Social determinants of health (SDOH) are the driving forces behind health inequities in various populations. Access to adequate healthcare being one of these determinants, is a challenge still faced by many Oregonians. Adolescents are in a unique position to access healthcare through school-based health clinics (SBHCs). Despite the 78 SBHCs that exist in Oregon, students are still not receiving preventative dental treatment and high rates of caries are still present. Every year in the U.S., hospital emergency rooms see an average of 2 million visits for dental pain. If these incidents could be prevented or even referred to a local dentist or clinic, the healthcare system could save an estimated $1.7 billion. (1) Additionally, poor dental literacy and inequities with adequate nutrition contribute to these oral health statistics. This project proposes to integrate an oral health component into high school health curriculum with the intent of meeting objectives identified by the Oregon Health Authority (OHA) to reduce the incidence of oral diseases and achieving a high standard of lifelong oral health.
Demographics
In 2020, 17.7% of 11th graders and 14.8% of 8th graders in Oregon reported having a cavity in the past 12 months. Conversely, 29% of 11th graders and 30% of 8th graders reported never having a cavity. (2) School-based health clinics (SBHCs) in Oregon include sealant programs and school fluoride tablet and rinse programs. (3) During the 2019-2020 school year, 43 schools participated in the fluoride tablet and rinse program with 752 students in the tablet program and 1,046 students in the rinse program. Unfortunately, the metrics from this most recent program were incomplete as a result of the COVID-19 pandemic and the program has since been discontinued due to difficulties distributing these products. (3) For school-based sealant programs, elementary and middle schools are eligible if at least 40% of the students are eligible for the federal Free-and-Reduced Lunch (FRL) Program. Currently, there are 21 school dental sealant programs across 36 counties certified by the state of Oregon. (3) Aside from these programs, there have not been any certified programs at the high school level that have integrated oral health education into the curriculum.
“According to the Centers for Disease Control and Prevention (CDC), each day in the United States, about 1,600 youth smoke their first cigarette and nearly 200 youth start smoking.” (2)
Tobacco use statistics are important to evaluate for this patient population when considering integration of oral health into high school health curriculum. The risks for oral cancer in conjunction with other complications nicotine can have on the body are well documented. E-cigarettes and vaping are another product that place adolescents at high risk for nicotine addiction. (2) Despite Oregon banning the sale of tobacco products to individuals under the age of 2021, studies reflect ease of access to these products as well as frequent use at a young age. (2)
According to the CDC an average of 20,000 cases of oropharyngeal cancer (OPC) per year are attributed to some strain of the Human Papilloma Virus (HPV). (4)
Historically, cancers of the head and neck are associated with alcohol and tobacco use as the primary etiological factor but during the mid 2000’s, diagnosed OPC increased significantly with evidence showing that 60-90% of cases were attributable to HPV strains 16 and 18. (5) Although a causative link between strains of HPV and OPC have not been definitively established, scientific evidence has shown that HPV infection can be prevented with vaccination. (7) Despite the proven prophylactic benefit, rates of those receiving the complete vaccine series have been historically low. Prevention is the key component to combatting the incidence of HPV-associated OPC and numerous studies have shown the effectiveness of vaccines for patients who are eligible. (8,9)
Prioritization of Needs
The OHA has created a plan to implement strategies that aim to improve the oral health for all Oregonians by reducing SDOH that contribute to access to care disparities. (10) One of the objectives identified was to increase school-based oral health access points for high school students. (10) In 2020, one in four 11th graders and roughly one in six 6th and 8th graders responded to a survey that indicated it had been more than a year since they had seen a dentist. (2) It is well documented that poor oral health has a negative impact on school performance and overall student well-being. With cariogenic snacks on school grounds, exposure to smoking through tobacco, e-cigarettes, and marijuana, lack of community water fluoridation, and not every student receiving routine preventative dental care, students- specifically adolescents- are not only at high risk for caries and periodontal disease, but also oral cancer and viral, bacterial, and fungal infections that initiate in the oral cavity. (2,10) The opportunity for students to further their understanding of the importance of preventative oral healthcare while also becoming equipped with resources to make healthy lifestyle changes, has the potential to improve oral systemic health of adolescents by empowering dental personnel to have constructive conversations with students through this integration program.
Proposed Blueprint for the Dental Hygiene Program
This school-based health program through the state of Oregon will fund a regional dental hygienist to provide a weeklong course on oral health education within high school health curriculum. Within the specified region, the dental hygienist will spend a week at each high school willing to participate in the program. The oral health integration program will consist of five core modules. The modules will cover the following:
Module 1: What is oral health?
Oral microbiome
Why oral hygiene is important
Mouth is the window to the rest of the body
Classroom activities: Swabbing the mouth and looking under a microscope
Assignment: Utilize PCR and disclosing solution at home to get percentage of plaque before and after brushing
Module 2: Nutrition and oral health
Module 3: Smoking and oral health
Cigarettes
E-Cigarettes/Vape
Marijuana
Smokeless tobacco/chew
Module 4: Oral viruses, fungus, and bacteria
Module 5: Oral systemic health
Goals and Objectives of Proposed Program
Goal: The oral health integration into high school curriculum program aims to improve the dental literacy of adolescent students to equip them with pertinent information regarding oral systemic health, while also empowering them to make choices conducive to their overall oral health and wellness.
Objectives:
1. Students will be able to explain the process of caries development, caries transmission, and identify anticariogenic snacks and beverages.
2. Students will evaluate their current oral health care routine and integrate positive changes for optimal oral hygiene.
3. Students will recognize risk factors for oral cancer.
4. Students will assess the oral systemic link and identify ways that their oral health can influence their body.
5. Student will analyze lifestyle contributors to poor oral healthcare and contrast these with positive contributors to optimal oral healthcare.
6. Students will recognize that achieving a healthy mouth goes beyond brushing and flossing.
7. Students will differentiate between oral hygiene medicaments and explain the benefits to oral healthcare.
8. Students will examine the oral microbiome to recognize the harmful properties of dental biofilm and the helpful properties of saliva.
Planned Surveys and/or Dental Indices
Surveys will be utilized at the end of each week for students to complete and provide feedback on the oral health course. This will help determine if students met the course objectives during the week. Dental indices will be utilized when students are dispensed disclosing tablets to take home for an assignment. Students will be instructed in class how to use the Plaque Control Record (PCR) and will be asked to utilize this at home to record the percentage of plaque on their teeth before and after brushing. Students will be asked to document findings such as where they found the most plaque on their teeth and areas they need to improve on with their oral hygiene routine.
Facilities
The facilities necessary for this program will include high school classrooms where health class is taught. The supplies and materials necessary for this program will include the following:
Projector/screen for slide presentations (i.e. PowerPoint)
Microscope, slide, cotton swab, and dropper- to show swab of oral bacteria
Disclosing tablets, disposable cups, disposable toothbrushes, floss
Single packets of Spry gum
Workforce
The workforce required for this program will include one dental hygienist employed per region of the state. This dental hygienist will be responsible for providing the oral health curriculum for each high school in their region that is willing to participate. The dental hygienist will collaborate with the high school health instructor to determine when the oral health program can be implemented into the curriculum during the semester.
Funding
The primary funding from this program will come from the state department of oral health for the dental hygienist employed per region. Once this program becomes accepted and certified through the OHA funding for materials could be supplied by the OHA, or a small grant could be applied for through the American Association of Public Health Dentistry (AAPDH) or the American Academy of Pediatric Dentistry (AAPD) Foundation. (11,12)
Possible Constraints and Alternatives
Possible constraints that may be encountered with this program include lack of approval by the OHA, not enough funding for the program to be successful, and limited willing dental hygienists to provide this course. Alternatives to this course could be instead of employing a dental hygienist in person, the course could be delivered virtually. If limited to no funding is available to support donation of supplies, this aspect of the course could be omitted and the dental hygienist could deliver the course without these additional items.
References
1. Emergency department referrals: Helping people find a dental home [Internet]. American Dental Association; 2023 [cited 2023 April 1]. Available from https://www.ada.org/resources/community-initiatives/action-for-dental-health/emergency-department-referrals
2. Oregon Health Authority, Public Health Division. (2020). 2020 Oregon student health survey: Helping all youth to be happy, healthy, and resilient. State of Oregon Report, 1-118.
3. School-based oral health programs [Internet]. Oregon Health Authority; n.d. [cited 2023 March 31]. Available from https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/ORALHEALTH/SCHOOL/Pages/index.aspx
4. HPV and oral cancer [Internet]. Centers for Disease Control and Prevention; 2022 February 24 [cited 4 May 2022]. Available from https://www.cdc.gov/oralhealth/fast-facts/oral-cancer-and-hpv-vaccine/
5. Cotter, J. C., Wilson, K. J., & Mallonee, L. F. (2019). Impact of HPV immunization training on dental hygiene students’ attitudes and confidence regarding HPV preventive education. Journal of Dental Education, 84(1), 66–93.
6. Oregon adolescent immunization rates [Internet]. Oregon Health Authority; 2022 [cited 31 March 2023]. Available from https://www.oregon.gov/oha/PH/PreventionWellness/VaccinesImmunization/Pages/researchteen.aspx
7. Arnell, T. L., York, C., Nadeau, A., Donnelly, M. L., Till, L., Zargari, P., Davis, W., Finley, C., Delaney, T., & Carney, J. (2019). The role of the dental community in oropharyngeal cancer prevention through HPV vaccine advocacy. Journal of Cancer Education, 36(2), 299–304.
8. Timbang, M. R., Sim, M. W., Bewley, A. F., Farwell, D. G., Mantravadi, A., & Moore, M. G. (2019). HPV-related oropharyngeal cancer: A review on burden of the disease and opportunities for prevention and early detection. Human Vaccines & Immunotherapeutics, 15(7-8), 1920–1928.
9. Näsman, A., Du, J., & Dalianis, T. (2019). A global epidemic increase of an hpv‐induced tonsil and tongue base cancer – potential benefit from a pan‐gender use of HPV vaccine. Journal of Internal Medicine, 287(2), 134–152.
10. Strategic plan for oral health in Oregon: 2014-2020 [Internet]. Oregon Oral Health Coalition; n.d. [cited 31 March 2023]. Available from https://www.orohc.org/oregons-strategic-plan
11. Small grants program [Internet]. American Association of Public Health Dentistry; 2022 [cited 1 April 2023]. Available from https://www.aaphd.org/small-grants-program
12. AAPD Foundation grants [Internet]. American Academy of Pediatric Dentistry; 2021 [cited 1 April 2023]. Available from https://aapdfoundation.org/what-we-do/apply-for-grants/
