best Practice Approaches
Research + Research +++
Expert Opinion + Expert Opinion +++
Field Lessons + Field Lessons +++
Theoretical Rationale +++ Theoretical Rationale +++
Research
+ A few studies in dental public health or other disciplines reporting effectiveness.
++ Descriptive review of scientific literature supporting effectiveness.
+++ Systematic review of scientific literature supporting effectiveness.
Expert Opinion
+ An expert group or general professional opinion supporting the practice.
++ One authoritative source (such as a national organization or agency) supporting the practice.
+++ Multiple authoritative sources (including national organizations, agencies or initiatives) supporting the practice.
Field Lessons
+ Successes in state practices reported without evaluation documenting effectiveness.
++ Evaluation by a few states separately documenting effectiveness.
+++ Cluster evaluation of several states (group evaluation) documenting effectiveness.
Theoretical Rationale
+++ Only practices which are linked by strong causal reasoning to the desired outcome of improving oral health and total well-being of priority populations will be reported on this website.
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