The school-based sealant program's goal to increase access to dental care for low income children in a financially sustainable model. In the first year, the objective was to establish a partnership with the Marion County School Board and provide services to the designated rural schools. Using portable equipment, the hygienist provided an assessment, fluoride varnish, oral hygiene instructions and sealants on permanent molars to students who returned their completed medical history and signed consent forms in designated schools. The first schools targeted were the Title I rural schools in the county, as they had the least access to care due to transportation. In 2017-2019 the objectives emphasized utilizing the same hygienist model while increasing the number of portable units and staff to reach more students. In June 2019, the objective was to increase access to care by providing teledentistry and dental cleanings. With the hygienist taking intraoral photos on each patient and using an asynchronized (store and forward) method, the dentist in the fixed clinic could review the photos and charting, complete a limited exam and thus authorize a dental cleaning and make recommendations for follow up care.
The steps of implementation were as follows:
- Create a memorandum of agreement with the Marion County Public School Board and update yearly. A separate MOA is needed for each entity, such as churches or day cares since they are not administered by the School Board. This is very important for communication so that everyone know their responsibilities and liability.
- Create a signed protocol authorizing the delegable duties that can be performed under the supervising dentist.
- Obtain a student count from the School Board Liaison and order consents and fliers. This program uses Pride, which is the prison-based printing company.
- Purchase portable patient chair and ProSeal II unit. This program purchased the chairs and portable unit through Patterson Dental which is a distributor for Dental Health Works. When the dental cleanings started this summer the two existing ProSeal units were retrofitted with a quick connect outlet so that the hygienists could use a cavitron. The new unit was ordered with both the quick connect outlet and an additional electrical outlet.
- Obtain lap top computers and in 2019 intraoral cameras to use in the field. The Sirona Schick USBCam4 was chosen as it was compatible with Eaglesoft.
- Install a stand-alone Eaglesoft work station on the lap top computer. This work station does not communicate with the main Eaglesoft server.
- Order all mirrors, explorers and dental cleaning instruments, cavitrons and cavitron tips. Order all supplies for sealants, dental cleaning, fluoride varnish, fluoride gel for the rare child that has a contraindication for the varnish, take home kits with toothbrush, floss and tooth paste, oral hygiene instructions. Also order any models needed to explain oral hygiene instructions. A portable eye wash and emergency equipment is needed. The program does not take an AED since the schools have them.
- Distribute the consent packets to the schools approximately 2-3 weeks ahead of the visit. We found that sending them all out for the entire year caused a lower response than sending them out two weeks ahead of the school visit.
- Collect the returned consents. Many times, the school office assistant will create a list of the students by classroom and by schedule for the middle school children. This helps with locating the children and minimizing classroom interruptions. Obtain a liaison for that school to help with communication and locate a volunteer, if possible, at the school who will help with getting the children to and from class.
- Review the medical histories and consents to make sure they are complete and follow up on any concerns.
- The office clerks enter the children in Eaglesoft and print out their Medicaid, Kid care insurance. This is attached to the medical history/consent and the child dental record to go with the hygienists to the schools.
- Using a van, transport all items to the school and set up equipment and supplies in the designated room at the school. This should be a room that is large enough to handle the equipment and supplies and able to be secured when not in use. No patient information is left at the school when not in use.
- Provide services to the children based upon the agreed schedule with the school liaison.
- Secure area, return to the fixed dental clinic, down load the intraoral photos into a designated secured drive, chart services in Eaglesoft, complete encounter form. Meanwhile instruments are properly sterilized for future use. This program ordered additional instruments so that there could be extra for the next day.
- The office assistant uploads the intraoral photos into the Eaglesoft chart at the clinic and the dentist reviews the photos, charting and makes notes. She also scans in all the consents, medical history and child dental record to the individual Eaglesoft record before giving them to the dentist. This provides extra assistance to make sure nothing is misplaced.
The hygienist calls any parent/guardian of a child in pain or has swelling that afternoon. Once the dentist reviews the records and makes notes the office assistant follows up with those parents to answer any questions and facilitate scheduling or referral. She sends a letter if the child has urgent dental needs and she was unable to make contact. She also calls the parents of children with identified early needs (no pain or swelling at this time). When a hygienist sees a child a subsequent year and they note that the follow up care was never completed, a letter is sent home to the parent identifying the problems and again listing places where care could be obtained. Once the dentist has reviewed and follow up calls/letters are completed and documented in the progress notes of the dental record, the paperwork is scanned as a bulk file to a patient record with the name of the school and date. This provides back up before the paperwork is shredded.
The criterion for school selection was to target the rural schools first. Therefore, the schools in the Reddick, Ocklawaha, Weirsdale, Dunnellon, Ft. McCoy, Belleview areas were first. Once the program finished those schools and time permitted contact was made to schools inside the city limits.
The timeframe for the program was Spring 2016 to begin the Memorandum of Agreement. Equipment was ordered in Summer 2016. Additional equipment was added the 2017-2018 to accommodate a second hygienist. The teledentistry pilot program MOA's were started in Spring 2019 and the program started Summer 2019. Finally, additional equipment was added 2019 for a third hygienist.
The LHD is the Florida Department of Health in Marion County. The stakeholder is the Marion County Public School Board with each of its 50 Title I school children and families.
The LHD fosters a relationship with the Marion County School Board (stake holder) by communicating with the School Board Liaison via phone and email in creating and updating the MOA each year in the Spring for the next year. Before school starts, the LHD provides the Liaison a list of the school visits planned for the coming year. The LHD provides an informational email and PowerPoint explaining the program in detail, its importance in prevention of oral health problems to the Liaison. The Liaison then sends the email and PowerPoint to the individual principals. The Liaison communicates to the LHD as necessary any questions or concerns. The LHD notifies the school principal and the Liaison of any incident report needed for the school.
Startup costs and funding are as follows: the ProSeal II units cost $5,622 per unit. The Ultralite patient chair with scissor base, arm rest slings and carrying case is $1,388. The basic operator stool is $274. The straight attachment for the electric motor on the ProSeal is $536.24. Cavitron Select SPS 30K Ultrasonic scalers with reservoir are $2,585 each. The quick connect on the ProSeal is $32 and the electrical outlet is $72. Cavitron tips cost $113.74 each, mirrors are $.91 each and explorers with periodontal probes cost $25.45 each. Hand scalers vary in price from $14-$25 each. The hygienists preferred head lamps ($400 each) rather than floor LED lamps. The supply cost per student visit averages to $2.75 if no sealants are needed. The supply cost of a student visit with 4 sealants in addition to the cleaning, fluoride varnish is $6.25. The cost of a student visit with 8 sealants in addition to the above services is $7.39. This program provides a take home goodie bag with a new toothbrush, floss and tooth paste with a cost per student of $.65. Other costs including autoclave bags, water, lab coats, hand sanitizer, gauze, floss and masks are approximately $26.46 per school. Printing costs are approximately $.32 per student packet and will vary depending on how many students are enrolled in a school. The Health Department purchased a dental van in the second year that made transportation easier, since the equipment must be moved school to school.