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Dept. of Pedodontics and Preventive Dentistry Christian Dental College

Wednesday, 4th May, 2011 09.00am

Harsimran Singh Sethi Final Year P.G. Resident

The school based oral health program provides an opportunity to reach the largest number of children during early stages of development when habit patterns can be more easily modified. The school setting also provides an environment conducive to learning and reinforcement for a considerable period of time and allows the teacher to use various strategies for inducing children to participate in appropriate preventive oral health actions. School health is an important branch of community health. It is an economical and powerful means of raising community health in future generations. In 1885, William Fisher published a paper entitled Compulsory Attention to the Teeth of School Children. Following this, British dental Association appointed a committee to investigate child dental health. The subsequent reports were an important step towards the initiation and development of a School dental Service. On July 23rd 1898, School Dentists Society was formed in London. History The beginning of School health service in India dates back to 1909, when for the first time medical examination of children was carried out in Baroda city. The Bhore committee in 1946 reported that School Health Service were practically non-existent in India, and where they existed, were in an underdeveloped state. In 1953, the secondary Education committee emphasized the need for school nutritional programs. In 1960, the government of India constituted a School Health committee and submitted its report in 1961. In Jan 1982, the task force constituted by the Government of India to accomplish the School Health Survey, submitted its report, according to which only 14 states had some progress with their own health department budget. Definition of School Health services The committee on Terminology of the American association for Health, Physical Education and recreation (1951) has defined school Health services as the procedures established to appraise the health status of pupils and school personnel, to counsel pupils, parents, and others concerning appraisal findings, to encourage the correction of remedial defects, to assist in identification and education of handicapped children, to help prevent and control disease and to provide emergency service for injury or sudden sickness. Aspects of a School health Service Health appraisal Curative Services Objectives To help every school child appreciate the importance of a healthy mouth. To help every school child appreciate the relationship of dental health to general health & appearance. To encourage the Health counseling School health education Emergency care and first aid Maintenance of school health records

observance of dental health practices, including personal care, professional care, proper diet, & oral habits. To enlist the aid of all groups & agencies interested in the promotion of school health. To correlate dental health activities with the total school health program. To stimulate the development of resources to make dental care available to all children & youth. To stimulate dentists to perform adequate health services for children. Ideal Requirements Be administratively sound. Be available to all school children. Provide the facts about dentistry & dental care. Aid in development of favorable attitudes toward dental health. Provide environment for development of psychomotor skills necessary for tooth brushing. Include primary preventive dentistry program. Provide screening methods. Advantages of a school based program Dunning has pointed out the advantages as: The children are available for preventive or treatment procedures. School Clinics are less threatening than private offices. A school dental program facilitates central education on dental subjects. The dental service supplements the nursing services by helping to provide total health care for school children. A school primary preventive dentistry program should not impose an excess or unusual teaching burden on teachers and should be cost effective in manpower, money and material and should produce observable results. These guidelines can be met by considering three different levels of care. These Levels of Care are: The first level program involves only participation by the existing staff and superimposes on additional time commitment other than that expected within the present school curriculum. The dental hygienist/dental nurse are the key individual to the accomplishment of the next level of sophistication in this program, as the training focuses on the delivery of preventive procedures. The third and final level of preventive dentistry sophistication is the identification and referral for early treatment of pathology. ELEMENTS OF A SCHOOL DENTAL HEALTH PROGRAM Improving school-community relations: - One of the first steps in organising a school dental health program is the formation of a community dental health council or advisory community. It should include broad representation from parents, teachers, health officers and community leaders. These communities are important in improving the school-community relations and make people realize the importance of dental health and the school administrations concern in the promotion of dental health.

Conducting dental inspections: Dental inspections are necessary because: Dental inspection is an opportunity for individual health education. Dental inspection also provides baseline information upon which the treatment program can be built. Positive findings on inspection serve as motivation for dental health measures. Benefits of dental inspections: It serves as a basis of school dental health instructions. It builds a positive attitude in the child towards the dentist and the dental care. The child is motivated to seek adequate professional care. Baseline and cumulative data is obtained. Status of dental needs is ascertained. Limitations of dental inspections: School inspections may be treated as comprehensive treatment by parents and complete treatment by a family dentist may not take place. It is desirable for parents to be present for dental inspections, which is not always feasible in schools. Conducting Dental health education: - A school dental health Program should include a suggested formal approach to teaching dental health in the classrooms. The dentist serves as the expert resource person to strengthen the teachers classroom instruction program. Performing specific programs: Tooth brushing programs In school tooth brushing programs, it is necessary to distinguish between the mechanical action of tooth brushing and the desired objective of plaque removal. In a classroom program, groups of 6-8 children can be taught brushing techniques and then, the children may be asked to chew a disclosing tablet. Once plaque deposit areas are revealed, the instructor can teach guided brushing. Classroom based fluoride programs Fluoride Mouth rinse Program: - A once a week fluoride mouth rinse program can be instituted. The rinse should be non-sweetened and non-flavoured and are advised for grades 1-12 and not below. 5ml of a 0.2% of the rinse is dispensed into a plastic cup and the children are instructed to rinse for a minute. Fluoride tablet program: - One tablet is given to each student. The students chew, then swish the 2.2 mg sodium fluoride around the mouth for a minute and then swallow. The swish and swallow technique allows the benefit of a topical application. The daily tablet is more effective than a weekly rinse. School water fluoridation programs School water fluoridation programs make fluoride available to children, for whom dental caries is a major problem, as compared to older age groups. The amount of fluoride added to school drinking water must be greater than that used in communal water supplies since children are in school for shorter hours than at home. 40% reduction in dental caries is reported.

In 1954, a school water fluoridation pilot study was initiated at St Thomas V.S. Virgin Islands, by the U.S. Public Health Service division of dental health. The school water was fluoridated slightly over 3 times the optimum indicated for the community water. After 8 years, students showed 22% less caries experience than children drinking non-fluoridated school water. Despite various studies documenting the effectiveness of school water fluoridation, it has not been widely implemented. One major disadvantage of school water fluoridation is also that children do not receive its benefits until they begin school. Nutrition as part of school dental policies School lunch programs/mid-day meals are designed to provide the child with an intake of nutrients that approximate one third of the daily intake of essential carbohydrates, proteins, fats, minerals and vitamins. The school dietician, dental hygienist, or teacher can aid sugar discipline through counselling. Emphasis cannot be on total restriction of sugars; it should be on reducing the frequency of intake and selecting sugar products that are rapidly cleared from the mouth. MID DAY MEAL PROGRAM OF GOVERNMENT OF INDIA: - It is to provide free food grains at 3kg/child/month to children of class 1st to 5th of government schools. Objectives of the Program To improve enrolment & attendance To reduce school drop outs

To improve child health by increasing nutrition level Sealant placement: The placement of pit and fissure sealants is ideally suited for a school dental health program. 1st and 2nd grades (because the 1st molars are sufficiently erupted), 6th and 7th grades (because 2nd molars are erupted) would be desirable grades to intervene to prevent pit and fissure lesions. Sealant placement, followed by an application of fluoride, helps provide a continuous protection of the whole tooth. Science fairs: Local and state dental associations can organise science fairs, painting competitions, best smile and teeth competitions where students can exhibit projects. Literature should be provided for students, outlining possible dental projects and offering assistance of local dentists to help students develop projects. Such projects increase awareness among students and the community at large.

Referral for dental care Many schools do not provide dental care within the school itself, such schools have to refer children to a dentist for proper dental treatment. Most schools also require the patients to be notified in writing of dental problems.

Blanket referral: - In this program, all children are given referral cards to take home and subsequently to the dentist, who signs the cards upon completion of examination or treatment or both. The signed cards are then returned to the school nurse, or the classroom teacher, who plays an important role in following up referrals. Follow-up of dental inspection Issuance of referral slips is of little importance to children if steps are not taken to follow up dental therapy. The dental hygienist is a good candidate to follow up dental examinations. Classroom teachers may also be allotted for this purpose. It is also important that someone from school health services coordinate the work of various teachers. ADVANTAGES OF SCHOOL BASED DENTAL PROGRAMS School dental health programs can bring school children when they are gathered in school for non dental reasons. A combination of education and health facilities is practical both ideologically and logistically. Higher utilization of dental care services has been obtained by this method than any other. In addition, the childrens daily contact with the dental personnel in other roles has a lasting effect on their attitudes towards dentistry in general. By providing certain basic dental services at govt expense, low income groups are also able to afford dental care of a specialized nature when necessary. SCHOOL DENTAL CLINICS School dental health clinics are less threatening to children, since they are in familiar surroundings. The location of dental clinics in school premises favours dental health education. Members of the dental health team can engage in classroom teaching and also reinforce their message at the chair-side. School dental health clinics also facilitate peer review, either at the informal level or formal level. When associated with medical clinics, medical problems of children can be addressed simultaneously. DISADVANTAGES OF SCHOOL BASED DENTAL CLINICS a) Short school hours and frequent vacations make full time employment of dental personnel difficult and thus make availability of personnel a problem. b) One-chair dental clinics as seen in older school programs have proven insufficient to address the health needs of the entire school.

VARIOUS SCHOOL BASED DENTAL PROGRAMS TEXAS STATEWIDE PREVENTIVE DENTISTRY PROGRAM- TATTLE-TOOTH PROGRAM Program Development The Tattle-tooth program was first developed in the 1970s as a cooperative effort between Texas oral health professional organizations, through a grant from the Dept. of Health and Human Services to the

bureau of dental health. This program was initially implemented with approx 50,000 children in Texas per year. In 1985, the Texas legislature mandated that the essential elements for comprehensive health education be incorporated in the curriculum state-wide. In 1989, the Bureau of Dental Health developed a new program, Tattletooth II-A for grades kindergarten through six. In 1993, a pre-school programme titled Superbrush was completed by the Bureau of Dental Health. The pre-school curriculum was designed for use with personnel in head start programs, pre kindergarten, public and private child care centres, public school programs and family day care homes. The curriculum contains: 1. Children-directed activities that children do largely on their own 2. Teacher- directed activities that teachers do with children on large or small scale groups Program Philosophy and goals To reduce dental caries and develop positive dental habits to last a lifetime in participants. To convince students at preventing dental diseases is important and can be done by them. To focus on dental health as part of total health. Program implementation Dental hygienists serve as technical consultants for school districts and promote dental education. Supported materials are available for teachers and program hygienists. Teachers are trained to present dental health information for school-aged children. They are also encouraged to invite a dental professional to demonstrate brushing and flossing in the classrooms. A field trip to a dental office is strongly recommended for kindergarten children. NORTH CAROLINA STATEWIDE DENTAL PUBLIC HEALTH PROGRAM Program development The need for an oral health program was realised as early as 1918 in North Carolina and oral hygiene was added to the North Carolina Public Health Program. In 1970, the North Carolina Dental Society passed resolutions advocating a strong preventive disease program embracing school and community fluoridation, fluoride treatment of school children, continuing education on prevention for dental professionals and plaque control education in schools and communities. In 1973, a report prepared for the North Carolina Dental Society defined the extent of dental disease problem and resulted in the initiation of a 10- year program to reduce dental disease. In the same year, a coalition of several agencies set up a committee that was responsible for developing a practical plan for a program in schools. With the North Carolina Oral Health Survey in 1986, the Oral Health section started the process of establishing new long range goals for the state that reinforce and expand on those started in 1973.

Program philosophy and goals 1. The North Carolina Oral Health Sections goals are based on prevention and education. Primary prevention and education are considered to be the most effective means of decreasing dental disease and promoting oral health. 2. School-age children are the primary focus. 3. Fluoride and sealants are recognised as the most effective public health measures for preventing dental caries. Program Implementation Teachers are trained to present dental health information for school-age population. The priorities are community water fluoridation, fluoride mouth rinse programs and sealants. Public health dental staff provides training and consultative services to teachers, parents, professionals and community. Several teaching aids are used- videotapes, guides and exhibits. SCHOOL HEALTH ADDITIONAL DEVELOPMENT PROGRAM (SHARP) This program was developed in Philadelphia where the lowest rate for correction of physical defects prevailed. The purpose of the program was to motivate parents into initiating action for correction of defects in their children through effective utilization of community resources. BRIGHT SMILES BRIGHT FUTURES (COLGATE) Colgate Oral Pharmaceuticals have developed an oral health educational program to teach children about caring for their teeth through proper oral hygiene, diet and physical activity. The program enhances childrens self esteem while giving them information about taking care of their oral health. Available material includes books, videos, posters, stickers, charts and guides for teachers or professionals administering the program. In several communities, a mobile van staffed by volunteer dental professionals provides dental attention on wheels, screening children and providing referrals for additional needed treatment and aims to provide dental care and information to children at risk for dental problems. CRESTS FIRST GRADE ORAL HEALTH EDUCATION PROGRAM Since 1961, Proctor and Gamble (P&G) has been providing the curriculum resources to schools throughout America. The curriculum encourages youngsters to go for regular dental check-ups and invites dental professionals to participate in classroom instruction. Each year, Crest kits containing toothbrushes and toothpaste samples have been provided for children in more than 20,000 classrooms. Materials are sent to participating schools each year in time for National Childrens Dental Health month (Feb). P&G also provides educational materials for professional and patient use.

COORDINATED SCHOOL HEALTH PROGRAMS One proven strategy for reaching low-income children most at risk for dental caries is through school based programs with supporting linkages with health care professionals and other dental partners in the community. In 1998, the National Centre for Chronic Disease Prevention and Health Promotion at CDC, Division of Oral Health, provided funding support to state educational agencies. The educational agencies in these states partnered with their state health depts. to promote, develop, expand and evaluate school based models, integrating oral health into their existing Coordinated School Health Programs (CSHPs). In 1999, the CDCs division of Oral Health provided 3 year funding to four US states. These models serve as a foundation of a comprehensive integrated and sustainable approach to address oral health needs of school aged children

DENTAL PROGRAMS IN PUNJAB A survey conducted by the Health Department during the year 1989-90 revealed that nearly 84.4 % of the State's population was suffering from one or the other Dental diseases. It was noticed that this alarming rise in the Dental diseases was mainly due to the lack of awareness among the people about the prophylactic, interceptive and curative treatment available in the existing infrastructure of the Dental Health Care Services in the State. It was also noticed that the Dental Surgeon population ratio was 1: 30000 in the urban areas. But the ratio in the rural areas is 1:1.19 lacs. To provide the best of the Dental Health Care Services to the people of the State, the Punjab Govt. has launched INTENSIVE DENTAL HEALTH CARE PROGRAMME for school children, school teachers and general public, which is first of its kind in the country. To reach the far-flung areas of each district one mobile Dental Clinic Van was provided to give interceptive and curative treatment to the people at their doorstep. To monitor and implement all the dental programmes it was proposed to establish a post of District Dental Health Officer for all the districts of the State. AIMS AND OBJECTIVE: To bring down the incidence of oral and dental diseases to less than 40%. To bring down the Decayed Missed Filled Teeth (D.M.F.T.) in School children of 6 12 years less than two. To achieve 25 % reduction in number of persons without teeth after the age of 60 Years. To provide one dental clinic to serve the population of 30,000 in the rural areas by opening 354 new Dental Clinics by the end of five years plan. To provide total oral health coverage to all the school going children in the age group of 6 - 12 years. To provide Dental Health Education Training to all the primary school teachers, medical & paramedical personnel. To organize special Dental Health Fortnights. To provide on the spot diagnostic preventive interceptive & curative Dental Health Care Services to the people in the far flung rural areas of the state and the school children through fully equipped Mobile Dental Clinic Vans.

INTENSIVE DENTAL HEALTH CARE PROGRAMME: - Punjab is the only state in India which has launched Intensive Dental Health Care Programme in the year 1989-90. Under this Programme one sub-division is selected and the schools are covered block wise. After covering the whole Sub-division the next Sub-division is taken up. At present three Medical Officers (School Health Clinic-I, Intensive Dental Health Care Programme-I & P.H.C. Medical Officers (Dental) I) visits the schools as per the detailed programs circulated to them. The Special feature of this Programme is that in addition to the imparting of Dental Health Education training to the School children & detailed Oral Health check up, each child is given a mouth rinse with the freshly prepared 2 % solution of sodium fluoride to arrest the initiation & progress of dental caries and this process is repeated after every six months. For school Children: Targets and achievements are as under: Year Target Achievements Children found % age of children found suffering from various suffering from various Dental Diseases Dental Diseases 123905 127494 80215 36.2 31.6 37.7

2005-06 2006-07 2007-08(Upto Dec. 07)

2.5 Lacs 3.0 Lacs 3.25 Lacs

342213 403880 212891

The children suffering from Dental Diseases are provided necessary Dental treatment on the Mobile Dental Clinic Vans. One day dental health education training workshop/camps are being held for primary school teacher, Medical and Paramedical Personnel so as to update their knowledge about commonly prevailing Dental diseases among the School children and their preventive measures to be taken. Imparting of Dental Health Education to School Teachers, Medical and Paramedical Personnel: Year 2005-06 2006-07 Target Achievement 6500 7000 9505 10468 4771

2007-08 (upto Dec. 07) 7500

Mobile Dental Clinic Van: Since the incidence of Dental Diseases is very high amongst the school children particularly in rural areas, curative Dental Health Care Services and effective Prophylaxis against Dental Caries can only be provided on the Dental Chair. So, it was decided to establish seventeen Mobile Dental Clinics in the State (one for each District) so as to provide curative and prophylactic Dental Health Care Services in the far-flung rural areas of the State and also to provide effective prophylaxis against Dental Caries to the children in the Schools. No. of Patients examined by the Mobile Dental Van during the year 2005-06 to 2007-08 are as under Year 2005-06 2006-07 2007-08(upto Dec 07) Target 70000 80000 85000 Achievement 114287 90026 44601

REFERENCES Burt BA, Eklund SA (2005). Dentistry, Dental Practice and Community. 6th edition Jong AW (1994). Community Dental Health.3rd edition Haag JH (1972). School Health Program. 3rd edition Hiremath (2009). Textbook of Preventive and Community Dentistry. 2nd edition Peter S (2009). Essentials of Preventive and Community Dentistry. 4th edition Yazdani R, Vehkalahti MM et al. School-based education to improve oral cleanliness and gingival health in adolescents in Tehran, Iran. Int J Paediatr Dent. 2009 Jul;19(4):274-81 7. Shenoy RP, Sequeira PS. Effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12- to 13-year-old school children. Indian J Dent Res 2010 Apr-Jun;21(2):253-9. 1. 2. 3. 4. 5. 6.