Toothy 2 Brings Dental Care to Children in Lake County, Florida

State: FL Type: Model Practice Year: 2012

Lake County Florida is designated as a medically underserved low income area where greater than 50% of children are on free or reduced lunch. The target population is children in second grade who are low income, Medicaid or Medicaid eligible, uninsured, and those who do not have regular dental care. The size of the population of Lake County is approximately 321,192. Lake County Health Department's School Sealant Program began in September 2008 providing visual exams, teeth cleanings, brushing and flossing instructions, and sealants to second grade children. Toothy 2 Mobile Dental Unit is a specialized vehicle equipped with two chairs that parks at select elementary schools. Since tooth decay is the most common disease of childhood, the School Sealant Program brings preventative dental care and oral health education directly to children while at school. By placing sealants as soon as the first permanent molars erupt, the chances of cavities developing are greatly reduced. Sealants are needed because brushing and flossing alone cannot clean the deep grooves and pits found in normal molar teeth. The program objective is to provide sealants to all second graders and follows up with the students when in third grade to recheck and reseal teeth if necessary. In 2008-2009, 306 students were treated in 4 schools using a rented Mobile Unit. The decision was made to purchase a Mobile Unit using grant funding. The Mobile Unit cost roughly $180,000 to purchase. In 2009-2010, 596 students were treated in 10 schools. In 2010-2011, 763 students were treated in 14 schools. Last year, the program reached over 1500 second grade students in 14 schools at no cost to the parents. The program is supported by Medicaid revenue and grant funding. We were able to more than triple the amount of schools we visited and more than double the amount of students treated since program inception. The processes and procedures have been streamlined to maximize treatment time during school hours to see the greatest amount of children per day. The staff is able to treat on average 27 students per day on the mobile unit. Last year, 51% of all second grade children participated in the program. Each year, improvements are made to the program to encourage maximum participation. Dedicated staff members and collaboration with community partners help make this program successful. We have learned the school administrators and nurses are the best asset in helping to promote the program to achieve maximum participation. We are continuing to meet our objectives year to year. By improving the tracking system, we will be able to see the program results and modify our practice if needed.
Health Issues The public health issue the School Sealant Program addresses is the lack of access to dental care for low-income populations and the high rate of dental decay among schoolchildren. Since tooth decay is the most common disease of childhood, the School Sealant Program brings preventative dental care and oral health education directly to children while at school. Application of fluoride varnish and sealants helps to prevent tooth decay from starting on newly erupted first permanent molars. According to the Pew Report, in 2009 the approximate percentage of Medicaid-enrolled children receiving dental care was only 25.7% in the state of Florida. Many children do not have access to dental care for various reasons, including lack of transportation, no dental insurance, lack of dental providers who accept Medicaid or have sliding fee scales, or the lack of parental education on the importance of oral health. The School Based Sealant program brings dental care directly to all second grade students regardless of income or insurance status while at school at no cost to the parents. The program also provides education for the students and parents on the importance of dental health as a part of overall health. Last school year, 53% of the children seen on the Mobile Unit had active tooth decay. 21% of the children seen had severe problems, including abscessed teeth and acute dental infections. The School Sealant Program is available at no cost to parents for second grade children in selected schools with at least 65% of the student population on the federal free and reduced lunch program. Roughly half of the children seen last year did not have any dental insurance. Parents do not have to take time off from work and children do not have to miss a school day while being treated on the Mobile Unit (Toothy 2). After a child is seen on the Mobile Unit, parents are sent a letter advising them of further treatment needs. An informative flyer is sent home with our office information for parents to follow up with our office if they do not have a dental home. If the child has a dental home, parents are encouraged to follow up if any dental problems are noted during the child's exam on the Mobile Unit. Innovation In order to meet several of the objectives set forth by Healthy People 2020 (OH 2.2, OH-8, OH 12.2), the Lake County Health Department mobilized Toothy 2 which allows second grade students attending select Lake County Public Schools the opportunity to receive a visual oral exam, oral hygiene education, prophylaxis (teeth cleaning), fluoride varnish application, and sealants in a comfortable setting. The unit is child friendly and equipped with a TV and DVD player for entertainment while the children wait for treatment. The walls display artwork from students who have been seen on the Mobile Unit in previous years and newspaper articles about Toothy 2. All procedures are explained and demonstrated to the students prior to treatment being rendered to help alleviate any fear or anxiety. Prior to 2008, the Lake County School Sealant Program was conducted inside the school building instead of using a Mobile Unit. The dentist and dental assistant set up portable equipment in the nurse's office or a designated area inside the school. There were issues with this approach, including the large amount of noise generated from suction equipment, lack of a proper sterilization unit, less than optimal lighting, large quantities of time consumed with transporting, setting up, and cleaning up equipment on a daily basis, and lack of a secure locked cabinet to store patient information. Using the mobile unit has significantly decreased the setup time, allowing for more time to see students. The mobile unit is set up on the first day upon arriving at the school and remains on the school campus until all students are seen and treatment is completed. The mobile unit is equipped with a Statim for sterilization of instruments, two fully functioning operatories with lighting, and a locked file cabinet for patient files to be stored. The state of Florida does not have a statewide mandate for dental screenings prior to starting school nor a mandated school-based sealant program. The program at Lake County was created from the ground up and has been modified several times to improve productivity. This year we have instituted a tracking system in which children are classified by severity of caries activity, presence of acute dental infections, and evidence of existing sealants and/or restorations. When the children are seen again in third grade, we assess for retention of the sealants placed the previous year and also if treatment needed last year was completed or not. In order to constantly improve the sealant program, we are actively tracking this information to determine the effectiveness of the program. Toothy 2 Mobile Dental Unit differs from other Mobile Dental Services by providing exams, cleanings, oral hygiene instructions, and sealants to second grade students at no cost to parents. The program also follows up with the students when in third grade to recheck and reseal teeth if necessary. If it is determined that any child has an active dental infection or is having acute pain, the parent is contacted by the school nurse immediately and encouraged to schedule an appointment with a dentist for treatment. Parents are sent home a letter after their child is seen on the Mobile Unit advising them of further treatment needs. Also, the tracking system implemented this year is very comprehensive and will yield data to help determine the oral health status of second grade students in Lake County.  
Primary Stakeholders Lake County Health Department, Lake County School District Role of Stakeholders/Partners Lake County Health Department partners with Lake County School District to bring the Sealant Program to underprivileged children. The office manager and dentist meet with the Director of Student Services prior to the beginning of each school year to determine the schools eligible to receive services. The list of schools is selected based on the highest percentage of students receiving free and reduced lunch. The schools selected must have at least 65% or more of the students on the federal free and reduced lunch program. Contact is made with the district nurses and the individual school nurses who then distribute parental permission packets to all second grade students. The school nurses and teachers help to promote the program by using numerous incentives such as sponsoring a pizza party for the class that returns the most permission packets. The program is promoted within the school on the morning announcements, in the school newsletter, and on the school website. Posters advertising the program are posted in the office and in the second grade classrooms. The number of schools has increased each year since the program inception. We started with 4 schools the first year of the program and are up to 16 this school year. Each year the program is modified to increase productivity and allow more students to be seen. More time is allotted for schools where students are most likely not to have easy access to dental services. Smaller schools are usually allotted 5 days to have all exams, teeth cleanings, and sealants completed. Larger schools can take up to 15 days to complete all students. Volunteers from the community participate with the program by escorting the children from their classrooms to the Mobile Unit and back to class after treatment. LHD Role Lake County Health Department sponsors the Sealant Program by providing all necessary staff, supplies, and transportation costs. The School Sealant Program has 4 employees. The office manager drives the mobile unit to the elementary school. The dentist and the dental assistant set up the mobile unit, provide all treatment, complete patient charting, and track all data. Through a remote access laptop, the dentist scans treatment encounter forms and inputs the data into a shared drive. From the office, the clerical supervisor views the data from the shared drive, prints encounter forms, and completes the billing procedures. The process has been streamlined to maximize productivity. This year, Smiles for Lake County was established as the local county chapter of statewide Oral Health Florida coalition. Coalition members include individuals from the Lake County Health Department, Lake County School District, Boys and Girls Club, and Headstart programs. Each of the members is committed to promoting oral health at the local level within Lake County. Since the program is new, we are in the process of establishing goals and identifying issues to address in the coming year. Having community members allows the program to reach more people and have a broad impact on the community. The coalition members are informed of the School Sealant Program news, including the school schedule and any newspaper articles written about the program. Lessons Learned The major barrier to developing collaborations has been the lack of oral health knowledge among school administration, school nurses, and parents. In many cases, there is no sense of urgency or importance where oral health or the need for sealants is concerned. In some schools, we have been seen as a burden being present on the school campus rather than an asset. We have learned that oral health education needs to be spread throughout all levels of the school in order to be effective. Updated information packets and flyers were developed to address these issues. We worked with a graphic designer to create a colorful informative flyer that addressed many frequently asked questions regarding the sealant program. School nurses, administrators, and all second grade parents were given a packet with the informative flyer along with the permission forms. This has helped to reduce many of the questions that are asked year after year about the program and what services are provided on the Mobile Unit. Implementation Strategy The School Sealant Program allows all second grade students attending select Lake County Public Schools the opportunity to receive a visual exam, oral hygiene education, prophylaxis (teeth cleaning), fluoride varnish application, and sealants. The goals and objectives of the practice are achieved by continuing to provide the program each year. Each school year, a schedule is made in August and confirmed with all of the school administrators. Toothy 2 runs from September through May, with breaks for all students' holidays. Last year, 97 days were spent at 14 schools providing treatment.  
Process & Outcome The data for all 3 objectives was collected by the dentist on the mobile unit and tallied by using a Excel spreadsheet to track all schools visited. After each school was completed, data was entered into a Summary Spreadsheet and the totals were tallied at the completion of the school year. The spreadsheets are continually updated by the dentist and the clerical supervisor. Objective 1: Increase the amount of children who have sealants on their first molars. In 2008-2009, 193 children received sealants. In 2009-2010, 516 children received sealants. For the 2010-2011 school year, 650 out of the 763 children treated had sealants placed on all erupted molars. For last year, this represented 85% of all children that were treated. Reasons that sealants were not placed were the following: 4% had unerupted first molars, 4% had behavior issues that would not allow for sealant placement, and the remaining 7% had existing sealants that did not need to be redone or were absent from school on sealant day. This data was collected from the student's examination findings and from charting the teeth sealed. Since the percentage of children with existing intact sealants was very low, the sealants provided supported the objective of increasing the number of children with sealants. This year, we are continuing to monitor the number of sealants placed and rechecking the sealants placed last year to calculate retention rates. For this current school year, 187 children have received sealants so far from 4 schools. There are 12 remaining schools to visit this year. Our efforts to increase participation have been paying off with increased numbers of children returning permission forms. The increase in participation has gone from an average of 48% of permission packets being returned and is now up to 61%. At one school this year we had 87% of packets returned, which has been our highest participation to date. Objective 2: Reduce the amount of children with decay by providing teeth cleanings, oral hygiene instructions, and fluoride varnish application For 2008-2009 school year, 287 children were treated and during 2009-2010, 548 children were treated. For the 2010-2011 school year, 758 out of the 763 children treated received teeth cleanings, brushing and flossing instructions, and fluoride varnish application. For this school year, 222 children have had teeth cleanings and oral hygiene instructions and 221 children have received fluoride varnish. Reasons that treatment was not provided are either because of parent refusal or behavior problems that prevented any treatment from being rendered. If a parent refuses treatment, we continue to provide education to the child and also to the parents by providing informational brochures about the benefits of fluoride varnish. Objective 3: Reduce the number of children with active untreated dental decay All of the children who receive treatment on the Mobile Unit are sent a letter home to their parents informing them of needed treatment. Of the 763 children seen last year, 434 required dental treatment, which is 57%. Treatment needs ranged from 4% having acute dental infections which required immediate care, 17% with severe problems which were likely to cause pain and infection if left untreated, and 36% who needed restorative care to prevent severe problems from occurring. This year, we are tracking the third grade children to see how many of the children seen last year had their treatment completed and how many did not. So far this year, 95 children have been rechecked. 21 children had their treatment completed and 51 children did not have any dental work since the last visit on Toothy 2. This is demonstrating that 54% of the children still have active untreated decay. The lesson that can be learned from this is that the importance of following up with a dentist is not reaching the parents. In the future, we may consider implementing a follow up phone call in addition to the letter sent home to the parents if their child is identified as having active tooth decay to encourage the parent to take their child to see a dentist for treatment.  
The Lake County Health Department is committed to maintaining the School Sealant Program for as long as it can sustain on Medicaid reimbursement and grant funding. Medicaid revenue and grant funding help to offset many of the program expenses. However, there are substantial changes coming to the Florida Medicaid reimbursement procedures in 2012 which will impact the program. It is unsure if this will be positive or negative at this time. Smiles for Lake County Oral Health Coalition is in the early stages of development and will continue to grow in membership and activity. Application to potential funding sources is currently underway with the hopes of helping to sustain the program. If approved, grant funding can be used to pay for the uninsured children to be seen on the Mobile Unit or in the office for follow-up treatment. The Sealant Program has had multiple modifications since inception that has made the process streamlined and efficient. The revenue for the 2008-2009 school year for 4 schools was an estimated $67,982. The revenue increased during the 2009-2010 school year to an estimated $143,375 for 10 schools. The revenue from the 2010-2011 school year for 14 schools was an estimated $235,101. Budget cuts have continued to reduce Medicaid reimbursement rates for dental care over the last 3 years from an estimated $213 in 2008 to $143 in 2011. The additional revenue was achieved this past year despite the reduction in Medicaid rates. Budget reductions have prompted usage of generic dental materials instead of name brand to reduce supply costs. The scheduling of the schools is grouped by region to reduce the costs of gas to move the mobile unit from one location to another. The staff is cross-trained to allow services to be provided continuously even if a staff member is absent. The transmission of information from mobile unit to office is completed electronically which reduces the amount of paperwork. The program will continue to be modified every year to increase participation and productivity to allow the most amount of students to be seen per school day. As long as Medicaid reimbursement and grant funding remains, the School Sealant Program can continue to provide dental care at no cost to second grade students in Lake County.
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