SAA Webinar – The Relationship Between Oral Health and Student Per

Smiles Across America Webinar Series

The Relationship Between Oral Health and Student Performance

Date: 11/17/2015

Connect with OHA! /Oral Health America

@Smile4Health

/Oral Health America

@Smile4Health

HOUSEKEEPING INFORMATION • •

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Questions are welcome! We’ll allow 10-15 minutes after the presentation for questions.

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Submit questions at any time; we will address them at the end of the presentation.

Webinar is being recorded; for rebroadcast on OHA’s website – OralHealthAmerica.org Your feedback is important to us. Please take our brief webinar evaluation after this session; link will be sent via email.

OUR MISSION Oral Health America’s mission is to change lives by connecting communities with resources to drive access to care, increase health literacy, and advocate for policies that improve overall health through better oral health for all Americans, especially those most vulnerable.

OHA PRIORITIES OHA’s Programs and Campaigns are designed to improve access to care, oral health literacy and policies that prioritize the impact of oral health on the overall health of all Americans – particularly those most vulnerable.

ACCESS

HEALTH LITERACY

ADVOCACY

Campaigns for Oral Health Equity Educate the public, including policy makers, about the importance of oral health for overall health Emphasize the need to prioritize oral disease alongside other serious health conditions Advocate for policies that positively impact programs and stakeholders Current campaigns include:

toothwisdom.org

Advocacy

Health Education & Communications

Professional Symposia

Demonstration Projects

Grant Funding

Product Donation

Technical Assistance

School Partnerships: The relationship between oral health and student performance Terri Chandler, RDH Founder/Executive Director Email: futuresmiles@centurylink.net Web: www.futuresmiles.net C: (702) 521-4550

EDUCATIONAL OBJECTIVES 1) Participants will learn about Future Smiles and our different school-based oral health delivery models.

2) Participants will learn how the evaluation team determined and analyzed the different “categories of care� within the evaluation design.

3) Participants will learn about our preliminary evaluation of oral health status and student performance.

MEET BELLA~ THIS IS WHAT SUCCESS LOOKS LIKE!

OUR MISSION Increase access to oral health education and services for underserved populations.

Research shows that students who are in poor oral health are more likely to experience dental pain, miss school, and perform poorly in school. It is estimated that 51 million hours per year are missed due to dental related illness.

WHY SCHOOL-BASED CARE Most barriers stem from overarching health, family and community issues.

OUR FAMILIES

The average family accessing oral health services at our school-based EPOD sites has 4 members and an income of $1,416 per month.

That’s $16,992 per year for a family of 4!

MAP AND LOCATIONS Future Smiles began providing preventive oral health care at School A through a generous donation from Oral Health America.

FUTURE SMILES OUTCOMES Outreach efforts since December 29, 2009:  18,745 oral health presentations  5,071 child cleanings  25,719 teeth with dental sealants  10,801 fluoride varnish  51% are uninsured  41% have untreated decay  11% are urgent

NEVADA ORAL HEALTH FACTS  2014 Georgetown University’s Center for Children and Families report 9.6% uninsured rate- NV is 1 of the 5 highest in US.  Equals 63,732 children in NV.  AZ is also one of the 5 highest with 10% of its children uninsured.  2011 Quality Report from Medicaid revealed that Nevada has a 37% dental utilization placing Nevada at the bottom quartile for access to dental services.

Nevada’s Oral Health Need 2012 Burden of Oral Disease NV 3rd Grade Findings  6 out of 10 (65%) children in Nevada have experienced tooth decay.

 Statewide 35% have untreated tooth decay.  In minority children 71% have experienced tooth decay.  11% have urgent dental needs and live with dental pain.

DENTAL DISEASE IS PREVENTABLE

WE FIND SOLUTIONS Case Management Can Make a Difference  Unmet oral health needs are addressed through case management.  School-Based Health Centers are a cost effective and accessible way to deliver health care to the most vulnerable members of our community.

SCHOOL-BASED ORAL HEALTH CARE FUTURE SMILES EPOD EPOD~ What does it stand for?  SCHOOL-BASED HEALTH CENTER FOR EDUCATION AND PREVENTION OF ORAL DISEASE  SBHC, Modular or Classroom Services Include:  Screening  Education  Prophylaxis  Fluoride Varnish  Sealants  Digital X-rays *limited locations  Case Management *referral

SCHOOL-BASED LOCATIONS  5 EPOD-Education and Prevention of Oral Disease  Future Smiles Mobile  Sealant Program  16 CCSD Title I Schools  Our Project Evaluated  2 EPODs  1 Mobile

CATEGORIES OF CARE School

A B C

SBHC School-Based Health Center Medical

Future Smiles EPOD

Future Smiles Sealant Program

Restorative Dental Case Management

Communities In Schools Student Enrichment

2013-2014 Snapshot of Elementary Schools School A 792 students with 208 FS participants 79% Free and Reduced Lunch $1,427 income family of 4 Title I – 3 Star School School B 717 students with 202 FS participants 95% Free and Reduced Lunch $1,122 income family of 4 Title I – 2 Star School School C 698 students with 136 FS participants 91% Free and Reduced Lunch $1,166 income family of 5 Title I – 3 Star School

School A School B School C

Medicaid Enrollment SY’12-’13 SY ‘13-’14 36% 39% 52% 55% 63% 62%

SCHOOL POPULATION SY 2012-2013 School A Demographics

School B Demographics

School C Demographics

Caucasian

Caucasian

Caucasian

African American

African American

African American

Indian/Hawaiian/Island

Indian/Hawaiian/Island

Indian/Hawaiian/Island

Asian

Asian

Asian

Hispanic

Hispanic

Hispanic

SCHOOL POPULATION SY 2013-2014 School A Demographics

School B Demographics

School C Demographics

Caucasian

Caucasian

Caucasian

African American

African American

African American

Indian/Hawaiian/Island

Indian/Hawaiian/Island

Indian/Hawaiian/Island

Asian

Asian

Asian

Hispanic

Hispanic

Hispanic

TRENDS IN UNTREATED DECAY AMONG FS CLIENTS PER SCHOOL AND BY SCHOOL YEAR 70% 60% 50%

40% 30% 20% 10% 0%

2009-2010

2010-2011 School A

2012-2013 School B

School C

2013-2014

TRENDS IN URGENT DENTAL NEEDS AMONG FS CLIENTS PER SCHOOL AND BY SCHOOL YEAR 45% 40% 35% 30% 25% 20% 15% 10%

5% 0%

2009-2010

2010-2011 School A

2012-2013 School B

School C

2013-2014

FUTURE SMILES OUTCOMES Figure 1: School A 120% 97%

100%

95%

95%

94%

80% 63% 60% 40%

50% 41% 31%

58% 47%

42%

36% 22%

20%

29% 17%

14%

0% SY 2010-2011 baseline Untreated Decay

SY 2011-2012 Urgent Needs

SY 2012-2013 Sealants Present

SY 2013-2014

Sealants Post Event

School Intervention  School-Based Health Center  Future Smiles~EPOD  Communities In Schools

FUTURE SMILES OUTCOMES Figure 2: School B 120% 100%

100%

100%

99%

94%

80% 60%

60% 49%

43%

42%

37%

40% 20%

20%

17%

39%

32% 13%

29% 7%

0% SY 2010-2011 baseline Untreated Decay

SY 2011-2012 Urgent Needs

SY 2012-2013 Sealants Present

SY 2013-2014

Sealants Post Event

School Intervention ďƒź Future Smiles~EPOD

FUTURE SMILES OUTCOMES Figure 3: School C 120% 100%

100% 80%

70%

60%

99%

63% 46%

42% 40% 20%

100%

98%

26% 17%

31%

29% 11%

13%

29% 8%

0% SY 2010-2011 baseline Untreated Decay

SY 2011-2012 Urgent Needs

SY 2012-2013 Sealants Present

SY 2013-2014

Sealants Post Event

School Intervention  School-Based Health Center  Future Smiles~Sealant Program  Communities In Schools

SEALANTS • Sealant application post service event was consistently high in all three sites.  95-100% • Consistently reaching children who did not yet have sealants.

• We know sealants are a powerful tool in preventing caries.

ORAL HEALTH TRENDS IN CHILDREN AGE 7-11

School A School B School C

Medicaid Enrollment SY’12-’13 SY ‘13-’14 36% 39% 52% 55% 63% 62%

ORAL HEALTH TRENDS IN CHILDREN AGE 7-11

School A School B School C

Medicaid Enrollment SY’12-’13 SY ‘13-’14 36% 39% 52% 55% 63% 62%

FIRST MOLAR DFT IN CHILDREN AGE 7-11

School A School B School C

Medicaid Enrollment SY’12-’13 SY ‘13-’14 36% 39% 52% 55% 63% 62%

FIRST MOLAR DFT BY AGE

School A School B School C

Medicaid Enrollment SY’12-’13 SY ‘13-’14 36% 39% 52% 55% 63% 62%

PARTICIPATION OVER TIME School A Program Participation %

School B Program Participation %

School C Program Participation %

24% 37% 47% 53% 63% 76%

Retained

New

Retained

New

Retained

Comparison from SY 2012-2013 to SY 2013-2014

New

% OF STUDENTS WHO RECEIVED RESTORATIVE DENTAL SERVICES FROM SY ‘12-’13 TO ‘13-’14 School A Program Participation % 87 students with caries

School B Program Participation %

School C Program Participation %

86 students with caries

36 students with caries

18% 38%

42% 58%

62% 82%

Restorative

Prevention

Restorative

School A School B School C

Prevention

Restorative

Medicaid Enrollment SY’12-’13 SY ‘13-’14 36% 40% 52% 55% 63% 62%

Prevention

HIGHLIGHTS OF PRELIMINARY OUTCOME ANALYSES Preliminary Analyses Examined: • Patterns/trends in total preventive care received by school by school year.

• Trends in sealant application rates by school by school year.

• Associations between FS care and student attendance and performance.

METHOD • Total Care Index Score: Summation of prophylaxis, sealants, and varnish applications per study.

• Repeated Measures ANOVA used to examine changes over time in the Total Care Index Score and Sealants.

• To examine FS student performance and school attendance, we conducted exploratory analyses that assessed for differences in these outcomes by school and over time.

PRELIMINARY FINDINGS Between school differences in total care and sealant applications existed across study years Total care index and sealant applications generally decreased over time. Some school level differences for some study years. Variation in rates of existing sealants and cohort effects may explain this pattern.

There were no significant patterns in absenteeism related to oral health status There was no correlation between total # of visits with FS and absenteeism.

PARENT INTERVIEWS • Feedback on the value of the school-based dental hygiene program provided by Future Smiles.

• Benefits to children—oral health, education.

• Family oral health practices.

• Barriers to oral health care.

• Recommendations for improving FS services.

IN THEIR WORDS….

“My son talked about the program and was really interested. To enroll I only had to sign a paper he brought home.”

“Before the program it was hard to get my son to brush his teeth, but because of the lessons they gave him explaining how to do it and how important it is, he does it!”

“Before we got educational materials from the program, I didn’t know we should change our tooth brushes every 3 months. Now we do.”

INTERVIEWS WITH TEACHERS • Teachers/staff participating in FS activities in 2014-15 Brush at Lunch 5 respondents per school ~ 3 schools n=15 • Phone interviews • $25 gift cards incentive

• Future Smiles Evaluation Report

TEACHER/STAFF PERCEPTIONS • Feedback on the value of the school-based dental hygiene program provided by Future Smiles.

• Benefits to children—oral health, education.

• Benefits to families of participants.

• Facilitators and barriers to FS services in their school.

• Recommendations for improving FS services.

IN THEIR WORDS….

“Kids always come back happy from their visits with the hygienist.”

“For parents, anything that benefits the child benefits them. This area is at-risk, low socioeconomic status, money is limited.

Saving money on dental care helps put food on the table. Other basic needs will be met if dental care needs are taken care of.”

“Preventative treatment helps kids have good experiences with dental professionals and they will be more willing to continue going. It avoids bad experiences and trauma.”

Method for Pilot Study Student Records from Future Smiles Patients in SY 2010-2014  Attendance Rates  Nevada Criterion Reference Tests (CRTs)

Future Smiles Oral Health Records  Restorative Care  Optimal oral health (visual screening)  Number of sealants, fluoride varnish treatments and prophylaxis  Family demographics

NEVADA CRITERION REFERENCE TESTS (CRT TESTS) State Grade-Level Achievement Tests  Measures how well a child has mastered the expected content.  Aligned to Nevada State standards.

Annual Reading and Math CRT  Given to students from third to eighth grade.  Science once in elementary, middle and high school.

Measure How Well a Child has Learned Subject Matter  Student only competes against him/herself.

NEVADA CRITERION REFERENCE TESTS (CRT TESTS) Four Levels of Scoring  Emergent/developing  Approaches standard  Meets standard  Exceeds standard Possible Federal Sanctions  Loss of federal funds  Providing free tutoring  Allowing students to transfer to another schools  Complete restructuring of the school

2012-2013 SCHOOL YEAR CRT Reading Scores- Comparison of Three Schools 160 140 120 100 80 60 40 20 0 Emerging//Developing

Approaches School A

Meets School B

School C

Exceeds p < 0.001

SY’12-’13 CRT Reading Standards

Visual Exam Caries Present

Visual Exam No Caries

Emerging

11%

13%

Approaches

9%

12%

Meets

15%

21%

Exceeds

6%

11%

2013-2014 SCHOOL YEAR CRT Reading Scores – Comparison of Three Schools 180 160 140 120 100 80 60

40 20 0 Emerging//Developing

Approaches School A

Meets School B

Exceeds

School C

SY’13-’14 CRT Reading Standards

Visual Exam Caries Present

Visual Exam No Caries

Emerging

12%

13%

Approaches

9%

13%

Meets

15%

22%

Exceeds

6%

8%

2012-2013 SCHOOL YEAR CRT Math Scores- Comparison of Three Schools 160 140 120 100 80 60 40 20 0 Emerging//Developing

Approaches School A

Meets School B

Exceeds

School C

SY’12-’13 CRT Math Standards

Visual Exam Caries Present

Visual Exam No Caries

Emerging

8%

10%

Approaches

11%

15%

Meets

19%

23%

Exceeds

4%

10%

2013-2014 SCHOOL YEAR CRT Math Scores- Comparison of Three Schools 180 160 140 120 100 80 60 40 20 0 Emerging//Developing

Approaches School A

Meets School B

Exceeds

School C

SY’13-’14 CRT Math Standards

Visual Exam Caries Present

Visual Exam No Caries

Emerging

11%

12%

Approaches

10%

16%

Meets

18%

21%

Exceeds

4%

6%

% OF STUDENTS WHO PARTICIPATED WITH CIS School A Program Participation %

School B Program Participation %

School C Program Participation %

0% 10%

23%

91%

95%

CIS & FS

100%

FS Only

CIS & FS

FS Only

SY 2012-2013 Data

CIS & FS

FS Only

NEVADA SCHOOL RATINGS ★★★★★  A composite of several performance indicators.  Maximum number of points.  Index score is the sum of all of these factors that is then measured against the star rating criteria.

NEVADA SCHOOL RATINGS 2012-2013

School A

School B

School C

2013-2014

Positive Findings - Frequency of Visits Students Seen Four or More Times by Future Smiles

33%

67%

Untreated Caries Present

Visual Screening- No Caries

CONCLUSIONS Confounding Factors  English Language Learners  Other Health Factors  Family Influences  Transient Population

Follow-Up Evaluation  Comparative Groups to Include o Oral Health Status o Account for Other Health and Disabilities in Students  Comparative Socio-Economic Status o Low Income o High Income

FUTURE EVALUATION DESIGN • Future evaluation will compare school performance between FS vs. non-FS students using a quasi-experimental design  Match 3 FS schools to 1 non-FS schools with similar student characteristics within a low socio-economic schools.  Match 1 high socio-economic school for comparison.

• Conduct a prospective study with 3rd grade students receiving FS in the intervention schools v. matched comparison schools  Conduct oral health screening of all youth (FS and non-FS) at baseline.  Validate visual oral health status screening with a full oral exam performed by a dentist to ensure visual screening is a sensitive assessment tool.

BRIGHTER FUTURE FOR ALL “We are shifting the focus of our country's health care system from sickness and disease to wellness and prevention.”

President Barack Obama National Public Health Week, 2015 Published April 6, 2015

Terri Chandler, RDH Founder/Executive Director Email: futuresmiles@centurylink.net Web: www.futuresmiles.net C: (702) 521-4550

Question and Answer Session • Questions are welcome! This session may last for 10-15 minutes.

• Write your questions in your control panel on the upper right hand of your screen.

• Submit questions at any time.

Contact Information • Terri Chandler – futuresmiles@centurylink.net • Tyler Brown tyler.brown@oralhealthamerica.org