Public Health Dental Hygienist (PHDH) Toolkit
Procedures, Equipment, and Supplies- School Programs
Office of Oral Health
Massachusetts Department of Public Health

PHDH Role

•	Work with school administrators, nurses, teachers, children, and parents to establish a preventive oral health program, providing evidenced-based preventive oral health services.

Prioritizing for School-based Oral Health Prevention Programs

•	Schools with greater than 50% of children participating in free and reduced school lunch programs
•	Communities with high numbers of MassHealth children
•	Rural communities or communities that have a shortage of dental professionals
•	Communities that lack water fluoridation 

Picture- Elementary school students in a classroom

It’s important to remember…
Each school district and school is different from another

Planning for School-based Prevention Programs

①	Communicate with school nurses, administrators, teachers, and parents
②	Develop a referral system for restorative treatment
③	Develop a consent package
④	Determine how it will be distributed and returned at each school
⑤	Develop assessment forms, documentation forms/information sheets, and data tracking system
•	Information sheets must be provided to the child’s parent/guardian and school nurse after each patient encounter.

Go to the Documents and Resources page for sample medical history/consent forms and a sample Information Sheet.

Dental Hygiene Services for School-aged Children

•	Assistance in Establishing/Maintaining a ‘Dental Home’
•	Oral Health Instructions
•	Oral Health Screening
•	Caries Risk Assessment
•	Fluoride Varnish and/or Fluoride Mouthrinse
•	Dental Sealants
•	Parent Education

Picture- Dental hygienist using portable equipment

Oral Health Instructions

•	Oral health instructions for school-aged children should focus on specific toothbrushing and flossing techniques, fluoride exposure, and nutrition for caries prevention.
•	Supplies can include anatomic models, toothbrushes, floss, games, activities, etc.
•	Resources:
•	ADA Smile Smarts Curriculum
•	A Lifetime of Healthy Smiles (grades 2-3)
•	Teeth to Treasure (grades 4-6)
•	Watch your Mouth (grades 7-8)

Picture- Two young girls brushing their teeth

Oral Health Screening for School-aged Children

•	Elementary- Middle School (ages 5 – 13)
•	Age appropriate mixed dentition
•	History of caries (fillings)
•	Possible incipient and cavitated carious lesions
•	Cariogenic diet
•	Plaque/calculus (Poor OH)
•	Soft tissue lesions
•	Gingival inflammation
•	Dental sealants
•	Malocclusion
•	High School (13-18)
•	All of the above + 3rd molar eruption

Assessing Caries Risk (ADA, 2006)
There is a box that describes caries risk criteria.  The criteria read:
Patients should be evaluated using caries risk criteria such as those below.

Low Caries Risk
All age groups
-No incipient or cavitated primary or secondary carious lesions during the last three years and no factors that may increase caries risk*

Moderate Caries Risk
Younger than 6 years
-No incipient or cavitated primary or secondary carious lesions during the last three years but presence of at least on factor that may increase caries risk*  
Order than 6 years (any of the following)
-One or two incipient or cavitated primary or secondary carious lesions in the last three years.  
-No incipient or cavitated primary or secondary carious lesions in the last three years but presence of at least on factor that may increase caries risk* 

High Caries Risk
Younger than 6 years (any of the following)
-Any incipient or cavitated primary or secondary carious lesions during the last three years.  
-Presence of multiple factors that may increase caries risk*
-Low socioeconomic status +
-Suboptimal fluoride exposure. 
-Xerostomia.**
Older than 6 years (any of the following) 
-Three or more incipient or cavitated primary or secondary carious lesions in the last three years.  
-Presence of multiple factors that may increase caries risk* 
-Xerostomia **

*- Factors increasing risk of developing caries also may include, but are not limited to, high titers of cariogenic bacteria, poor oral hygiene, prolonged nursing (bottle or breast), poor family dental health, developmental or acquired enamel defects, genetic abnormality of teeth, many multi-surface restorations, chemotherapy or radiation therapy, eating disorders, drug or alcohol abuse, irregular dental care, cariogenic diet, active orthodontic treatment, presence of exposed root surfaces, restoration overhangs and open margins, and physical or mental disability with inability or unavailability of performing proper oral health care
+- On the basis of findings from population studies, groups with low socioeconomic status have been found to have an increased risk of developing caries.  In children too young for risk to be based on caries history, low socioeconomic status should be considered as a caries risk factor
**- Medication-, radiation- or disease-induced xerostomia

•	Supplies for Screening and Caries Risk Assessment
•	Gloves
•	Mask
•	Disposable Mirror
•	Safety glasses
•	2x2 gauze 
•	Light
•	Source: Assessing Caries Risk (ADA, 2006)

Fluoride Varnish & Fluoride Mouthrinse

•	Both fluoride varnish programs and fluoride mouthrinse programs can be effective in reducing dental caries risk in school-aged children. 
•	ADA Recommendations:
•	Moderate-Risk
•	Children ages 6 to 18 years with moderate-risk for dental caries should receive fluoride varnish or gel applications at six-month intervals in addition to fluoridated water.
•	Higher-Risk
•	In addition to fluoridated water, children ages 6 to 18 with higher-risk for dental caries should receive fluoride varnish or gel application at six-month intervals; however, fluoride varnish applications or fluoride gels at three-month intervals may provide additional caries prevention benefit.

Fluoride Varnish Supplies

•	Fluoride varnish/disposable applicators
•	Gloves
•	Mask
•	Safety glasses
•	Disposable mirrors
•	2x2 gauzehttp://fha.maryland.gov/pdf/oralhealth/m8_FV_Supply_Ordering_Information.pdf

Picture- Front tooth with fluoride varnish

Fluoride Mouthrinse

•	Fluoride mouthrinse programs MUST be monitored closely to ensure safety of children 
•	If you are interested in implementing a fluoride mouthrinse program, please see the Massachusetts Department of Public Health Office of Oral Health Fluoride Mouthrinse Monitors’ Training Program Manual

Picture- Child in a classroom swishing with fluoride mouthrinse

Dental Sealants

•	The Centers for Disease Control and Prevention (CDC) estimates that if 50 percent of children at high-risk participated in school sealant programs, over half of their tooth decay would be prevented and money would be saved on their treatment costs.

Picture- Dental hygienist using portable equipment

Evidence-based Information for the Application of Dental Sealants

Indications for Dental Sealants
•	On sound, at risk surfaces

Picture- Molar tooth without any markings or staining

•	To arrest questionable or non-cavitated (incipient) caries lesions

Picture- Molar tooth with some staining

*** Sealing incipient lesions is recommended

Using the Explorer for Sealant Placement

•	The explorer does NOT need to be used during an oral health screening to determine if a tooth needs a dental sealant
•	However, the explorer can be used appropriately to:
•	Clean debris from fissures and interproximal spaces
•	Confirm and assess cavitations (breaks in the continuity of the surface) during sealant placement
•	Feel the texture (roughness) of non-cavitated lesions, if they extend well beyond the opening of the fissure
•	Help assess the sealant’s quality & integrity

Picture- Dental instrument

Determining which teeth should receive dental sealants

•	Visual examination is sufficient to detect early noncavitated lesions in pits and fissures.
•	The use of explorers is not necessary nor recommended for the detection of early carious lesions.
•	Teeth can be dry brushed with a toothbrush prior to placing sealants; the use of a handpiece and prophy paste is not needed.

Picture- Molar tooth
Image Source: http://www.uic.edu/classes/peri/peri343/WhiteSpt/whitspt1.htm

What about x-rays and other diagnostic devices?

•	Radiographs should not be taken for the sole purpose of placing sealants.
•	Diagnostic devices are not recommended and may result in false positives resulting in premature restorative interventions.

Picture- Dental hygienist using portable equipment

Recommendations for placing dental sealants

•	Only resin-based sealants should be used
•	Retention of dental sealants should be checked:
•	short-term (within weeks of placement), and 
•	long-term (within 12 months of placement). 
•	Goal is to reach at least 80-90% retention at 12 months
•	When to consider replacing a sealant (Ohio Department of Public Health):
•	Defects in sealant material (e.g., bubbles) do not require repair unless underlying tooth surface is exposed by the defect.
•	Catches in marginal areas do not require repair unless they expose noncleansable caries-prone areas of the fissure system.
•	Although staining at the interface of sealant and enamel does not, of itself, indicate caries, it may suggest an area of microleakage that could benefit from coverage with additional sealant material.
•	Before finalizing a decision on the need for repair of a partially retained sealant, try to dislodge the remaining sealant to assure that it cannot be lifted off, thus requiring total replacement.

School-base Sealant Program Supplies
•	Gloves
•	Mask
•	Toothbrush (to clean teeth)
•	Resin sealant material
•	Curing light
•	Suction
•	Air/water syringe tips
•	Patient bibs
•	Trash bag
•	Cotton rolls
•	Disposable mirror
•	Safety glasses for hygienist and patient
•	Sharps container

Evaluating a School-based Sealant Program

•	You should consider keeping records of three major variables to calculate and quantify the program’s outcomes:
①	Determine the quality of the dental sealants placed   (Retention checks!)
②	Calculate the program’s cost
③	Analyze program participation

Picture- Molar tooth with dental sealant

Parent Education
•	It is very important to communicate with school-aged children’s parents/guardians about oral disease prevention.
•	Parents should be advised regarding oral hygiene instructions, dental sealants, needed dental care, nutrition, fluoride, etc.
 
Picture- Cartoon poster with Uncle Sam

Documentation and Reporting of the Patient Encounter 

•	The PHDH Regulations an information sheet for each patient encounter should include:

•	Results of the screening
•	Description of service(s) provided and follow-up treatment needed
•	Name and signature of the licensed dental professional(s) who provided the service(s)
•	Information about how to contact the provider for more information
•	Written referral to the child’s dentist of record or to a referring dentist
Table
There is a table describing ideal characteristics and practical advantages of a dental home. 

Dental Home is accessible.
-	Care provided in the child’s community
-	All insurance accepted and changes in coverage accommodated
-	Source of care is close to home and accessible to family
-	Minimal hassle encountered with payment
-	Office ready for treatment in emergency situations
-	Office is nonbiased in dealing with children with special health care needs, or CSHCN
-	Dentist knows community needs and resources (fluoride in water)

Dental Home is family-centered.
-	Recognition of the centeredness of the family
-	Unbiased complete information is shared on an ongoing basis
-	Low parent/child anxiety improve care
-	Care protocols are comfortable to family (behavior management)
-	Appropriate role of parents in home care is established

Dental Home is continuous
-	Same primary care providers from infancy through adolescence
-	Assistance provided with transitions (for example, to school)
-	Appropriate recall intervals are based on child’s needs
-	Continuity of care is better owing to recall system vs. episodic care
-	Coordination of complex dental treatment is possible (traumatic injury)
-	Liaison with medical providers for CSHCN is improved (congenital heart disease)

Dental Home is comprehensive
-	Health care available 24 hours per day, seven days per week
-	Preventive, primary, tertiary care provided
-	Emergency access is ensured
-	Care manager and primary care dentist are in same place

Dental Home is coordinated
-	Families linked to support, education and community services
-	Information centralized
-	Records centralized
-	School, workshop, therapy linkages established and known (cleft palate care)

Dental Home is compassionate
-	Expressed and demonstrated concern for child and family
-	Dentist-child relationship is established
-	Family relationship is established
-	Children less anxious owing to familiarity

Dental Home is culturally competent
-	Cultural background recognized, valued, respected
-	Mechanism is established for communication for ongoing care
-	Specialized resources are known and proven if needed
-	Staff may speak other languages and know dental terminology

Assistance in Establishing/Maintaining a ‘Dental Home’ 

•	The American Association of Pediatric Dentistry (AAPD)- Policy on the Dental Home
•	A ‘Dental Home’ should deliver oral health in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist.
•	Resources
•	The Dental Home AAPD Online Resource Center

Resources

•	Massachusetts Department of Public Health Office of Oral Health Fluoride Mouthrinse Program
•	Massachusetts Department of Public Health Office of Oral Health Fluoride Varnish Fact Sheet
•	Massachusetts Department of Public Health Office of Oral Health- Sealant Resource Webpage
•	Massachusetts Coalition for Oral Health
•	American Academy of Pediatric Dentistry- Parent Brochures 
•	First Smiles Program- Parent Corner
•	ADA- Fluoride Facts
•	CDC- Community Water Fluoridation
•	CDC- Dental Sealants Fact Sheethttp://www.mchoralhealth.org/materials/multiples/smilesforohio/Supplies.pdf
•	Fluoride Varnish supply information
•	Watch a video on fluoride varnish application!

What’s Next?

•	The next PowerPoint presentation will review procedures, supplies, equipment, and reporting that may be applicable to providing preventive dental services in nursing home or elder/adult oral health programs.