Improving Oral Health in the School Setting Amanda ...

Running head: IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 1

Improving Oral Health in the School Setting

Amanda Hollingsworth

Touro University, Nevada

October 20, 2018

In partial fulfillment of the requirements for the

Doctor of Nursing Practice

DNP Project Team: Dr. Nadia Luna, DNP, MBA, RN, CNE

Dr. Denise Zabriskie, DNP, RN, CWOCN, WCC

DNP Project Member(s): Dr. Juanita Rosales, DNP, RN, PHN

Date of Submission: October 20, 2018

IMPROVING ORAL HEALTH IN THE SCHOOL SETTING 2

Table of Contents

Abstract ......................................................................................................................................... 3

Background ................................................................................................................................... 5

Problem Statement ....................................................................................................................... 8

Objectives .................................................................................................................................... 10

Review of Literature ................................................................................................................... 11

Theoretical Model ....................................................................................................................... 20

Project Design.............................................................................................................................. 27

Implementation ........................................................................................................................... 28

Project Timeline ........................................................................................................................ 32

Ethics of Human Subjects ........................................................................................................ 33

Evaluation ................................................................................................................................... 34

Analysis ..................................................................................................................................... 35

Significance and Implications in Nursing ................................................................................. 38

Limitations of the Project ......................................................................................................... 39

Project Sustainability ................................................................................................................ 41

Conclusion ................................................................................................................................... 42

References .................................................................................................................................... 43

Appendix ...................................................................................................................................... 48


Abstract

Tooth decay is the most chronic common condition in childhood in the United States (Centers

for Disease Control and Prevention [CDC], 2017). One in five children ages five to 11 have had

a least one untreated decayed tooth (CDC, 2017). The state of California has recognized the

importance of oral health of school age children. On September 22, 2006, the California

Governor signed Assembly Bill [AB] 1433 stating that schools must send notification of the new

oral assessment requirement to parents or legal guardians (California Dental Association [CDA],

2017). Effective January 2007, children attending public school must submit proof of an oral

assessment performed by a licensed or registered dental health professional by May 31, before

entering the first grade (CDA, 2017). The purpose of this project was to increase oral health of

schoolchildren through assessment compliance among kindergarten students in a Southern

California school district. The school nurse plays an essential role in providing support,

education, and referral for children and their families. Thirteen school nurses received an oral

health education toolkit to reinforce oral health hygiene and the requirements of California law

AB-1433. Eighty five percent of the participants answered the 20 multiple choice questions with

a score greater than 75%. A school-based dental clinic was implemented at one elementary site

with approximately 165 enrolled kindergarten students. At the start of the 2018-2019 school

year at this project site, 160 kindergarten students (N=160) were enrolled and one hundred

percent of kindergarten students were missing the oral health screening. By August 31, 2018,

86% of students turned in a completed oral health assessment form. The results of this project

provide support for the establishment of school-based programs within school nursing and in

outside school districts.

Keywords: oral health, school health, students, school nurse, kindergarten


Improving Oral Health in the School Setting

Dental decay is the most common chronic disease in children and teens affecting nearly

two-thirds of California’s children by the time they reach third grade (CDA, 2017). Dental

decay is the result of acid breakdown of tooth enamel produced by bacteria found in a film that

gathers on the teeth (CDC, 2017). If left untreated, the child may develop infection severe

enough for emergency treatment resulting in permanent damage (CDC, 2017). Although cavities

are preventable in the United States, 21% of children between the ages of 6 to 11 years old had at

least one cavity in their permanent teeth in 2011-2012 (CDC, 2017). Children with oral decay

stop smiling, eat poorly, and have difficulty in the learning environment (CDA, 2017).

Invasive treatment to address disease can be avoided with prevention. Low-cost oral

health decay can be prevented by providing education to caregivers on preventing caries,

effective oral hygiene, a healthy diet, and low-cost fluoride (Hummel, Phillips, Holt, & Hayes,

2015). With early intervention, cavities can be detected and treated. The state of California has

recognized the importance of oral health of school age children. On September 22, 2006, the

California Governor signed Assembly Bill [AB] 1433 stating that schools must send notification

of the new oral assessment requirement to parents or legal guardians (CDA, 2017). Effective

January 2007, children attending public school must submit proof of an oral assessment

performed by a licensed or registered dental health professional by May 31, before entering the

first grade (CDA, 2017). Parents may opt to waive this requirement if the parent cannot afford to

pay for it, if the child’s insurance is not accepted, or if the parent simply chooses not to have the

child’s oral health evaluated (CDA, 2017). This form provides the school nurse information

needed to identify barriers to care and need for follow-up.

Childhood decay often goes unrecognized and untreated resulting in serious health


problems that may lead to surgical extraction or crown placement (Hummel et al., 2015). These

late-stage interventions, waste healthcare dollars and introduce patients to risks such as increased

risk for disabilities in language acquisition and abstract reasoning from a single exposure to

general anesthesia before age three (Hummel et al., 2015). Implementation of an oral health

program within the school setting will provide added preventative oral health care to reduce the

burden of oral disease in the kindergarten student.

Background

In 2006, a Healthy People 2020 survey revealed nearly 54% of California kindergarten

children had a history of tooth decay in comparison to the United States baseline prevalence of

33.3% for children aged 3-5 years old (California Department of Public Health [CDPH], 2017).

The underserved population face challenges to oral health care access including transportation

problems, health literacy challenges, and social and cultural factors (CDPH, 2017).

Socioeconomic status is a strong determinant of oral health and outcomes (CDPH, 2017).

Children of all ages who live below the federal poverty level (FPL) are more likely to have

untreated dental decay than the children living above the FPL. Students who receive free or

reduced lunch in California schools are more likely to have a history of tooth decay, untreated

decay, or needed urgency dental care more than the children who does not qualify for the free or

reduced lunch program (CDPH, 2017).

In compliance with AB 1433, this school district provides the oral health assessment form

included in the kindergarten registration packet of the public-school child prior to the start of

kindergarten. The parent has until May 31, before the student enters first grade, to complete the

oral assessment. On the form, the parent has the right to waive the oral assessment. This data is

then reported to the County Office of Education (CDA, 2017). If the parent returns the form to


the school site indicating they choose to waive oral care, this identifies the student as entering

school with possibly untreated decay and more specifically, the follow up may reveal barriers

the child faces in receiving proper oral health care in the community (CDA, 2017).

Significance

Tooth decay is the most chronic common condition in childhood in the United States

(CDC, 2017). One in five children ages five to 11 have had a least one untreated decayed tooth

(CDC, 2017). By kindergarten, more than 50% of children in California have already

experienced tooth decay, 28% untreated tooth decay, and 19% accounting for extensive decay

(California Dental Association [CDA] & California Society of Pediatric Dentistry [CSPD],

2014). Children age five to 11 from low-income families are twice as likely to have untreated

tooth decay (CDC, 2017). Tooth decay is painful and the consequences of untreated tooth decay

are expensive with negative consequences such as teeth, gum, and tooth loss (CDA & CSPD,

2014). Dental disease is infectious and progressive yet largely preventable with early

examination and intervention. California Dental Association and California Society of Pediatric

Dentistry recognize the importance of preventative programs and the need to implement oral

health policy at the local, state, and national levels (CDA & CSPD, 2014).

Needs Assessment

The purpose of this project is to improve oral health assessment compliance in the regard

to AB 1433. An initial self-study conducted by the school nurse found that 155 out of 163

kindergarten children currently enrolled at an elementary school in a public school district in

Southern California have not returned the oral assessment form in the 2017-2018 school year.

The school nurse has found that the methods of holding the parent accountable in obtaining the

school entrance oral health evaluation form varies from school to school, district-wide. At the


end of every school year, each school site’s unlicensed assistive personnel [UAP] gathers and

reports the oral health assessment data to the district office Student Records Technician. The

oral health assessment data includes the total number of kindergarteners and those who

presented proof of a dental exam, and those found with untreated tooth decay at initial

evaluation. Additional information, the total number of students who could not complete an

assessment due to lack of access to a licensed dentist or registered dental health professional,

those who did not consent to their child receiving the assessment and the total number of

students who did not return either the assessment form or the waiver form is included in this

data collection. The Student Record Technician inputs the district wide total oral health

assessment/waiver data through Student Oral Health Assessment System ([SCOHR], 2012).

SCOHR (2012) tracks the status of all oral health assessment/ waiver request forms through an

online database. Tooth decay is the most chronic yet preventable heath care need among

children in California (California Department of Education, 2017). Tooth decay is the cause of

874,000 school days missed each year, costing school districts $29 to $32 million annually in

average daily attendance funding (California Department of Education, 2017). The goal of the

Kindergarten Oral Health Assessment Requirement (AB 1433) is a way for schools to play an

active role in reducing dental disease in children through oral education, awareness, and

connecting families to a source of regular dental care (California Department of Education,

2017). This program will identify children in need of further examination and dental treatment

and with help in the identification of barriers to the delivery of oral care (CDC, 2017). The low

compliance rates in receiving the completed evaluation/waiver form reveals the need for a

district-wide action plan and the implementation of interventions. A school district located in

Southern California is meeting the very minimum standards of California law by simply sending


the oral assessment form in the kindergarten registration packet then reporting the compliance

rates through the online database SCOHR.

Problem Statement

An understanding of oral health in school-aged children is an important step in examining

the patterns of delivery and the barriers that the student may face in obtaining care (Reed et al.,

2016). Tooth decay is significant, although preventable (Reed et al., 2016). Refocusing the

school and the school nurse role of improving oral health compliance enables to student to

function at the most optimal level in the classroom (Reed et al., 2016).

The school nurse plays an essential role in providing support, education, and referral for

children and their families. In this Southern California School District, the school nurse is held

to the minimum requirement of California law to gather the end-of-year data of oral health

assessment compliance from the UAP after it has been reported to the Student Records

Technician. Recognizing the oral health status of the kindergarten student allows the nurse to

examine the patterns in the delivery of care, the impact of contributing factors, and the use of

oral health services by these children (Reed et al., 2016). Dental diseases are preventable and

the implementation of activities will improve oral care by carrying out school-wide

interventions, referral to local dentists, and follow up (Voogd, 2014).

Purpose Statement

The purpose of this project is to increase oral health of schoolchildren through

assessment compliance among kindergarten students in the public-school setting. At this time,

there are 3,435 kindergarten students enrolled in the project school district. At one school, 95%

of the enrolled kindergartens did not return the oral assessment form in the 2017-2018 school

year by August 31, 2017. In compliance with California Law (Education Code Section


49452.8), this school district includes the Oral Health Assessment Form in kindergarten

registrations packets to be returned by May 31, prior to the start of first grade. Whether or not

the oral health assessment form is returned to the school site, the kindergarten child will

continue on to the first grade; no child is excluded from school due to lack of an oral health

evaluation.

The aim of this project is to increase the oral health assessment return compliance rates in

the 2018-2019 school year. Providing oral health education supports the importance of

compliance with California State Law to decrease the number of students entering school with

possible untreated decay while increasing the return of the oral health evaluation among

kindergarten students. If the parent opts to waive the oral health examination, the school nurse

must be aware to follow up with the parent. Documenting this information will allow the school

to know the reason behind the decision to waive care.

The National Association of School Nurses [NASN] recognizes the importance of the

school nurse in identifying social determinants of health in the school community, deliver health

care to all students, support school staff, and create partnerships with local community members

to decrease health disparities (National Association of School Nurses [NASN], 2016).

Vulnerable and underserved populations include racial and ethnic minorities, including

immigrants and non-English speakers, uninsured and publicly insured individuals, children, and

populations of lower socioeconomic status (National Academy of Sciences, 2011). In the

project school district, there were 53,147 students enrolled in the 2016-2017 school year

(Education Data Partnership [Ed Data], 2017). The demographics of this school district in 2016-

2017 school year include 28,074 enrolled as Hispanic and 24,646 students who qualified for the

free or reduced meal program (Ed Data, 2017). The National Academy of Sciences identifies


the child, ethnic and minority groups, and poor and minority children are substantially less

likely to have access to oral health care (National Academy of Sciences, 2011).

Project Question

The purpose of this project is to examine the oral health assessment compliance rates and

the improvement of compliance rates prior to the start of 1st grade after implementation of an

oral health program using the research question: In the kindergarten student, does

implementation of a school-wide oral health program improve the compliance of completing the

oral health evaluation form by the start of 1st grade?

Project Objectives

• Develop a school-dental office partnership to provide free or low cost dental services to

uninsured or underinsured kindergarten students by April 2018

• Design an evidence-based practice (EVP) oral health education toolkit program

throughout school district by May 2018

• Improve oral health assessment compliance to 65% by the end of August 2018

Search Terms

A comprehensive literature review was performed using multiple databases including

CINAHL Complete, Academic Search Premier, Alt Health Watch, and Health Source: Nursing

Edition, MEDLINE, PubMed, Cochrane Database, and EBSCOhost. The studies were selected

based on oral health in the school-aged child. Key terms included oral health, school health,

school nurse, school nursing, oral health assessment, and school-aged children. The original

search yielded 5,886 search results. The results were narrowed by date of publication, to include

articles published from 2011 to the present, full text, peer-reviewed scholarly articles in the

United States. The final 10 studies were selected included qualitative, quantitative, cross-

sectional, randomized control trials, and comparative data analysis.


Review of Literature

The purpose of this review of literature is to examine current research pertaining to oral

health in the school-aged child. Key concepts will recognize the school-aged child as a

vulnerable population, the oral health effects on school performance, parental literacy of oral

health education, and the collaboration between organizations in providing an additional access

to dental care. The goal of this review of literature is to identify common themes and potential

gaps, and identify the relationships among the studies found.

Impact of the Problem

Poor, minority children, younger than five years are at a high risk to dental caries (Beil,

2014; Biordi, 2015; DeMattei, 2012; Mahat, 2017; Matsuo, 2015; Seirawan, 2012). Matsuo,

Rozier, & Kranz (2015) revealed that more than 51.7% of Hispanic children and 39% of Black

children had dental caries at the time of enrollment in comparison with 30.4% of White children

(Matsuo et al., 2015). Hispanic and Black children were more likely to have experienced dental

caries then White children, regardless of poverty status (Matsuo et al., 2015). This study

magnified the disparities that an individual of lower socioeconomic status faces that can affect

the child’s oral health indirectly and directly (Matsuo et al., 2015). Families of higher

socioeconomic status are more likely to have access to healthy food and a quality dentist,

perhaps, due to transportation and location of neighborhood (Matsuo et al., 2015).

Bell, Huebner, & Reed (2012) revealed 47% of children and youth were in excellent oral

health, 24% in very good oral health, and 8% in fair/poor oral health. Most children rated in

excellent oral health were younger, white, had health insurance, two married or cohabiting

parents, higher family income, no special health care needs, and a usual source of medical care,

received regular preventive medical care, and resided outside a metropolitan statistical area (Bell


et al., 2012). Overall, 78% of children and youth received a preventative dental visit (Bell et al.,

2012). Only 24% of children ages 1 to 2 years old and 73% of those ages 3 to 5 years received

preventative visit (Bell et al., 2012). Children without special health care needs had lower rate of

receiving preventive dental care services (Bell et al., 2012).

Simmer-Beck et al. (2015) evaluated the effectiveness of an alternative dental workforce

program—Kansas’s Extended Care Permit (ECP) program—as a function of changes in oral

health. Low income children attending a Title 1 elementary school (defined as exceeding 40%

poverty based upon the number of students that qualify free or reduced-price lunches) located in

a Midwestern suburb participated in this intervention (Simmer-Beck et al., 2015). This study

revealed 64% of participating children in this program had decayed teeth (Simmer-Beck et al.,

2015). This rate is significantly higher than that reported in the state, county, and school district

where the program was located (Simmer-Beck et al., 2015). This rate also exceeded the Healthy

People 2020 baseline (23.8%) and target (21.4%) decay rates (Simmer-Beck et al., 2015).

Children of parents who had low knowledge of oral hygiene were more likely to

experience dental decay in comparison to those with more knowledge (Bell, 2012; Mahat 2017).

Mahat & Bowen (2017) found that the parents who participated in this study were

knowledgeable about some aspects of children’s oral health risk factors however; they lacked

knowledge of certain aspects in oral care. For example, 97.7% of parents knew baby teeth were

important and that baby teeth (92%) and permanent teeth (98.9%) needed to be brushed twice

daily (Mahat & Bowen, 2017). Only a few parents (28.7%) recognized that cavities in baby

teeth could cause long lasting problems (Mahat & Bowen, 2017). Bell, Huebner, and Reed

(2012) examined the associations between parent’s report of their children’s oral health and

receipt of a dental visit for preventative care. The findings of this study revealed 47% of


children and youth were in excellent oral health, 24% in very good oral health, and 8% in

fair/poor oral health (Bell, Huebner, & Reed, 2012).

Addressing the Problem with Current Evidence

In this section, the impact of the problem will be discussed. The articles collected are

analyzed and the recommendations of prevention, current management, current

recommendations for managing the issues, issues still under investigation, and issues that have

not been addressed.

Prevention. There are significant differences in the families with greater access and use

of services; those with poor access may be at higher risk for poor oral health status (Bell et al.,

2012). Preventative oral health services and receipt of care is disproportionate by age, race and

ethnicity, and the presence of special health care needs (Bell et al., 2012). Matsuo et al. (2015)

recognized the importance of public health strategies to reach high-risk students in low-risk

schools who do not usually benefit from most school-based oral health intervention because their

schools are not targeted (Matsuo et al., 2015). The findings of this study support the need to

implement public health interventions to reduce racial and ethnic oral health disparities (Matsuo

et al., 2015).

Primary prevention. Encounters with alternative providers play a large role in the oral

health status of children (Biordi, 2015; DeMattei, 2012, Simmer-Beck, 2015). School nurse

involvement in school-based dental centers improves access for many children without special

health care needs (DeMattei, Allen, & Goss, 2012). DeMattei et al. (2012) support the benefits of

partnerships between schools and local dental organizations. School-based dentist programs

provide an alternative, easy access to the school-aged child in a familiar environment that

supports academic performance (DeMattei et al, 2012). Similar to California State Law, Illinois


requires mandatory dental exams for kindergarten, second and sixth grade students (DeMattei et

al., 2012). DeMattei et al. (2012) recognizes the importance of providing oral health care in the

school environment as an additional access to meet this requirement.

Secondary prevention. Beil, Rozier, Preisser, Stearns, and Lee (2014) found that children

who had a dental visit by age 24 months had similar numbers of teeth affected with dental caries

at the time they were examined in kindergarten as the children who had a visit at age 24 to 36

months. The children who had a dental visit by age 24 months were at higher rates of disease

than those who had a visit at 37 to 60 months (Beil et al., 2014). Children who had two or more

visits before 24 months had the same rate of disease as children who had visits with two or more

treatments at older ages (Beil et al., 2014). Children who received two or more restorative

treatments by age 24 months had the same amount of disease as children who had their first visit

at older age, which suggests that early visits may have been effective in treating disease for the

high-risk children (Beil et al., 2014). This study supports early screening and intervention as an

effective way to detect and reduce chronic oral health problems in children.

Tertiary prevention. Dental problems affect quality of life, school performance, and

school attendance (Guarnizo, 2012; Jackson, 2011; Seirwan, 2012; and Simmer-Beck, 2015).

Seirawan, Faust, and Mulligan (2012) measured the impact of dental disease on academic

performance of disadvantaged children by sociodemographic characteristics and access to care

determinants. The results indicate that 6.4% of parents miss workdays and 5.5% of elementary

and high school students miss school due to their children’s dental problems (Seirawan et al.,

2012). In this sample of children, almost 169 days were missed by students because of dental

problems and 218 days lost by parents because of their children’s dental issues. In Los Angeles

Unified School District (136,873 students), this translates to 16,431 school days missed annually


(Seirawan et al. 2012). Students with toothaches in the past six months were almost four times

more likely to have a grade point average lower than the median of 2.8 compared with students

without recent toothache (Seirawan et al. 2012).

Guarnizo-Herreno and Wehby (2012) found that children ages 6 to 11 years old with

dental problems are more likely to have problems in school (30.22%) and miss school (78.51%).

Guarnizo-Herreno & Wehby, 2012). This study shows dental health is positively associated with

all psychosocial outcomes (Guarnizo-Herreno & Wehby, 2012). Children with dental problems

are more likely to feel worthless/inferior (1.47%), unhappy/sad/depressed (0.79%), and are less

likely to be friendly (55.41%) (Guarnizo-Herreno & Wehby, 2012). Good dental health is

associated with less shyness and more friendliness in contrast to poor or fair dental health

associated with more shyness and feeling worthless, unhappy, sad, and/or depressed (Guarnizo-

Herreno & Wehby, 2012).

DeMattei et al. (2012) implemented service-learning project to eliminate barriers to oral

care for children with special health care needs. Of the sample size, approximately 15 % of the

children presented with severe restraint behavior and no treatment was provided (DeMattei et al.,

2012. The findings of this study detected dental decay in 85 children with 10% urgent need for

restorative care, root canals, and extractions (DeMattei et al., 2014). Implementing alternative

access to care will improve the quality of life for the school-aged child. This project was a

collaboration between a school district’s special education population and a local dental

hygienist program. This project not only proved beneficial to the special needs children but for

the student dental hygienists who learned tactics on performing oral care on this population.

Furthermore, the studies support that dental disease directly affects school performance, school


attendance, and the psychosocial aspect of the school-aged student (Guarnizo, 2012; Jackson,

2011; Seirwan, 2012; and Simmer-Beck, 2015).

Current management.

In the project school district in Southern California, there is currently no oral health

policy in place. Assembly Bill [AB] 1433 states that schools must send notification of the new

oral assessment requirement to parents or legal guardians (CDA, 2017). The project district

office has instructed school sites to include the oral health assessment form to be included in all

kindergarten registration packets. The return data of the completed oral health assessment

forms are collected and then reported to the district office at the end of every school year. This

school district has site-specific partnerships that the UAP or school nurse has organized.

Currently, there is no standardized process regarding what partnerships or school-based oral

health care should be in place for the kindergarten students.

Current recommendations.

The literature supports the implementation of school-based oral health care and the

collaboration with dentists within the community to increase the child’s quality of life, increase

school performance, and reduce absenteeism (Guarnizo, 2012; Jackson, 2011; Seirwan, 2012;

and Simmer-Beck, 2015).

Biordi et al. (2015) recognized fluoride varnish as a routine tool in dental caries

prevention as it is easy to apply, efficient, and safe in young children. Fluoride varnish remains

an evidence-based practice method in decreasing incidence of early dental caries in high-risk

students. Implementing a school-based project to increase the parent’s knowledge and recognize

the benefits of preventive measures will aid in preventing oral health problems especially for

high-risk students.


Issues still under investigation.

An objective of Healthy People 2020 is to reduce the proportion of children who have

dental caries and untreated decay (as cited in Mahat & Bowen, 2017). The American Academy

of Pediatric Dentists (2014) recommends that parents receive better oral health education about

children’s baby teeth and oral hygiene to minimize and eliminate dental disease (as cited in

Mahat & Bowen, 2017). Bell et al. (2012) recommended future qualitative research to explore

parent perceptions of the young child’s preventive dental health needs and the best ways to

promote this awareness at a population level. Bell et al. (2012) recommended utilizing public

health in an effort to educate parents on preventative screenings and early treatment rather than

seeking services in the response of problems. Bandura’s Social Cognitive Theory (1986)

signifies a central source of social influence (as cited in Mahat & Bowen, 2017). This theory

makes sense that if parents are well informed about oral health, they can influence their child’s

oral health behaviors (Mahat & Bowen, 2017). Ongoing research to identify public health efforts

in prevention and early treatment is beneficial to this target population.

Issues not yet addressed.

Jackson, Vann Jr, Kotch, Pahel, & Lee (2011), examined school days missed for routine

dental care versus dental pain or infection to determine the relationship between children’s oral

health status and school attendance and performance. The study found that children with good,

fair, or poor reported oral health were nearly three times more likely than were children with

very good or excellent oral health to miss school because of dental pain (Jackson et al., 2011).

Black children were less likely than white children to miss school for routine dental care

(Jackson et al., 2011). Although a relatively small percentage (4%) missed school because of


dental issues, further evidence is needed to identify school performance of children who are

experiencing dental pain or infection (Jackson et al., 2011).

Seirawan et al. (2012) measured the impact of dental disease on academic performance of

disadvantaged children by sociodemographic characteristics and access to care determinants.

This study supports oral disease affects individuals contributing to lower academic achievement,

compromising the parent’s ability to maintain a job, and the need for high-quality outcome

measures to promote oral health programs. Future study implications include the evaluation of

socioeconomic, cultural, and clinical challenges in children with dental issues (Seirawan et al.

2012).

Controversies.

Biordi et al. (2015) created a nurse practitioner-dietician collaboration to provide oral

health services and of the 4,360 children who received at least one fluoride varnish, 1,832

children returned for a second visit, and 728 received three or more fluoride varnishes within the

project span (Biordi et al., 2015). At the first visit, 17.1% of the children had dental caries, with

a greater proportion in the urban site compared to the rural site (Biordi et al., 2015). The number

of dental caries declined with the increase of visits (Biordi et al., 2015). Preventative dental

services include examination, education on diet and home hygiene, topical fluoride, and dental

sealants (Bell; 2012, Biordi, 2015). In contrary, Simmer-Beck et al. (2015) found that the

number of fluoride varnish applications did not affect decay, which is inconsistent with the

literature. This finding may have been due to the lack of baseline measurement at the start of

decay-free teeth. Furthermore, Simmer-Beck (2015) recognized that encounters with alternative

providers decrease decay, increased restorations, and decreased treatment urgency significantly

for the children who may not have received oral health care services.


Implications for nursing practice.

The results of this literature review could help to promote the importance of oral health

assessment in the kindergarten student prior to 1st grade entry. The school-aged child is at risk

for tooth decay that lead to lower school performance, absenteeism, and if left untreated, the

student faces risk of permanent dental damage. Best-practice guidelines will result in increased

student wellness, oral health knowledge, and oral health assessment compliance rates. School

nurses serve as a catalyst for the school district and the students regarding school health. It is

essential for the school nurse to understand the factors associated with tooth decay. As

healthcare providers, the school nurse serves as the frontline to prevent and reduce tooth decay in

students entering school.

Recommendations for practice change.

Dental caries lead to a variety of problems such as oral pain, excessive school absences,

difficulty concentrating, poor appearance and poor oral health as an adult (Mahat & Bowen,

2017). Better parental education about children’s primary teeth and oral hygiene minimize or

eliminate dental disease in support of Healthy People 2020 objective: to reduce the proportion of

children who have dental caries and untreated decay (Mahat & Bowen, 2017). Understanding

this information is supportive in the implementation of oral health evidence-based practice

guidelines for school nurses caring for students in the school district. The recommended changes

include proving oral health protocol for school nurses. A written policy would serve as a tool for

the school nurse in addressing oral health at each school site. The best practice guidelines should

include oral health education and materials to present to the kindergarten parents by explaining

the procedure in the language of the learner, providing pamphlets with appropriate literacy and

age-appropriate care. Matsuo et al. (2015) recognizes racial and ethnic disparities that exist


among children with dental caries signifying the need to close the gap and improve oral health in

the entire community. The oral health assessment form should be included in registration

packets with extra copies in the classrooms, especially during parent events. Referral and follow

up methods, and the development of collaboration with a local dentist should also be addressed,

as the lack of dental insurance is a contributing factor to waiving the dental assessment.

DeMattei et al. (2012) found that enlisting a practicing public health dentist who had

access to federally qualified health centers was beneficial in referring clients to appointments on

an as needed basis. The importance of follow-up care with parents and guardians may have

accounted for low number of children who received treatment for dental care through a school-

based oral health program (DeMattei et al., 2012). This literature supports the sharing of results

and recommendations through face-to-face interaction rather than handwritten notification

(DeMattei et al., 2012).

Theoretical Model

Oral health is an essential part of overall health with complex interaction from many

influences such as nurses, healthcare providers, dental providers, parents, and teachers. To

improve and promote oral care practice in the public-school setting to enhance the kindergarten

child’s health and wellness, the 21st Century School Nursing Practice developed by the

National Association of School Nurses (NASN) best addressed the clinical issue and PICOT

question. The framework for 21st Century School Nursing Practice is designed to guide

evidence-based standards of practice of each unique school community, with the goal of

professional development (Allen-Johnson, 2017). This framework creates a solid foundation

for public health interventions where the nurse motivates the client to make everlasting life

choices to improve health and wellness.


Historical Development of Theory

The development of this framework began with an assessment of current health needs

and healthcare issues of the school-aged child, evidence-based literature, and the skills needed

to meet various student health challenges (NASN, 2016b). Outside consultation experts,

individuals from the NASN’s 2015 annual conference during three feedback sessions, and

individuals from state and local meetings, explored the framework and the initial draft was

published in July 2015 NASN School Nurse with a link to identify the school nurse’s

information (NASN, 2016b). The NASN Board of Directors reviewed and finalized the

framework in 2016.

Major Tenets of Theory

The framework for 21st century school nursing practice is aligned with the whole school,

whole community, whole child model (WSCC), which calls for the integration of health-

promoting practices in the school setting (CDC, 2015; NASN, 2016). Central to the model is

student-centered care that occurs within the perspective of the student’s family and school

community (NASN, 2016b). Surrounding the student, family, and school community, are the

elements of intersecting key principles: (1) care coordination, (2) leadership, (3) quality

improvement, and (4) community/public health (NASN, 2016b). The fifth principle, standards

of practice, encompasses the key principles as a foundation for evidence-based quality of care

(NASN, 2016b). Practice components of each principle are outlined in Figure 1B.

Care Coordination

Care coordination is based on an assessment of the student and family needs (NASN,

2016b). The school nurse initiates the process of identifying children who are not achieving

their optimal level of health or academic success due to oral health issues based on assessment

(NASN, 2016b). The nurse works as the case manager, which directly affects the child, parent,


teacher, and care providers in determining interventions that are goal oriented (NASN, 2016b).

Motivational interviewing and counseling can serve as an opportunity to educate parents and

children on self-care behaviors and health care needs (NASN, 2016b). Motivational

interviewing empowers the family to identify their own concerns and solutions, rather than the

nurse providing solutions (NASN, 2016b). Due to the large student population, the school

nurse relies on collaboration and delegation. Nursing delegation will require the assignment of

specific tasks during this project such as ongoing documentation of specific health issues by

other members of the school health team. For example, the UAP will need to indicate

complaints of tooth pain, foul mouth odor, constant chewing on pencils, and cracked teeth.

This information is vital to the nurse, as electronic reports will identify oral health issues.

Leadership

Leadership requires the ability to lead policy development and procedures.

Implementing an oral health care policy within the district is an example of performing

advocacy, change, and health care reform. School nurses are viewed as change agents who

participate in the multidisciplinary team to coordinate policy development and implementation

to address the school-aged child’s health concerns within the school and community (NASN,

2016b). The school nurse shows commitment to be a lifelong learner when engaging in

professional practice and development (NASN, 2016b).

Quality Improvement

Electronic collection and management of data overlaps with the quality improvement

(QI) principle, as data collection is a major practice component (NASN, 2016b). QI is the

continuous and systematic process that leads to measurable improvements and outcomes

(NASN, 2016b). The nurse integrates the QI process daily in an effort to identify the greatest


impact on student health and outcomes (NASN, 2016b). QI changes practice and builds on

current evidence in school nursing. Evaluation of the outcomes identifies the appropriateness

of the process and interventions in place. Collecting the project’s compliance rates will reveal

the effectiveness of the oral health program.

Community/Public Health

School health is grounded in the framework principle community/public health as the

school nurse focuses on the student and the school community (NASN, 2016b). Healthy

People 2020 recognizes the need for oral health promotion and disease prevention, which

supports the need for school nurses to prioritize health assessments and interventions (NASN,

2016b). Recognizing the levels of prevention is a key in addressing issues through health

education, risk reduction, disease prevention, screening, referrals, and follow up activities.

Outreach to kindergarten families will remain key to the success of this oral health program.

Standards of Practice

The principle, standards of practice guides the WCSS framework and incorporates the

practice and performance standards (NASN, 2016b). The school nurse serves this population

with the specialized skill and knowledge to provide the best possible health care. Clinical

competence, clinical guidelines, NASN’s code of ethics, critical thinking, evidence-based

practice, position statements from NASN, Nurse Practice Acts (NPAs), and scope and

standards of practice will guide the school nurse in providing the school community with the

most current and effective oral health care program. The school nurse leader uses the skills

outlined in the practice components of each principle to promote and support the health and

wellness of the student. See Appendix A for 21st Century School Nursing Practice Framework.

Applicability of Theory to Current Practice


Although the concept of the school nurse has existed since the early 1900’s, uniformity

among states and school districts regarding the school nurse role in schools and the laws

governing are lacking (Holmes & Sheetz, 2016). The credentialed school nurse benefits the

community in surveillance, chronic disease management, emergency preparedness, behavior

health assessment, ongoing health education, and case management (Holmes & Sheetz, 2016).

With an increase in the student population with chronic health care issues, which affects the

ability to learn, safety, and quality of life, the school nurse plays a vital role in disease

management by working in coordination with parents and healthcare providers (Holmes &

Sheetz, 2016). The 21st Century School Nursing Practice framework supports the

communication between school community and health care community. The school nurse is in

the best position to coordinate care through early identification, data collection, treatment,

management/follow-up, and continued communication with the healthcare provider. A growing

amount of evidence indicates the school nurse role can improve attendance by reducing illness

rates through preventative education, early recognition of infection, and chronic health disease

management (Holmes & Sheetz, 2016).

Application of Theory to DNP Project

There are immediate and long-term effects from oral health decay. A school nurse is able

to take the necessary steps to prevent and intervene on health care issues by: (1) implementing

oral health risk assessment screenings and referrals to local dentists, (2) collaborating with a

local dentist office to provide free school-based oral health exams, (3) working with school staff

to promote opportunities for oral health education, (4) educating parents on oral health and

healthy food choices, and (5) involving community providers and organizations in these efforts.

The nurse can play a pivotal role in to monitoring and recognizing the effects of interventions by


asking questions about classroom and home response, side effects to care, follow-up issues, and

family counseling. The process of care coordination improves the response to students with

unmet health care issues. The role of the school nurse supports the teachers, staff, parents, and

family providers concerns for the students by distinguishing what is medically necessary from

what is educationally necessary.

Care Coordination

School nurses play an essential role in the implementation of care coordination by

conducting a needs-assessment. The goal of the nurse is to improve student health and wellness

with the support of the school community. In this project, the aim is to intentionally organize

and share information on oral health in the kindergarten child by collaborating with

administration and nursing staff to increase the compliance rates of the kindergarten school

entrance oral health exam. The school nurse will work to delegate tasks to the UAP such as

nursing office visit input to be sure that all oral health data is retrievable in current data software.

Educating the UAP on the different symptoms of oral health problems will aid the UAP in being

a key contributor in this project. Reaching out to the parents will be essential in the success of

this program by telephone and letter templates to remind the family of the upcoming deadline to

complete the dental exam.

Leadership

In this project, the school nurse is in the position to advocate for this vulnerable

population. Section three of the oral health exam allows the parent the option to waive care.

This alerts the nurse to reach out to the parent and understand why the care was waived. In the

event that the student does not have dental insurance, the nurse can advocate for this student and

coordinate with the district’s insurance program to get the student the care needed. Health fairs


are excellent ways to help entire families seek oral health care. Advertising the health fairs in

print and electronic means targeting mobile home parks and other low-income areas will reach

various crowds. The nurse advocates for the vulnerable populations and they become change

agents (NASN, 2016b). Coordinating health promotion, disease prevention, and care

coordination for students bring the possibility to create and implement the oral health policy

districtwide (NASN, 2016b).

Quality Improvement

Quality improvement is the ongoing process to seek change. One example of this is to

ensure the success of the oral health policy by ongoing follow-up with school nurses, oral health

activities, and identifying trends in data. Training the other school nurses to implement specific

activities will enable to school nurse to become more involved in increasing oral health

awareness. The success of this program will rely on other school nurses to continue their

involvement to decrease absence and increase wellness. Recognizing an increase in dental

activities in the school setting provides an alternative to care outside of a dental office.

Community/Public Health

The levels of prevention will aid in the development of interventions. The oral health

exam is an excellent way to gather data of current oral health status. When this information is

not returned, the student is at risk for entering school with oral health problems. Literature

proves that tooth decay is the cause of 874,000 school days missed each year, costing school

districts $29 to $32 million annually in average daily attendance funding (California Department

of Education, 2017). Recognizing this information, the nurse is the leader to organize an

education program to inform parents on the importance of oral health. Health promotion

programs geared towards kindergarten students with an incentive such as a tooth pillow or a


tooth stuffed animal in exchange for the oral health exam will increase the likeliness of the return

of the form to the school site. A school-based exam opportunity will aid in the screening and

referral process. Follow-up activities with the school nurse will promote the most optimal

functioning in school (NASN, 2016b).

Standards of Practice

The school nurse maintains the high level of competency and professional knowledge and

skills (NASN, 2016b). Collaborating with peers and community healthcare professionals

enriches the school with the best practice and academic outcomes (NASN, 2016b). Reaching out

to families in need, collecting data with honesty and integrity, and understanding the

confidentiality within the California Department of Education and our healthcare system enables

the nurse to perform to the best of one’s ability.

Project Design

The following project will incorporate a quality improvement (QI) design to develop,

implement, and evaluate an oral health education toolkit (OHET). This project will address

school nurses’ self-awareness of oral health education, staff knowledge of California law AB

1433, and activities to improve oral health assessment compliance rates districtwide. Descriptive

analysis will be utilized post implementation of the oral health presentation to identify the school

nurses’ characteristics and measure of the outcome variables. The overall purpose of this project

is to increase the knowledge of the school nurses’ as well as to utilize school-based activities to

increase the oral health compliance rates among kindergarten students in this school district.

Setting

This project will take place at a school district located in Southern California. The

current population within this district is about 56,000 students. As of May 2018, there are 3,518


enrolled kindergarteners in this school district. This school district is one of the largest in

California. A school-based dental clinic will be implemented at one elementary site with

approximately 165 enrolled kindergarten students. This elementary school site encompasses

52.8% Hispanic or Latino and 26.0% white students, furthermore, 6,638 students received

special education services, 14.1% students are English learners, and 43.1% students receive free

or reduced lunch. There are currently 19 Title I schools within this school district who receive

supplemental funding based on the percentage of students who qualify for the National School

Lunch Program (NSLP).

Implementation

Description of Population

The health staff working within this school district during dates of data collection will be

invited to participate in the presentation of the OHET. Inclusion criteria for this project are as

follows: the age of 18, currently employed registered nurses, and currently employed at this

school district. There will be 11 nursing staff who will participate in the implementation of this

project. The average years of practice for this group of nurses is 22 years with 12 years

dedicated to school nursing. Demographic information can be found in Appendix B. Data will

be collected from July 2018 to September 2018. An unlicensed assistive personnel (UAP) who

works within one elementary school site is of the age 18, employed in this position for two years,

and has not had previous training on oral health education in the school setting.

Stakeholder Support

This school district supports and recognizes the value of this project to improve the

educational experience for the students. The school district superintendent authorized the

following DNP project. The administrative director provided ongoing collaboration to ensure


this project is in alliance with district goals and objectives. The 10 school nurses will participate

in a presentation on OHET at the district office during a monthly staff meeting.

In June 2017, an agreement between the dental office and the school district was obtained

to provide in-district, free preventative dental services at school sites. This agreement is in place

for health camps that take place in March of every year. With permission from the school

district, this agreement will be used for this project and the agreement for services can be found

in Appendix C. The partnership with this local dentist will provide a school-based dental

screening for the kindergarten students at one elementary school site at no cost. In collaboration,

the dental office and the DNP student will adapt the oral health assessment form for this school-

based dental clinic service.

A school administrator supports the implementation of a school-based dental clinic to

take place in August 2018. The school administrator will coordinate with the DNP student to set

a date and create a phone and electronic message to all kindergarten student’s parents for the oral

health assessment requirement. The UAP who works at this school site’s health office will be

directly involved in communicating with parents, collaborating with the school nurse to execute

a school-based oral health clinic, and the collecting and documenting of the completed oral

health assessment from parents.

Recruitment

Staff

The school nurse is the population of interest as they play a role in ensuring ongoing

surveillance of school district oral health compliance rates as well as guidance for school-based

dental activities to provide all students with oral health support. Mandatory participation is

required of the school nurses in this practice change initiative to ensure that all the RNs


understand the new protocol. The ten school nurses are considered a convenience sample as they

are required to attend this monthly staff meeting. No financial incentives will be offered.

Confidentiality will be assured in writing to all participants and no identifiable information will

be used. No consent from the nurses is needed because this is a new standard for managing oral

health screenings. The UAP who works within this project site’s health office is required to

participate in this practice change initiative to adopt the process of implementing the school-

based dental clinic, communication to parents, documentation of data, and inputting data in to

current tracking software.

Oral Health Documentation

The Oral Health Assessment form was adopted from the California Department of

Education (CDE) template. This form will be ordered through the district’s print shop. The oral

health assessment form includes three sections: (1) child’s information to be filled out by parent,

(2) oral health data collection to be filled out by licensed California dental professional, or (3)

waiver of oral health assessment requirement to be filled out by the parent or guardian to be

excused from this requirement. The oral health assessment form, an introduction letter to

California law AB 1433 provided by this school district and the consent form will be provided to

every parent or guardian with an enrolled kindergarten student at this elementary school site with

a goal to participate in the school-based dental clinic provided in partnership with a local dentist

(see Appendix D).

All services offered by Tran’s Dental are free and meet the requirements of California

law AB 1433 and the school district policy. Once the oral health assessment screening is

completed at the school site, the dentist will document the information on the oral health

assessment form and return the completed form to the project lead. The school nurse will review


the information, follow up with the parent/guardian, record the information electronically, and

file the form to the child’s health record for auditing purposes.

Tools and Instruments

Participants Knowledge

The tools utilized within the OHET will include a PowerPoint and a handout of local

dental home resources (see Appendix E). In order to measure the outcomes of this DNP project,

the following instruments will be used: posttest only design (See Appendix F). The

administration of the posttest will be in a handout form on the same day of the toolkit

presentation. The posttest blueprint describes the participants and the 23 oral health knowledge

questions in multiple-choice, true/false, yes/no, select all that apply, and open-ended question

and the three content experts completed the CVI with a score of 3.95 (Appendix G).

Oral Health Compliance Rate

A retrospective audit will be conducted to compare compliance rates of the kindergarten

students enrolled pre-implementation in the 2017-2018 school year—August 2017 and after

implementation in the 2018-2019 school year-- August 2018, pre and post implementation of the

school-based dental clinic (see Appendix H.).

Data Collection Procedures

Data will be collected two weeks before the presentation of the OHET using Survey

Monkey to collect the school nurse participants’ demographic data, to include the highest level

of education, years of nursing experience, years of school nursing experience, length of

employment in current school district, receipt of oral health training, and confidence in providing

oral health education to school staff, students and parents (See Appendix J).



Prior to the school-based dental clinic, the project lead will conduct an electronic report

of the missing oral health screening using the school site’s Q software to identify the non-

compliant enrolled kindergarten students at this school site for the 2017-2018 school year as of

August 2018. Following the school-based dental clinic, the oral health assessment non-

compliance rates, pre and post implementation will be described using descriptive statistics. The

results of the oral health screening will be entered in to the electronic record on Q software then

filed to the child’s health record to provide ongoing compliance data throughout the school year.

At the end of the school day on August 31, 2018, the project lead will conduct a final audit to

conclude the final compliance rate post-implementation of the school-based dental clinic (See

Appendix K). At the end of the day on May 31, the UAP will submit a final step outside of this

project in compliance with California Department of Education data reporting (see Appendix L).

Project Timeline

A detailed timeline for this project can be found in Appendix O. using the Gantt chart.

• Week 1- Parent consent form and letter on AB- 1433 requirement will be distributed to

kindergarten parents at the project site.

• Week 2- Finalize OHET presentation. Send reminders for school-based dental clinic

education to the participants.

• Week 3- Conduct 1st school-based dental clinic at project site.

• Week 4- Conduct school nurse pre-implementation survey via Survey Monkey. Analyze

the data.

• Week 5- Conduct 2nd school-based dental screening at project site.

• Week 6- Present OHET to school nurse participants. Administer same day posttest.

• Week 7- Conduct School Nurse follow up. Gather post-implementation data.


• Week 8- Evaluation of project effectiveness. Analyze data.

• Week 10- Disseminate results of the project to school board.

• Week 12- Disseminate project findings to DNP instructors and student colleagues.

Ethics of Human Subjects

The DNP project is deemed a QI project according to the DNP faculty project team

therefore, review by the institutional review board (IRB) is not necessary (Appendix M). This

DNP project focuses on implementing existing knowledge to improve practice rather than

developing new knowledge, therefore, the project lead is not required to submit a project

proposal to the IRB for the protection of human subjects. The Collaborative Institutional

Training Initiative (CITI) program modules on human subjects’ research were also completed to

educate the project lead in upholding the standards of practice related to protection, policies and

procedures.

This QI project upholds the American Nurses Association (ANA) position statement on

privacy and confidentiality. The ethical principles associated with this QI project include justice

and beneficence. This project will not require informed consent as this is a new standard of care

and QI. No financial incentives will be offered to participants. Data collected will be stored and

locked in a filing cabinet. All computerized data will be stored through a computer secured by a

password. All personal identifying data will not be used or coded in the analysis and evaluation

of data.

The risk for participation to the school nurse are as followed: (1) misinterpretation of

information provided, (2) experience of stress due to significance of presentation, (3) being

inconvenienced by the need to implement activities to increase oral health within their school

sites, and (4) burden of time for participation in educational presentation.


The benefits to the school nurse participants include acquiring the knowledge to improve

oral health within the school setting for every kindergarten student within this school district by

implementing activities to increase compliance rates of the oral health assessment.

Evaluation

Participants Knowledge

Data collected throughout this project will highlight the training and assessment of the

school nurses’ current knowledge in oral health and oral health problems, hygiene, and screening

requirements regarding California law AB-1433. The posttest will assess the degree of

understanding of the material presented. The CVI is a guide used to create the test and the

descriptors of the nurse population. Three content experts completed the CVI with a score of

3.95. The McNemar test for this tool and use of a 2x2 table will be used to show percent correct

for each question along with an average percent correct for the entire test with 95% confidence

interval. Cronbach’s alpha is not needed because the concept of internal consistency is not

useful in this instance. This empirical test will identify the improvement by item. The construct

validity is not needed as it relates to latent constructs, which is not present in this case.


The project lead will compare oral health assessment compliance rates before and after

the implementation of the school-based dental screening. The independent variable is time,

before implementation in August 2017 and after implementation in the 2018-2019 school year--

August 2018. The dependent variable is the compliance percentage of the oral health assessment

forms returned. A proportion test will be used to determine the mean scores.

Analysis

Participant Knowledge


An email link via SurveyMonkey as well as a paper version of the school nurse posttest

was offered immediately after post implementation of the OHET. Paper surveys were important

to deliver at this time to gather immediate responses from the school nurses. McMaster,

LeardMann, Speigle, and Dillman (2017) recognize that although online surveys have an

advantage including less time and cost associated with data collection and processing, previous

evidence supports a choice of survey response modes offered via paper as it leads to the most

responses. Eighty five percent (N=11) chose to fill out paper surveys immediately following the

OHET presentation and fifteen percent (N=2) chose to use the SurveyMonkey link within two

weeks of the OHET presentation.

The breakdown of responses of the registered, credentialed school nurses (N=13)

employed in this Southern California School District were as follows: Appendix N. One school

nurse retired during the pre-implementation of this project and was not included in the post-

implementation data collection process. Fifty four (N=7) percent of survey responders reported

“no” to having previous dental education in the school settings. Of the respondents, fifteen

percent (N=2) felt extremely confident, fifteen percent felt very confident (N=2), over fifty three

percent (N=7) reported feeling somewhat confident, and fifteen percent feeling not so confident

(N=2) in providing oral health education in the school settings. Fifty four percent (N=7) agreed

to take part in a future fluoride varnish with the director of the oral health program to take place

at the public health department.

The school nurse posttest highlighted oral health, oral hygiene, and the oral health

assessment requirement to meet the objectives of the OHET. Eighty five percent of the

participants answered the 20 multiple choice questions with a score greater than 75%. Sixty two

percent of the participants answered the “select all that apply” question correctly. The last two


narrative questions asked participants to identify the action of a scenario and how the role of the

school nurse can aid in the ongoing dental care within the school setting. Suggested local

resources were highlighted by the participants in the narrative questions answered. In this

posttest only design, the participants answered the 23 questions with a mean average of 85%.

The standard deviation is 0.18. With 95% confidence, the average questions answered correctly

in this entire posttest is between 75% and 95%, based on this sample data.


At the start of the 2017-2018 school year at this project site, 163 kindergarten students

(N=163) were enrolled and by August 31, 2017, 95% of kindergarten students were missing the

oral health screening requirement with a compliance rate of 5%. At the start of the 2018-2019

school year at this project site, 160 kindergarten students (N=160) were enrolled and one

hundred percent of kindergarten students were missing the oral health screening. Post-

implementation of the first school-based dental clinics held on August 1, 2018, 64% of students

were missing the oral health assessment requirement. After the second school-based dental

clinics was held on August 15, 2018, 36% of students were missing the oral health assessment

requirement. By August 31, 2018, 86% of students turned in a completed oral health assessment

form. The McNemar test was used to find the non-compliance rates pre and post

implementation, with the first sample with ninety five percent and sample size of 163, and the

second sample with thirty six percent and sample size of 160. The results of the McNemar test

was a difference of 59% with a significance of P<0.0001.

Discussion

Summary


The outcome results of this project were congruent with those found in literature.

Kindergarten children, ages five to six years old, are at high risk for dental caries (Beil, 2014;

Bell, 2012; Biordi; 2015; DeMattei, 2012; Guarnizo-Herreno, 2012; Jackson, 2011; Seirawan,

2011; Simmer-Beck, 2015). The school-based dental clinic intervention proved to be

successfully implemented during school hours at the elementary school site. The dental office

staff provided an oral health screening, averaging less than two minutes per student. DeMattei et

al. (2012) support the benefits of partnerships between schools and local dental organizations as

an additional resource to access oral care. Schools play a large role in the oral health care status

as they provide additional access to care (Biordi, 2015; DeMattei, 2012, Simmer-Beck, 2015).

Effective interprofessional teaching-learning strategies is necessary for school nurses to

take part in reducing oral health disparities in America (Dolce, 2014). The oral health education

toolkit (OHET) allows school nurses to recognize oral health, hygiene, and the requirements of

California law AB 1433. Findings from this project add to the growing body of evidence that

interprofessional education improves oral health in the school setting. A study found that school

nurse involvement in school-based dental centers improves access for many children without

special health care needs (DeMattei, Allen, & Goss, 2012). This evidence supports the Healthy

People 2020 goals to reduce oral health problems and increase access to preventative oral health

care through public health interventions.

Significance and Implications in Nursing

Good oral health is recognized as an essential component for a child’s healthy life. The

traditional dental workforce model is unable to reach every child needing oral care (Carpino et

al., 2017). In California, nearly two-thirds of children are affected by dental decay by the time

they reach third grade (CDA, 2017). School nurses are in the perfect position to work with


administrators and school staff to meet the needs of the family and student in a culturally

sensitive manner (Carpino et al., 2017). Dental decay is preventable; however, progressive

infection does not heal without treatment (CDA, 2017). Children need their teeth to eat, speak,

and smile with confidence (CDA, 2017). Educating school nurses on the oral health assessment

requirement increases awareness and maximizes student access to oral health activities within the

school setting. Moving forward with an improved system of care delivery, a school-based dental

clinic provides access to high quality, cost effective oral health care (Carpino et al., 2017). This

project lays the foundation for a comprehensive oral health toolkit that can be implemented into

school nurse practice of school health. This DNP project aided in raising awareness of the

importance of oral health, connect children with dental professionals, assist in enrolling children

in government benefit programs, and maximize access to care (CDA, 2017). Future projects

should address the impact of the collaboration of school nurses in oral health care as well as the

long-term sustainability of integrating school-based dental health initiatives. Policy development

is recommended to outline oral health procedures for this intervention. Addressing

parent/guardian knowledge would be effective to improve oral health behaviors, as the caregiver

is the exclusive domain during the first years of life (Mahat & Bowen, 2017). A qualitative

study would address self-care, diet, and oral health knowledge to identify the influences, norms,

beliefs, and barriers in achieving oral health behaviors in the school-aged child. Beyond the

requirements of the law, the school plays an essential role in ensuring children are healthy and

ready to learn (CDA, 2017). This project is significant to the nursing profession because it

provides insight on the leadership role of the nurse within a school district and the steps to

implement a school-based dental partnership to increase the oral health assessment compliance

rates by reaching students in an effort to screen, triage, and refer children whose families may be


experiencing barriers to dental care (CDA, 2017). The creation of an OHET will guide nurses in

outside school districts with the most current evidence-based practice in support of the

requirements of California law AB-1433.

Future Research Recommendations

This DNP project serves to provide school nurses a tool on the importance of oral health,

connecting children with dental professionals, assistance in enrolling children in government

benefit programs, and maximizing access to care in the school setting (CDA, 2017). Future

projects should address the impact of collaboration with school nurses on oral health care as well

as the long-term sustainability of integrating school-based dental health initiatives. Policy

development is recommended to outline oral health procedures for this intervention. The

director of the local oral health program offered to train the school nurses in this school district

on fluoride varnish application, where an additional study could examine school nurse

application rates of fluoride varnish in the school setting.

Limitations of the Project

There were several limitations to this project. The project implementation and data

collection was within a short time period. Quality improvement takes time, continuous

monitoring, evaluating, and the need to revise in an effort to maintain the program. The time

frame for implementation was limited because of the DNP program constraints as well as the

school-based dental clinics in the immediate start of the new 2018-2019 school year. Data

collection was tracked using paper then entered in to the school district’s electronic record (Q

software). This was a strength as it was easily accessible but a drawback because of possible

human error. Staff training may be needed throughout the school district on how to accurately

enter the data for each student and run a report to capture the data-type per each school site to


avoid inconsistent documentation methods. Another limitation of this project was the need to

translate materials sent home during the implementation phase of the school-based dental clinic.

Project lead bias must be considered as a limitation due to the oral health screening results and

the interpretation of this data. The follow-up and referral processes were challenging as some of

the students received a recommendation on the screening form that urgent/emergent care is

needed. This required the school nurses to follow up with parents, some on more than one

occasion. This caused limitations since the DNP project was to be completed in a specific length

of time. Although the referral process may not be feasible within this project, the school nurse

must work with the school site to ensure the parent has the resources to obtain dental care for the

student.

Dissemination

The OHET was presented to the school nurses at the district office at the monthly staff

meeting. This being the first staff meeting for the 2018-2019 school year in August 2018, the

nurses had much to share in addition to this project. This could be considered a limitation due to

minimal time and the priority over education and health promotion. All staff attended the OHET

presentation and the posttest scores showed increase knowledge. Asking the school nurses at

specific future dates if they have implemented the recommended oral health activities within

their school site assignment would provide real-time data as to whether there is an increase in

oral health compliance rates. An oral health workgroup was recommended in this group of

school nurses to continue monitoring the outcomes of this project.

Areas for Future Dissemination

A vital part of the DNP QI project is to disseminate the project outcomes to the

organization and within the academic community. There are various ways that this project’s


results will be shared among others. The project lead presented the project results to the OHET

school nurse participants and the school-based dental clinic school staff participants.

Additionally, the project lead presented the project outcomes and recommendations to the district

administrator and the school site administrator. The project lead will seek to disseminate project

outcomes by presenting the project at a districtwide administrator meeting held at the district

office at the request of the administrative director of student services. Further opportunities to

disseminate this project’s outcomes would be to present this project at school nurse conferences

and the submission of the project summary to appropriate journals for publication. The

dissemination of this quality improvement program outcomes to the organization and the

academic community fulfill the purpose of the DNP project.

Project Sustainability

After the completion of this project, it was necessary to recognize a sustainability plan to

continue the processes established during the project. The OHET will be distributed to new

school nurse hires to ensure continuation of the project processes. The OHET will be adapted

and presented at the annual districtwide unlicensed assistive personnel (UAP) training in August

2019. The school site administrators and district school nurses could collaborate and require the

UAP to review the OHET prior to August 2019 and keep an ongoing log of those who completed

the training. The school-based dental clinic schedule process will take place at the beginning of

each school year in collaboration with the UAP and school nurse. The school nurse may need to

seek additional dental partnerships as there are over 23 elementary school sites in this school

district. The school nurse oral health advisory group can serve as a resource for the school sites

to disseminate an additional partnership agreement process. The school nurse oral health

advisory will continue to monitor oral health assessment compliance rates using site specific


reports generated through Q software. This information will be shared at each monthly district

nurse meeting. One member of the school nurse oral health advisory group will attend the

monthly local public health oral health advisory board meeting and share meeting notes with the

district school nurses via email.

Conclusion

School nurses are in the perfect position to work with administrators and school staff to

meet the needs of the family and student in a culturally sensitive manner (Carpino et al., 2017).

Educating school nurses on the oral health assessment requirement increases awareness and

maximizes student access to oral health activities within the school setting. The results of this

project confirm that implementation of a school-based dental program can lead to an increase in

oral health assessment rates in compliance with California law AB-1433. Results of this project

provide support for the establishment of school-based programs within school nursing and in

outside school districts.


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Appendix A.

Figure 1A. Framework for 21st Century School Nursing Practice from NASN (2016).

Figure 1B. Practice Components of the 21st Century School Nursing Practice Principles from NASN (2016b).


Appendix B.

Pre-Implementation School Nurse Survey


Appendix C.

School-Based Dental Partnership Agreement


Appendix D.

Parent Notification of AB 1433


Figure 1.

Oral Health Assessment


Figure 2.

Parent Consent Form


Appendix E.

OHET Powerpoint


Figure 1.

OHET Resources


Figure 2.


Appendix F.

School Nurse Posttest


Appendix G.


Table 1.

CVI Expert Rating Score

Item

Expert 1

Expert 2

Expert 3

Mean

1 4 4 4 4.0 2 4 4 4 4.0 3 4 4 4 4.0 4 4 4 4 4.0 5 4 4 4 4.0 6 4 4 4 4.0 7 3 4 4 3.67 8 4 4 4 4.0 9 4 4 4 4.0 10 4 4 4 4.0 11 4 4 4 4.0 12 4 4 4 4.0 13 3 4 4 3.67 14 3 4 4 3.67 15 4 4 4 4.0 16 4 4 4 4.0 17 4 4 4 4.0 18 4 4 4 4.0 19 4 4 4 4.0 20 4 4 4 4.0 21 4 4 4 4.0 22 4 4 4 4.0 23 4 4 4 4.0

Results: The mean total of all of the means was 3.95 indicating that all of the questions were moderately/highly relevant.


Appendix H.

Pre-Implementation Audit Tool

Enrolled Kindergartners _____ Pre-Implementation of School-Based Dental Clinic _____ Number of kindergarten students who presented proof of dental exam/waiver _____ Number of kindergarten students who could not complete assessment due to financial burden _____ Number of kindergarten students who could not complete assessment due to lack of access to licensed/registered dental professional _____ Number of kindergarten students who could not complete assessment because their parent/guardian did not consent to receiving assessment _____ Number of kindergarten students who were assessed and found to have untreated tooth decay _____ Number of kindergarten students who did not return the assessment or waiver_____


Appendix I.

Pre-Implementation School Nurse Survey Results

Participant

Highest Level of Education

Years of Nursing

Experience

Years of School Nurse

Experience

Length of Employment in Current

School District

Previous Oral

Health Education in School Setting

Confidence in proving Oral

Health Education to

School, Students, Parents

1 Master 36 30 30 No Very Confident

2 Master 30 6 6 Yes Very Confident

3 Master 20 10 10 Yes Very Confident


5 Baccalaureate 6 3 3 Yes Somewhat Confident


7 Master 39 19 14 Yes Somewhat Confident

8 Master 34 15 15 Yes Somewhat Confident

9 Master 21 7 7 No Somewhat Confident

10 Baccalaureate 6 4 2 No Very Confident


Appendix J.

Oral Health Project Audit Form

School NameAug-17 Aug-18

Enrolled KindergartnersPre-Implementation of School-Based Dental ClinicNumber of kindergarten students who presented proof of dental exam/waiver Number of kindergarten students who could not complete assessment due to financial bur Number of kindergarten students who could not complete assessment due to lack of acces Number of kindergarten students who could not complete assessment because their paren Number of kindergarten students who were assessed and found to have untreated tooth dNumber of kindergarten students who did not return the assessment or waiverInformed Consent for School-Based Dental ClinicNumber of forms distributedNumber of forms returned to participate in school-based dental clinicSchool-Based Dental Clinic Number of kindergarten students screened at school-based dental clinicNumber of kindergarten students who were assessed and no obvious problems were foun Number of kindergarten students who were assessed and early dental care was recommenNumber of kindergarten students who were assessed and urgent was neededPost-Implementation of School-Based Dental Clinic Number of kindergarten students who presented proof of dental exam/waiver Number of kindergarten students who were assessed and found to have untreated tooth d


Appendix K.

SCHOOL ORAL HEALTH ASSESSMENT DATA FORM

Send to Students Services, Bld. E, Attn: M. Mitchell by the end of May

School Name: ____________________________________ Date: _________ Person completing form: __________________________________________

1. The total number of students in kindergarten: ________

2. The total number of students in kindergarten who presented proof of a dental exam: ________

3. The total number of students in kindergarten who could not complete an assessment due to financial burden: ________

4. The total number of students in kindergarten who could not complete an assessment due to lack of access to a licensed dentist or other licensed or registered dental health professional: ________

5. The total number of students in kindergarten who could not complete an assessment because their parent or legal guardian did not consent to their child receiving the assessment: ________

6. The total number of students in kindergarten who were assessed and found to have untreated tooth decay: ________

7. The total number of students in kindergarten who did not return either the assessment form or the waiver request: ________


Appendix L.

Project Timeline

2017 2018 Action

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Apr

il

May

June

July

Aug

ust

Sept

embe

r

Oct

ober

DNP 761 Literature Search Project Mentor Approval Advisor Approval Project Proposal Approval Network with Potential Project Site DNP 763 Site Approval Participant Recruitment Craft Toolkit DNP 767 Present OHET School Based Dental Clinic Gather Implementation Data Analyze Findings Evaluate Project Effectiveness Complete Project Report Final Presentation


Appendix M.

Project Classification Decision


Appendix N.

Post-Implementation School Nurse Survey Results Participant

Highest Level of Education

Years of Nursing

Experience

Years of School Nurse Experience

Length of Employment in Current

School District

Previous Oral Health Education in

School Setting

Confidence in proving Oral

Health Education to

School, Students, Parents

Interest in fluoride varnish training

with Public Health

Department

1 Master 35 31 31 No Somewhat confident

No

2 Master 30 6 6 Yes Extremely confident

No

3 DNP 20 10 10 Yes Extremely confident

Yes

4 Master 15 11 11 Yes Somewhat confident

No

5 Baccalaureate

7 4 4 Yes Very confident

No

6 Master 40 20 15 Yes Somewhat confident

Yes


No


Yes

9

Baccalaureate

7 4 2 No Very confident

Yes

10 Master 7 7 7 No Somewhat Confident

Yes

11 Baccalaureate

25 <1 year <6 months

No Somewhat confident

No

12 Master 40 23 22 Yes Not so confident

No

13 Baccalaureate

5 2 1.5 No Not so confident

Yes

What is the most common chronic childhood disease

among US children?

Response Percent Response Count

Answer Options Response Percent Response Count Asthma 8% 1 Tooth Decay 92% 12 Obesity Diabetes Mellitus Answered Question 13


Answered Correctly 92%

Dental caries is: Response Percent Answer Options Response Percent Response Count A type of gum disease

A bacterial infection of the tooth structure

62% 8

The same as cavities

38% 5

A viral infection Answered Question 13 Answered Correctly 62%

How can bacteria that causes tooth decay transmit from parent to child?

Response Percent

Answer Options Response Percent Response Count Through germs caused by illness

7.5% 1

Through contact such as sharing spoons or forks

85% 11

Through the air Through cuts and open sores

7.5% 1

Answered Question 13 Answered Correctly 85%

Which of the following is a potential outcome of oral health problems in young children?

Response Percent

Answer Options Response Percent Response Count Impaired speech development

Inability to concentrate

Failure to thrive All of the above 100% 13 Answered Question 13 Answered Correctly 100%


What does tooth decay in the primary teeth often lead to?

Response Percent

Answer Options Response Percent Response Count Tooth decay in the permanent teeth

92% 12

Difficulty swallowing

Fluorosis Not a usual long-term problem because primary teeth fall out

8% 1


What typically happens when tooth decay is not treated?

Response Percent

Answer Options Response Percent Response Count The tooth will fall out

7.5% 1

Decay will proceed through the enamel and into the dentin

54% 7

Depends on the extent of decay

31% 4

Decay will enter the bloodstream

7.5% 1


When should the first oral health examination performed by a dentist take place?

Response Percent

Answer Options Response Percent Response Count When the child is developmentally ready

7.5% 1

No later than age 1 77% 10 No later than age 3 7.5% 1 When the child can sit without support

7.5% 1



How often should a child receive an oral examination performed by a dentist?

Response Percent

Answer Options Response Percent Response Count Every 6 months 92% 12 Every year 8% 1 Every 2 years It depends on the child’s age


What is the purpose of an oral health screening?

Response Percent

Answer Options Response Percent Response Count It helps the health professional determine whether signs of oral disease are present

15% 2

It helps infant and young children become comfortable with having their mouths examined

It helps the health professional become familiar with different manifestations of oral disease

All of the above 85% 11 Answered Question 13 Answered Correctly 85%

How long does an oral health screening take to complete?

Response Percent

Answer Options Response Percent Response Count Approximately 15 minutes

8% 1

Approximately 2 to 3 minutes

92% 12

Approximately 1 hour


Approximately several hours


How should an infant or young child’s healthy lips and tongue appear?

Response Percent

Answer Options Response Percent Response Count Soft, pink, & moist 100% 13 Dry & warm Smooth & free of bumps

Appearance depends on skin color


How should a child’s primary teeth appear?

Response Percent

Answer Options Response Percent Response Count White & opaque 85% 11 Straight 7.5% 1 Cream colored & translucent

Smooth & bright 7.5% 1 Answered Question 13 Answered Correctly 85%

When should parents begin cleaning their infant’s teeth?

Response Percent

Answer Options Response Percent Response Count At birth 8% 1 When an infant or child is able to sit still & cooperate

When an infant or child is developmentally ready

As soon as the first tooth erupts

92% 12

Answered Question 13



When should a child begin using fluoride toothpaste?

Response Percent

Answer Options Response Percent Response Count As soon as the first tooth erupts

At around age 2 years

92% 12

At around age 5 years

8% 1

Children should not use fluorinated toothpaste


When is the oral health assessment requirement due in California public schools?

Response Percent

Answer Options Response Percent Response Count March 31 of the first year of public school

7.5% 1

May 31 of the first year of public school

69% 9

March 15 of the first year of public school

May 15 of the first year of public school

23% 3


Can a dental provider outside of California perform the oral health assessment requirement?

Response Percent

Answer Options Response Percent Response Count Yes 15% 2 No 85% 11 Answered Question 13



An oral health assessment meets the requirement of AB 1433 if the form was completed prior to entry of kindergarten, as early as:

Response Percent

Answer Options Response Percent Response Count 12 weeks 12 months 100% 13 24 weeks 24 months Answered Question 13 Answered Correctly 100%

If a student enters public school in 1st grade, the oral health requirement does not apply:

Response Percent

Answer Options Response Percent Response Count True 23% 3 False 77% 10 Answered Question 13 Answered Correctly 77%

The parent may indicate on the oral health assessment form to waive the oral health assessment requirement:

Response Percent

Answer Options Response Percent Response Count True 92% 12 False 8% 1 Answered Question 13 Answered Correctly 92%

Verbal communication of obtaining an oral health assessment

Response Percent


for a child by the parent or legal guardian is acceptable documentation. Answer Options Response Percent Response Count True 8% 1 False 92% 12 Answered Question 13 Answered Correctly 92%

Who can perform an oral health assessment to meet California law AB 1433? (Select all that apply)

Response Percent

Answer Options Response Percent Response Count Registered Nurse (RN)

7.5% 1

Licensed Dentist 85% 11 Licensed Vocational Nurse (LVN)

School Health Clerk

Registered Dental Hygienist (RDH) under Dentist Supervision

92% 12

Pediatric Medical Doctor

15% 2

Registered Dental Assistant under Dentist Supervision

62% 8


A school nurse receives notice that the oral health assessment form was returned although the parent requested to be excused from this requirement and the box is checked “I cannot afford a dental check-up for my child.”

Participant

What next action should the nurse take? How can the nurse aid in the ongoing management of a student’s oral health?

1 Refer to medi-cal/denti-cal Distribute toothbrush 2 Talk to parent & look at resources

available Screening program at school

3 Refer to community resources Prevent missed school days & improve oral health


4 Contact parent, refer to denti-cal, connect to dental home

Follow-up with oral health assessments when needed, educate families & students, connect to dental home

5 Contact parent & offer to refer to ProjectKind

Follow-up every 6 months to remind parent that students needs care, provide fliers for dental fairs

6 Retired

7 Consult health department Provide outside resources & education materials

8 Oral health assessment of child & call to parent

More time & staffing

9 Find resources for parent Find dental home 10 Resources for parents Refer to dental home 11 Refer to free/reduced cost services Cooperate with a dental home for the

child 12 Refer to community dental service Educate students & parents 13 Provide resources including denti-cal Education 14 Provide resources, refer to

ProjectKind Follow up with parent

Table 1. Participant’s Final Score

Participant

Score

1 83% 2 91% 3 74% 4 96% 5 74% 6 Retired at Project Implementation 7 87% 8 97% 9 92% 10 87% 11 70% 12 96% 13 70% 14 100% Average Mean

86%

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