Improving Access to Care Through School Oral Health Assessments

ABSTRACT

Background

States across the country have recognized and prioritized the value of oral health for children by legislating measures such as the California Oral Health Assessment Mandate, which requires children to receive a dental screening when entering public school. Sometimes known as the kindergarten oral health assessment (KOHA), these screenings utilize a public health approach to link children at highest risk of dental disease to dental homes. Though challenges exist in implementing the objectives of these dental screening laws, myriad strategies have risen to meet these challenges. This article describes the goals of mandated school oral health assessments and examines some of the barriers to and strategies for increasing participation in and effectiveness of these assessments.

Types of Studies Reviewed

A summary of the literature related to the KOHA is presented, along with barriers and innovative approaches to its implementation.

Conclusions

The data collected through school districts’ KOHA result in collaborative approaches to emphasize and meet a community’s need for early dental care in the context of overall health.

Practical Implications

The KOHA plays a valuable role in combating the high prevalence of caries in the pediatric population. The barriers to oral health equity and access to care highlighted by KOHA screening data underscores the need for engaging the dental workforce in pursuit of contemporary approaches to ensure children with high caries risk are connected to oral healthcare providers in their communities.

KEYWORDS:

• Dental screening
• kindergarten oral health assessment
• public health
• oral health policy

Over the past decade, a stubbornly high prevalence of dental disease continues to be a significant cumulative and progressive public health issue among children.¹ More recently, between 2019 to 2020, the percentage of children aged 1–4 years who had a dental examination in the previous 12 months decreased by 7.3%, according to the National Health Interview Survey conducted by National Center for Health Statistics.² Dental and craniofacial diseases that are not recognized in a timely manner can lead to a delay in care, thereby leading to pain, discomfort and irreversible damage.¹ The integration of early education and preventive oral health services through dental screening programs such as the kindergarten oral health assessment (KOHA) can greatly improve children’s access to care to a dental home by assessing needs at a local level.¹

In the last 20 years, research has recognized social determinants of health (SDOH) as predictors of oral disease and contributors to oral health disparities in children.¹ Oral health assessments alleviate disparities by addressing the different branches of SDOH in the following ways³:

• Economic stability – By providing an economical resource toward treatment.

• Neighborhood and physical environment – By screening children within schools to reduce the need for arranging transportation.

• Education and food – By providing informative oral hygiene instructions and nutritional counseling while screening.

• Community and social context – By addressing the needs of oral care in underserved, disadvantaged and/or marginalized communities.

• Health care system – By providing clinically and culturally competent care and availability through mandatory screenings.

A 2006 study of the oral health status of San Francisco public school kindergartners focused on the prevalence of dental caries and oral health disparities in San Francisco by conducting annual screenings.⁴ At these screenings, after a brief visual inspection of a child’s oral cavity in their school setting, the child’s oral health status and treatment needs were presented to their caregivers, who were encouraged to follow-up with appropriate treatment at a dental office. The study posited that other cities and counties could benefit by establishing similar models of public health collaborations aimed at surveilling children’s dental health.⁴ In the same year, Assembly Bill 1433, sponsored by the California Dental Association (CDA) and known as the California Oral Health Assessment Mandate, was signed into legislation with the purpose of addressing the public health problem of high dental disease rates in young children by spurring parents to seek a dental home for their children.⁵ For over 15 years, California’s KOHA policies have supported public health efforts to improve children’s oral health status by raising awareness of the importance of dental care through publicizing and requiring compliance.^6,7 In 2017, Senate Bill 379 was passed, allowing California public schools to provide on-site screenings to fulfill KOHA via passive consent unless a Waiver of Oral Health Assessment Requirement is completed; the updated KOHA form, waiver and opt-out letter that explicitly include this change became effective July 2022.⁸

School oral health assessments serve as a bridge between young children and dental homes.⁶ The model, mission and objectives of public health legislation such as the KOHA address several different arenas: reducing caries rate in school-aged children, establishing dental homes, serving vulnerable and underserved populations and introducing preventive care for children at a young age.⁴ Through examining some of the impactful barriers to achieving the goals of the KOHA and surveying various responses to these challenges, future possibilities can be explored for greater effectiveness of mandated school oral health assessments.

Barriers to Achieving School Oral Health Assessment Objectives

The typical steps to complete the kindergarten oral health assessment (KOHA) begin with parents receiving a letter about the requirement and assessment form during their child’s initial registration at school.⁷ Families are then expected to seek out a dentist to complete the assessment and return the form to the school by the end of the first year. Some families choose to submit a waiver of the Oral Health Assessment requirement, excusing their child or children from the dental checkup due to reasons such as inability to find a dental office accepting the child’s dental insurance, inability to afford an assessment, inability to find time to see a dentist, difficulty due to location of a dental office or the belief their child would not benefit from an assessment.⁸ Workforce shortages, economic imbalances and public health crises can compound these barriers to access to care.⁶

Provider Shortages

Kindergarten oral health assessments help to increase access to care by identifying children who do not have an established dental home and connecting their families to dental providers, thereby encouraging regular dental visits and establishing a dental home for preventive and comprehensive needs.⁷ Therefore, follow-up care is imperative to determine the effectiveness of KOHA.⁹ Nonetheless, a significant barrier to access to care is the shortage of oral health providers.⁶ Upon reviewing June 2022 data from the U.S. Health Resources and Services Administration (HRSA) 7,018 geographic areas are designated as a Dental Health Professional Shortage Area (DHPSA), accounting for 68 million people in the U.S.¹⁰ Of these designated DHPSAs in the U.S., 509 are found in California, accounting for over 2 million people with only 31.8% of need met. Compounding existing oral health disparities is HRSA’s estimation that over 11,000 additional providers would be needed to remove shortage designations of current DHPSAs.¹⁰ Additionally, HRSA estimates that by 2025, California will have an overall shortage of 1,234 dentists.¹¹ As millions of Americans live in DHSPAs, many remain underserved and this number will most likely increase as the population grows and inadequate workforce continues.

Rural communities are also disproportionately impacted, as the geographic distribution of dentists in these areas remains inadequate to meet the needs of the population.¹² Furthermore, over 60% of the nation’s DHPSA has been found to be in rural America.¹³ Due to geographic isolation, many children in rural communities may suffer from unmet oral health needs and have a higher incidence of dental disease due to underutilization of preventive dental services and difficulty finding dental providers, especially those accepting government-funded insurances.¹² Though implementing KOHA has helped to bridge the gap to access to care and increase oral health literacy and education, one way to address childhood dental disease is to grow the number and geographic distribution of dentists.¹⁴ Also, though the number of primary oral health care providers grows with the addition of new dental schools, a significant unmet need still exists for vulnerable and underserved populations. Thus, expanding the dental workforce is instrumental to overcoming health disparities and works toward the goal of KOHA in early identification of and prevention of dental disease progression and establishing dental homes.⁶

Economic Imbalances

Because dental disease was found to be a common reason for school absences and difficulty in learning, the kindergarten oral health assessment was mandated to ensure all children are healthy and ready for school as well as to provide support for families who do not have a dentist.⁷ To help address dental disease in children, government-funded insurances, such as Medicaid and the Children’s Health Insurance Program (CHIP), included coverage of dental services for beneficiaries under age 21 leading to a steady increase in the utilization of oral health services.¹⁵ As of 2019, 58.7% of children in the U.S. and 66.8% of children in California were enrolled in a government-funded insurance.¹⁶ Despite these efforts, a low percentage of dentists accepting Medicaid or CHIP remains, creating difficulty for families to find dental homes.¹⁷ Nationally, only 43% of providers accept Medicaid and a low volume of pediatric patients.¹⁸ Efforts to relieve financial burden fall short due to the insufficient number of dentists participating in Medicaid, with low reimbursement rates being one of the major deterrents.¹⁸

In a 2016 analysis of Medicaid reimbursement rates by the Health Policy Institute, the national average Medicaid fee-for-service reimbursement relative to fees charged by dentists for child dental services was 49.4% compared to 80.5% for private dental insurance reimbursement.¹⁷ According to the American Dental Education Association (ADEA) Survey of U.S. Dental School Seniors, 94% of 2021 dental graduates reported outstanding education debt from dental school loans reaching an average of over $300,000.¹⁹ The combination of low reimbursement rates though Medicaid and the immense debt accrued by pursuing a dental education can be a major disincentive for dental school graduates to participate in government-funded insurances or work in underserved areas, which inadvertently diverts essential care away from underserved areas.¹⁸

Oral health care providers and patients carry the strain of a cumbersome Medicaid system.¹⁸ Although the KOHA seeks to link children, especially underserved and vulnerable children, to dental homes, these efforts are often hampered by the challenges to obtaining dental care faced by Medicaid-insured patients, such as difficulty in locating a provider, struggles in scheduling appointments, excessive wait times, demeaning and negative interactions with dental staff and providers and perceived discrimination and stereotyping due to Medicaid coverage.²⁰ These potential negative effects to provider-patient relationships often lead to decreased patient trust and satisfaction and eventually to reduced utilization of dental services, counteracting KOHA objectives.²⁰

Public Health Crises

The COVID-19 pandemic shocked the world, including the realm of dentistry, further compounding the challenges mentioned previously. Before the pandemic, children living in poverty and from low-income households were already at a higher risk for dental disease. Due to the pandemic, dental disease in this population worsened.^21,22 The closure of schools and dental clinics significantly affected the number of KOHA, because dental providers were not readily available to provide these services as procedures were limited to only emergency dental treatment and triaging.²² Results taken from CDA show that in the 2019–2020 and 2020–2021 schools years in Los Angeles County, the numbers of children assessed were 14,503 and 8,434, respectively.²³ These numbers are significantly lower than in the 2017–2018 school year — 24118 children – and the 2018–2019 school year — 24901 children. The effect of the COVID-19 pandemic on children’s oral health was also evident when comparing oral health status from 2018, 2019 and 2020. Analysis of results from the National Survey of Children’s Health found that children in 2020 were “16% less likely to have excellent dental health as perceived by parents and 75% more likely to have poor dental health than in 2019.”²² The perceived reduced oral health can be attributed to dental practice closures, because during the first wave of the pandemic, 60% of dental practices were closed and only seeing emergency patients while 8% were closed to all patients.²⁴ In addition, elective dental procedures and preventive dental services were delayed, exacerbating the dental disease burden and underutilization of preventive dental services.²² The pandemic further revealed the underlying health disparities that exist, as well as the potential negative implications on the oral health of children through the underutilization and/or avoidance of KOHA due to public health concerns.²¹

Innovative Approaches

Achieving the goals of the KOHA assessment program as stated previously involves a multi-pronged approach to generate community- and systems-level changes.⁶ The following examples serve to highlight various strategies that have been employed to mitigate the aforementioned challenges in attaining KOHA objectives.

Engaging the Dental Workforce

To achieve the goals of the kindergarten oral health assessment of improving access to care, the distribution of dentists in HPSAs must increase.¹⁴ In an attempt to recruit and retain dental providers in HPSAs, scholarships were made available to encourage and increase diversity at the dental school level. These scholarships targeted students from disadvantaged backgrounds who agreed to pursue postgraduation practice in primary care dentistry, particularly in medically/dentally underserved communities. Numerous scholarships and loan repayment programs were created to aid in the financial burden that dentists face after graduating dental school and to provide support to care for the underserved communities. Examples include the HRSA National Health Service Corps (NHSC) Loan Repayment Program and the Indian Health Services Loan Repayment Program, which both require a two-year minimum commitment with the purpose of providing primary health services to underserved populations in designated HPSAs or within IHS facilities.²⁵ These efforts aim to expand the dental workforce and address the goal of KOHA linking children with a higher risk of dental disease to dental homes. Utilization of allied dental professionals, such as registered dental hygienists in alternative practice (RDHAP), is a key component in increasing the dental workforce in DHPSAs.²⁶ In California, RDHAPs are trained and certified to provide preventive services independently but must have a dentist of record on file with the Dental Hygiene Committee of California to gain licensure.²⁶ This is important as dentists or community clinics in DHPSAs can work with allied dental professionals to extend care to communities that are in need of dental professionals. RDHAPs can provide oral assessments, such as the KOHA, without the direct supervision of a licensed dentist and are able to “close the loop” by referring to dental homes if they see signs of caries or infection.²⁷ Reviewing the literature has provided insight on the effectiveness of increasing encounters with alternative providers showing statistical significance in yielding a decrease in decay, an increase in restorations and a decrease in the level of treatment urgency in children in school-based oral health programs.²⁸ Thus, engaging the workforce requires the whole dental team to increase the reach to medically and dentally underserved communities and advance the objectives of mandated school oral health assessments.

Addressing Economic Imbalances

Additionally, increasing diversity within the dental profession may be a key factor in increasing access to care through such programs as mandatory oral health assessments. A study by Logan et al. shows that minority dentists were more likely to participate in Medicaid and underrepresented minority (URM) dental graduates were more likely to provide care to their own communities.²⁹ The study found that greatest gap lies in the number of disadvantaged and URM students compared to the entire dental student population. In an effort to promote diversity among the health professions, the HRSA Scholarships for Disadvantaged Students (SDS) grants were created to fund schools to improve diversity in the future dental workforce.³⁰ This scholarship is awarded to students from disadvantaged backgrounds who demonstrate financial need and are enrolled full time in a health profession program. Providing support to students from disadvantaged backgrounds can help increase representation in the profession as well as provide for underserved communities. In addition, recruiting dentists who are participating in Medicaid has proven to be difficult due to the financial burdens stated previously; however, to support dental providers accepting Medicaid to expand their practice to underserved populations, the loan repayment program CalHealthCares was established in an effort to provide financial relief.³¹ Eligible dentists can apply for CalHealthCares if their patient caseload is at minimum 30% Medicaid beneficiaries in exchange for loan repayment or practice support grant. Over the past three years of the establishment of CalHealthCares, 120 California dentists have been awarded funding and creating an impact in the underserved populations. By engaging the workforce through tackling economic imbalances to increasing the number of dental homes for young children across the nation, the overarching objective of the KOHA can be more readily met.

Responding to Public Health Crises

A public health crisis such as the COVID-19 pandemic can radically and rapidly transform oral health policies and guidelines.²¹ The pandemic significantly disturbed the education sector across the globe, in some cases shuttering entire countries’ school systems.³² In early March 2020, many states, including California, responded with full or partial closure of schools due to the public health concerns. Though efforts were made to reduce disruption in education, school closures inevitably led to vast reconstruction of educational models and put on hiatus many programs such as the kindergarten oral health assessment.³² By no means an exhaustive list, the following describes some alternative methods that were deployed on caries risk and experience faced by the young pediatric population.

Interprofessional Collaborative Practice

Recognizing the essential role of school nurses in combating caries incidence and risk in the wake of initial school closures, the National Association of School Nurses released a call to action in August 2020 to help combat anticipated increases in the percentage of children with dental-related pain or serious oral infections.³³ Though many schools began to slowly reopen as early as fall 2020, oral health assessments were often postponed and children experiencing oral disease went undetected. School nurses were encouraged to identify and triage children in need of dental care following protocols that reduced the risk of COVID-19 transmission. Equipped with resources for conducting dental screenings through verbal and visual assessments, school nurses came alongside the dentists and allied dental professionals to ensure access to oral health care to the most high-risk and vulnerable populations despite reduced dental provider capacity and continued parental fear of virus transmission through dental care.³³

Alternative Screening Modalities

Before the most recent global pandemic, to increase access to dental screenings for the KOHA and ensure children receive timely dental care, organizations such as dental schools often partnered with local school districts to bring screenings to the classroom. For instance, the long-standing partnership between the Western University of Health College of Dental Medicine (WesternU CDM) and El Monte City School District (EMCSD) is the result of close collaboration toward the common goal of making oral health a priority in the community. By bringing dental students, under the close supervision of RDHAPs and general and pediatric dentists, to the classroom, WesternU CDM has screened over 2,000 EMCSD kindergarten students in the last five years alone (Table 1).

Table 1. EMCSD KOHA Screenings Conducted by WesternU CDM.

Academic year	Number of students screened
Fall 2017-Spring 2018	825
Fall 2018-Spring 2019	641
Fall 2019-Spring 2020*	555
Fall 2020-Spring 2021*	0
Fall 2021-Spring 2022*	308

* Denote the years impacted by the COVID-19 pandemic.

Many families rely on such in-classroom screenings to complete the mandated oral health assessment. Due to closures of schools and dental clinics during the pandemic, however, there was a significant decrease in the number of oral health assessments that were provided for children in California.²³ Table 1 details the numbers of kindergarten students screened per academic year. Asterisks denote the academic years impacted by the COVID-19 pandemic. During this time, screenings were abruptly halted due to EMCSD school closures in March 2020, remained “on hold” through the entire 2020–2021 academic year and began climbing slowly during the 2021–2022 academic year.

Between fall 2020 and spring 2021, school districts and other organizations hosted drive-thru screenings to safely provide oral health assessments and preventive services such as fluoride varnish application. These screenings were open to the community and gave families an opportunity to complete the mandatory KOHA for their children and receive hygiene kits and oral hygiene instructions as well as fluoride varnish application. Figure 1 shows WesternU CDM students conducting oral health assessments at a drive-thru screening in Pomona, California, in March 2021.

Figure 1. Dental students from Western University of Health Sciences College of Dental Medicine conduct oral health ‘drive-thru’ screenings in Pomona, California.

State Medicaid Efforts

Across the country, statewide efforts were rolled out to meet the challenge of reduced access to oral health care services, and California’s Medicaid dental program Medi-Cal Dental, or Smile, California, tackled the documented decline of KOHAs by activating a statewide, multi-tiered outreach program aimed at encouraging caregivers to find a dental home for their children prior to entering school in fall 2021.^23,34 One example of these statewide efforts is the “Back-Tooth-School” initiative, which consisted of radio and television media partnerships across the state. Through “Back-Tooth-School,” Smile, California leveraged community relations and partnerships to engender support at the local level, providing event support and material distribution for social media, including a new Oral Health and School Readiness website page, videos, infographics and a more accessible “Find a Dentist” tool.³⁴

Wider Telehealth Use

Prior to the pandemic, telehealth-connected teams consisting of dentists and allied oral health professionals such as RDHAPs already existed to connect children and their families to virtual dental homes; these “dental care systems without walls” expanded access to care by reaching underserved populations to improve the population’s oral health care.³⁵ At the height of the pandemic, as distance learning became the norm for many school districts, oral health care providers coordinated with elementary schools to hold virtual sessions focusing on oral hygiene instruction, nutritional counseling and overall dental health.³² Families were encouraged to continue to seek dental care in office or via telehealth modalities, especially for urgent and emergency treatment. California – which led the nation in adopting legislation to determine and bolster the role of telehealth as early as 1996 — sought to address access to care issues by making teledentistry a reimbursable service and enabling payment to Medi-Cal dental providers who delivered select dental procedures via teledentistry during the pandemic.³⁶

Future Opportunities

KOHA on its own will not solve the challenges arising from structural and social imbalances or public health crises. KOHAs can, however, inform a collaborative approach by providing data to expose areas of need within a school district, bringing to stakeholders greater understanding of children’s health and underlining the need for early dental care in the context of overall health.⁵ Only a few of the various means by which the KOHA can be successfully implemented in the face of noted barriers were described here, and there is still much room for development to ensure timely, equitable access to dental care for young school children.

Partnerships between school districts and institutions such as dental schools and community and nonprofit dental clinics can lead to more accessible in-school and telehealth dental screenings.³⁵ For example, WesternU CDM followed an action plan similar to that shown in Figure 2 to identify, formalize and maintain relationships with several local school districts, such as the El Monte City School District (EMCSD) and Pomona Unified School District (PUSD). Partnering with EMCSD and PUSD enables WesternU CDM to provide services such as kindergarten oral health screenings at each school site, as well as offer comprehensive dental treatment through dental clinics at family centers, school-linked oral health centers and school-based oral health centers (SBOHCs). SBOHCs may prove especially advantageous in advancing the goals of mandated oral health screenings because access to dental care is improved simply by enabling children to receive the KOHA and any necessary preventive or restorative treatment in the same location.³⁷ SBOHCs also enable a more robust use of telehealth by expanding the reach of dental providers to underserved communities and populations through the on-campus presence of allied dental professionals such as RDHAPs.³⁵

Figure 2. Action Plan.

School officials can examine KOHA data available on the online database System for California Oral Health Reporting to better understand factors leading to chronic school absenteeism, which affects student achievement.^5,7 Utilizing KOHA program data within a specific population, Los Angeles County’s Smile Survey 2020 pinpoints the areas of continued need for more effective dental disease prevention in combination with connecting high-risk children with dental homes.³⁸ Achieving the goals of KOHAs requires improved access to and coordination of oral and overall care, as well as the development and growth of the workforce to provide this care. To further bridge the gap to access to care, creating accessible dental homes is necessary and may be achieved through expanding the dental workforce to increase dentists in DHPSAs and utilizing allied dental providers such as RDHAPs.²⁷ To support providers’ roles in ensuring accessibility and availability of oral health care, policymakers must address this call to action through tangible incentivization efforts such as increased reimbursement rates and loan repayment and loan forgiveness programs. In addition, the COVID-19 pandemic has presented a unique opportunity for researchers to study the effects of public health emergencies on areas such as the perception of patients and their caregivers toward the KOHA or changes in caries risk resulting from an interruption in mandated oral health screenings.

Ensuring families can complete the KOHA through engaging the workforce, reducing economic imbalances and surmounting the challenges of public health crises can help achieve the KOHA goals of improving dental health, school readiness and population health by enabling early oral disease detection and the linkage of the school-aged population to dental homes.⁷ Exploring some of the barriers hindering the full benefit of mandated school oral health assessments highlights the advantages of a multi-faceted, intra- and interprofessional approach in providing for those at most risk for poor oral health, while underscoring KOHA’s value in guiding future policy to attain improved oral health status and equity across communities.

Acknowledgments

This publication is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $303,307 with zero financed with nongovernmental sources. The contents are those of the authors and do not necessarily represent the official views of nor an endorsement by HRSA, HHS or the U.S. government. For more information, visit HRSA.gov.

The authors thank WesternU CDM’s Dean Elizabeth Andrews, DDS, MS, and Dean Emeritus Steven Friedrichsen, DDS, for their continued support of research in the community. The authors also thank the El Monte City School District, the Pomona Unified School District and the El Monte and Pomona communities. The authors also thank Keith Boyer, DDS, for assistance in preparation of the manuscript.

Additional information

Notes on contributors

Paulina A. Saraza

Paulina A. Saraza, DMD, MS is an assistant professor within the community-based dental education curriculum at the Western University of Health Sciences College of Dental Medicine. She is the lead general dentist at the School-Based Oral Health Center sites. Her research focus is on access to care for underserved populations.

Jong Choi

Jong Choi, MS is a DMD 2024 candidate at the Western University of Health Sciences College of Dental Medicine. He is the current president of the American Dental Education Association student organization at WesternU CDM.

T. Jamie Parado

T. Jamie Parado, DDS, is an associate professor in the College of Dental Medicine at Western University of Health Sciences and a diplomate of the American Board of Pediatric Dentistry. Her key areas of interest include community-based dentistry and interprofessional collaborative practice.