Need: To improve the oral health status of children ages 3 to 17 living in underserved rural areas of Louisiana.
Intervention: School-based nurse practitioners perform oral health assessments, apply fluoride varnishes when indicated, and make dental referrals, with completion rates of the latter tracked by dental case managers.
Results: Significant numbers of school children are receiving oral health examinations, fluoride varnish applications, and receiving care coordination to improve numbers of completed dental appointments.
According to a 2016
Morbidity and Mortality Weekly Report, tooth
decay is noted as "one of the greatest unmet treatment
needs among children. Pain and suffering associated with
untreated dental disease can lead to problems with
eating, speaking, and learning."
To specifically address tooth decay issues, the
MMWR report noted "increasing sealant use
prevalence could substantially reduce untreated decay,
associated problems, and dental treatment costs."
experts have pointed to the effectiveness of fluoride
varnishes and the
U.S. Preventive Services Task Force 2014
recommendations are that "application of fluoride varnish
to the primary teeth of all infants and children starting
at the age of primary tooth eruption in primary care
Louisiana's Innis Community Health Center, Inc. — with a
recent name change to Arbor Family
Health — is positioned to address the oral health
disparities of school children in Pointe Coupee,
Avoyelles, Iberville, Morehouse, Richland East Feliciana
and Grant parishes. With start-up federal grant funding,
Arbor Family health has formulated a network of 4 other
Federally Qualified Health Centers (FQHCs) who are
participating partners in an oral health initiative. The
children's portal of access is through school-based
health centers (SBHCs). These school-based health systems
are able to deliver primary medical and behavioral care
in their communities, but are also providing primary
dental care and becoming the dental home for the
students. They collaborate with the area's dental
providers. However, this is often a challenge since the
area has a shortage of dental providers.
Advanced nurse practitioners who serve the primary care
SBHCs received additional training to perform focused
oral health assessments during comprehensive physicals.
When indicated, they apply fluoride varnishes. They make
referrals to dental partners when treatment interventions
Funding through several Rural Health Care Services
Outreach Grants from the Federal Office of Rural Health
Policy (FORHP) has supported Innis/Arbor Family Health in
its effort to integrate oral health into a primary care
Early in 2012-2015 grant period, the primary providers
discovered dental referrals were not getting tracked to
completion. This concern prompted the addition of dental
Case management, as described by the Case Management
Society of America, provides care coordination that,
specific to this concern, helps navigate barriers to
completing dental care appointments. Support for this
work came from the
2015-2018 FORHP outreach grant.
The oral health outreach activities conducted to date:
Oral health assessment training of primary care
providers working in the SBHC primary care settings.
Integration of oral health exams within the
comprehensive physical exam.
Application of fluoride varnish as an evidence-based
Oral health education for children in order to
influence overall oral health status.
Dental case management initiated on all referrals
which were specifically classified as a preventive
referral for routine preventive cleanings or problematic
referrals for treatment interventions.
Identification of the SBHC dental case manager, a
non-licensed SBHC employee, to track the referral to
completion or increase efforts to get the student seen by
a dental provider.
Dental case managers identify barriers to getting the
child seen for the referral to a dental provider and
classifies them as transportation, low family parental
involvement, or lack of identified dental home provider.
Dental referral tracking completion rate is measured
as a performance indicator for the SBHC and targets are
established for completion rates for each center.
The referral tracking statistic
becomes a quality measure for the program and is
unique to each center.
Baseline trend is established and the % of
increase is then set as the target for that
performing school year.
Electronic health record data makes the referral
tracking for oral health assessments, fluoride varnish
applications, and treatment referrals possible in a more
2012-2015 Outreach Grant Cycle results:
SBHC providers were trained in oral health
assessments and fluoride varnish applications.
Initial assessment of SBHC
capacity for oral health exams in advance of the
2012-2015 grant goal anticipated that 1,250, or
nearly 41% of the target population would need
fluoride varnish applications.
The actual number of applications exceed that
initial estimate by nearly 900, or 171% of the target
In a similar light, oral health
caries risk assessments totaled 2,273, or 182% of the
original target estimates.
Despite these successes, only 14% of those provided with
a dental referral went on to complete that referral and
establish a dental home. This result prompted the
decision to initiate dental case management, implemented
with the support of the 2015-2018 grant.
2015-2018 Outreach Grant Cycle results:
100% of providers now trained in oral health
assessments/fluoride varnish application through the
American Academy of Pediatrics program Protecting All
6403 completed oral health assessments
5100 applications of fluoride varnish
2350 dental referrals, averaging
a 64% completion rate, substantially above the baseline
14% prior to dental case management implementation
Dental case management has now emerged as key to the
SBHC's oral health assessment program success, leading to
an increased number of students who ultimately are seen
by dental providers.
Over the grant cycle intervals, students, parents, and
school faculty have come to realize that oral health
assessments are just as critical as vision and hearing
assessments and an impact overall health and learning
Engagement of dental colleagues was an initial challenge
largely due to the low numbers of dental professionals in
Because training primary care providers in basic oral
health assessment and fluoride varnish application is
achievable, the program is replicable in SBHCs and
primary care facilities anywhere state laws allow the
intervention. Referral follow-up is the key component
that impacts the child's overall oral health status.
Some important strategies for success are:
Use electronic health record data-tracking for
monitoring of follow-up
Laws vary across states regarding professionals
allowed to apply fluoride varnish
Oral health assessments integrated into the periodic
comprehensive physical exam can generate revenue as a
provider visit within the school-based health system
Fluoride varnish is an inexpensive preventive
SBHC dental case management should be sustainable
since these centers already provide referral tracking on
other type of referrals on children seen in the centers.
Collaboration between school systems and
organizations providing SBHCs can positively impact
future grant proposals and projects
Please contact the models and innovations contact directly for the most complete and current information
about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The
programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural
community should consider whether a particular project or approach is a good match for their community’s
needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep
in mind that changes to the program design may impact results.