Introduction of a Novel School-based, Business Driven Dental Program to Alleviate Pain and Unmet Dental Needs for Underserved Children

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By Marisa Moret, Samuel Lynass and Greg Evans, D.D.S.
From the Fall 2015 Journal of the Colorado Dental Association

Nationally, 14% of our 6-12-year-old children are likely to have suffered from a toothache in the last six months. Preventive measures such as dental sealants only reach a fraction of children, while the lifetime cost of a decayed permanent molar ranges from $2,187 to $6,105. At the same time, fewer adults are seeking dental care and more young adults are using the emergency room for dental treatment. It is widely recognized that children need to be reached before dental problems become painful or chronic. Efforts to address this need meet many barriers.

In Colorado, Medicaid dental coverage does not reach every eligible child. Efforts such as Give Kids a Smile day or the Colorado Mission of Mercy call attention to dental health needs but do not provide comprehensive, long-term care. Non-profit dental clinics serve as a safety net but are not in every community and have continued funding challenges. New community programs such as Cavity Free at Three or SMILES Dental Home Project serving rural areas are making inroads, but have yet to conquer the problem of providing services for those without the ability to pay for treatment. School-based programs have proven successful in reaching children for sealants and dental health awareness; still only 25% of low income children receive sealants and are twice as likely to have unmet dental needs. Reaching low income children for dental treatment requires both financial backing, awareness, and a passion to treat. This paper describes a unique school-based, business driven arrangement that accomplishes those goals without the help of government agencies.

In 2006, a group of businesses representing the northern Fort Collins Business Association (NFCBA) asked what they could do to help Irish Elementary, a school with three quarters of children on free and reduced price lunches, a loose measurement of poverty. The answer surprised the business group: they needed dental care. On a frequent basis, children were seeking pain relief for untreated dental treatment in school. The NFCBA reached out to local dentists and “went to work” on the project as private business can. In short order, “Project Smile” raised over $100,000 in the first two years, bridged the barriers between dentists and school-aged kids, and essentially solved the problem of unmet dental need and pain at Irish Elementary. This seemingly intractable, chronic problem that affects people at a national level saw results in fewer than three years at a local level. The program now has become a model for how communities can engage the private sector to alleviate unmet dental needs. Here is the story of Irish Elementary and Project Smile.

Method:
The authors interviewed both present and past participants in the Project Smile efforts to reconstruct the method by which Irish Elementary attained and benefitted from business-sponsored dental care. In addition, research into the screening and treatment records as well as financial statements was done to quantify the program’s effect.

The NFCBA is a group of small businesses whose goal is to grow and develop northern Fort Collins, Colo. The NFCBA had a desire to serve the community, and Irish Elementary’s location in north Fort Collins combined with the sheer amount of need and poverty that existed at the school made it the perfect place to affect change. Research strongly supports a correlation between poverty and untreated dental caries. The Centers for Disease Control and Prevention states that “[d]ental caries is the most common chronic condition in children and adolescents, with the greatest prevalence […] in those who live in poverty.” Student poverty level is typically based on free and reduced price lunch (FRPL) rates. A study done by the Minnesota Department of Health corroborated this idea, showing that in public schools with low (less than 25%) FRPL, only 12% of third grade students had untreated tooth decay, whereas in high (more than 75%) FRPL rate schools, 67% of third grade students had untreated tooth decay. In light of this research, it makes sense that when the NFCBA went to the principal of Irish Elementary in the fall of 2006 to ask what the school needed, her unhesitating response was dental care. Principal Brenda Gifford reported that student focus was being impaired by pain resulting from a lack of dental hygiene attention.

Given this seemingly “herculean task” of providing dental care for a school of over 250 students, the NFCBA tapped into its connections in the community and began to put together a supportive, motivated board after attaining 501(c)3 non-profit status as “Project Smile.” Today the board consists of an executive team running the day-to-day activities and a paid part-time operations coordinator who organizes all the dental education programs and screening support. Other board members from the business community lend financial and public awareness muscle to the cause. Local dentists were contacted, including Dr. Geoff Engelhardt, whose previous involvement at Irish Elementary created the perfect segue for the establishment of an organization to meet children’s dental needs. A pediatric dentist also came on board at the start of Project Smile’s creation to advise and treat emergencies. These two dentists provided the initial core clinical support, reviewing complex cases and advising on reimbursement rates and hospital dentistry when necessary.

From Project Smile’s beginnings there was never a shortage of dentists willing to help the cause. The organization also made contact with the Northern Larimer County Health District, which “provided an amazing partnership” by bringing the families a sense of familiarity and subsequent comprehensive follow-up care. On a sliding fee scale, or by assisting families to qualify for Medicaid, the children were transferred to the Northern Larimer County Health District for largely preventive dental care, which bolstered the Health District’s funds and met its objectives for existence.

Local dentists’ willingness to get involved and serve took care of the treatment side of Project Smile’s agenda, leaving only the financial side of the organization to be developed. Rather than approaching foundations for grants to fund their work, NFCBA president and Project Smile founder Ron Lautzenheiser felt that the “more sound way to do it [was] to focus on small businesses.” The major players in the NFCBA were able to get business leaders throughout Fort Collins to fund Project Smile. Annual fundraisers put on by Project Smile continue to generate funds for their services. One example was the “Night at the Oscars” event held in 2008 where patrons enjoyed a black tie event and learned about Project Smile’s work and how to help the cause. While fundraising is a “twelve-month a year job,” Project Smile has been self-sufficient financially from the start. A 2015 Project Smile annual luncheon targeted at the local community was highly successful and has allowed Project Smile to expand to add two new elementary schools in the 2015-2016 school year. A large portion of funding efforts go toward the purchase of dental supplies that are distributed to each child for classroom and at-home use in Project Smile supported schools. Historically, another large percentage of funding goes to cover the cost of corrective dental treatment provided by private dentists and the health district that is not covered by insurance or pro bono services.

The services Project Smile provides when it enters a school can be divided into two categories: education and screening. The educational component of Project Smile consists of volunteers speaking to students in the classrooms about the importance of dental health, how to properly care for one’s mouth, and what students can do to prevent caries. This hygiene instruction is done in cooperation with the Northern Larimer County Health District, Colorado State University Pre-Dental students, and volunteer dentists. Each student is given a dental care kit with two sets of a toothbrush, toothpaste, and floss; one set is for home and one for school. It is Project Smile’s goal that the teachers will encourage good oral hygiene habits by having students brush and floss their teeth once a day in class. Support from teachers as well as the principal for following through on in-classroom oral hygiene is one of the most important aspects of Project Smile. Dentists in the organization credit this component as the single most influential factor in eliminating recurrent decay in the children who receive dental care through Project Smile.

The other component of Project Smile’s services is the screening itself. Approximately 10-15 dentists volunteer to screen the students in the school on a rotating basis throughout the school year. In collaboration with the Fort Collins Lions Club, Project Smile also cares for students’ vision needs at these screenings by testing for a variety of vision conditions. If necessary, Project Smile is able to help students receive further eye treatment and/or financial assistance for prescription glasses. Prior to the screening day, consent forms in both English and Spanish are sent home with the students; they must be completed if the student is to undergo a screening. This form asks for information regarding the student and parents’ names, current dental provider, and dental insurance. All students who receive parental approval are screened for both dental and vision problems. As a dentist examines a student’s mouth with an explorer and mirror, they place the student at one of three levels based on the severity of their dental needs.

Level 1 being the most severe and indicating a need for immediate care.

Level 2 indicating that the child needs restorative care.

Level 3 identifies children who need sealants or routine cleanings

All students are then given a fluoride varnish as a tangible treatment benefit of the screening. The results from the screening are recorded and sent back to the parents along with recommendations for follow-up care if it is necessary. All level 1 and most level 2 patients are personally contacted by Project Smile’s care coordinator for further treatment. The care coordinator refers the patient to a specific dentist and follows up to make sure the need has been met, a key component to the success of obviating chronic care issues. To date, over 40 dentists volunteer their time and work pro bono or are compensated according to Project Smile’s fee schedule, which is substantially less than Medicaid fees. Difficult or complicated care is referred to one of five pediatric dentists in Fort Collins. After treatment is rendered, the children are referred secondarily to the Health District for comprehensive care going forward. In addition, all school nurses in the school district have direct access to the Project Smile care coordinator to refer children they identify as needing dental care. The care coordinator is employed in one of the pediatric dental offices, making her well suited to take calls as she integrates them into her normal job duties.

Project Smile has also developed strategic partnerships with local businesses for finances as well as the Poudre School District, Harmony Surgery Center, dental supply companies, service clubs, local churches, and donor individuals to enable growth. Project Smile has expanded since its “humble beginnings” at Irish Elementary and in the 2014-2015 school year reached over 2,100 students in seven schools.

After obtaining a strong qualitative knowledge base about the formation and development of Project Smile at Irish Elementary from interviews, a more quantitative approach was taken. In its early years Project Smile did not have the time, money, or manpower for meticulous, organized data collection. While some records were kept to show the numerical effects Project Smile’s work was having on Irish Elementary, there were gaps. For example, the 2008-2009 data was estimated based on the averages of the other school years due to a lack of recorded data for that year. Supplemental information was also obtained from Poudre School District regarding FRPL rates as well as school enrollment statistics. Throughout the process of gathering information and data, all Health Insurance Portability and Accountability Act (HIPAA) guidelines were followed in order to protect the patient’s health information.

Results:
Since the implementation of Project Smile into Irish Elementary School in 2007, there has been a reduction in both the untreated caries rate and the number of urgent care cases within the student population. The initial 2007-2008 school year baseline screening showed that 57% of student had untreated dental caries. In the inaugural screening, of the 284 students screened, 85 were labeled as level 1 urgent care cases and an additional 77 students were labeled as level 2 cases. Over the following eight school years, the percentage of students attending Irish Elementary School with untreated dental caries decreased from 57% to 12% (Figure 1). The number of level 1 urgent care needs was cut from 85 in 2007 to 6 in 2015 (Figure 2). For Irish Elementary, age distribution data from school screenings between 2011-2014 showed an average of 4.33 level 1 kindergarten students compared to the average of 2.07 students in each individual grade 1-5.

Figure 1. Summary of the caries rate at Irish Elementary School from 2007-2015

Figure 2. School screening data from 2007-2015 revealing the number of level 1 urgent care cases at Irish Elementary

According to the Colorado Department of Education, Irish Elementary had free and reduced price lunch rates ranging from 81.75% to 73.63% between 2007 and 2015. When Project Smile was initiated in 2007, 74.58% of students were on free or reduced price lunch. In 2015, 74.94% of students were receiving financial aid for lunch services. The school’s baseline rate of untreated caries was established at 57% in comparison to its 74.58% FRPL rate. While the poverty rate of Irish Elementary in the last eight years remains virtually unchanged, both urgent dental needs and numbers of children with unmet needs have dramatically decreased. Not only have the numbers decreased, but children are not coming back with recurrent needs year after year.

Discussion:
Based on caries rate and FRPL statistics, this study agrees with previous studies that there is a correlation between the existence of high numbers of untreated dental caries and schools with large free and reduced price lunch student populations. Our data supported this and showed that schools with more students on free or reduced price lunch generally had a higher rate of dental caries. Irish Elementary was originally identified as a prime candidate for Project Smile due to its high rate of FRPL students at 74.58%. The relatively consistent FRPL percentage over the last eight years reveals that there was no dramatic change in poverty level within the school. Therefore, it can be said with reasonable certainty that the dramatic reduction of untreated caries (from 57% to 12%) within the student population can be largely contributed to the Project Smile Program. By comparison, National Health and Nutrition Examination Survey studies from 1988 and 2004 show caries rates for Medicaid patients ages 2-18 increasing from 55% to 61%, very similar to Irish Elementary’s initial caries rate. With the implementation of Project Smile, the caries rate at the school dropped well below the national Medicaid average. Additionally, 100% of level 1 children were treated and put into a recall system. The school saw a decline in the number of level 1 urgent care needs from 85 students in 2007 to only 6 in 2015. This data suggests that although a small portion of the student population was still getting caries, the number of students with three or more caries or severe caries causing pain was dramatically reduced. Irish Elementary teachers report better classroom attentiveness and higher test scores. One principal went so far as to say Project Smile helped to “take care of [its] students at all levels,” and “students were meeting or exceeding all academic expectations.” These reports are in line with pre-existing studies looking at the link between improving students’ oral health and their subsequent academic performance.

From data collected between 2011-2014 at Irish Elementary, it can be seen that kindergarteners were more than two times more likely to have urgent dental needs than upper grade levels. Any school will obviously have a certain degree of student turnover in grades 1-5, but the biggest student turnover is due to the introduction of kindergarteners to the student population. With this influx, new students were introduced into the Project Smile program even at a school like Irish Elementary that supported dental screenings for years. The higher rate of untreated caries in kindergarteners contributed a large proportion of the existing level 1 students. A sizeable portion of these students had never been to the dentist and did not have their own healthcare coverage. Additionally, this was the first time many of these kids received a fluoride treatment and the individual attention of a dental care professional. Although kindergarten students were more likely to experience untreated caries in comparison to their first grade through fifth grade counterparts, the number of level 1 kindergarten students had decreased substantially from the baseline screening at Irish Elementary in 2007. This decrease in caries rate for entering students may suggest a link to in-home care learned from older siblings or increased parental awareness as a result of Project Smile’s work, but this affect was not specifically investigated for this paper.

Before the implementation of Project Smile into Irish Elementary, teachers and former principle Brenda Gifford reported that student focus was being impaired by pain resulting from a lack of dental hygiene attention. The students’ “basic need weren’t being met. They were in pain in front of their teachers and they couldn’t focus.” As the culture at Irish Elementary changed, so did the need at the school. After the initial financial output that focused on treating the 57% of the student population with untreated caries, there has been a transition of the financial support toward preventive care. The implementation of hygiene education programs into the curriculum at Irish has helped sustain the continuous decline of untreated caries at Irish Elementary. One of the many people to see a culture change at Irish Elementary is local dentist, Dr. Geoff Engelhardt. “I knew I was helping the kids out; it always puts things in perspective for me. We’ve made a huge dent in this problem at these schools.”

In fact, recognition of dentists by businesses has created both a motivating factor for businesses to support a local charity and caused dentists to be recognized by their peers, local business leaders, and in many cases their own patients. Unlike other pleas for support, Project Smile’s benefits are very immediate for all parties involved. This is a novel approach and does not involve heavy chair commitment by dentists, travel, or creation of paperwork by dental staff. No government agencies became involved, no insurance submissions are required, and dentists are directly recognized in their communities. In other words, care for children is made possible by dentists as they would have it: “see a need, treat a need.”

Conclusion:
A dental program focused on one elementary school at a time and driven by a business entity was able to attract the attention and support of local dentists, school administrators and volunteers. The personal connections of influential business people created a cycle of recognition and assistance that proved to be very cost effective. At Irish Elementary, a school of roughly 75% free and reduced price lunch qualification, dental pain and unmet dental care was reduced from 57% to 12% of the population in eight years. Through dental education and an in-school brushing program, Irish Elementary was able to keep recurrent dental treatment to a minimum and significantly reduce the expenditure on restorative dentistry over an eight-year time frame. Volunteers were able to manage this program without undue paperwork or oversight with almost 100% patient participation, achieving sustainable results that can be emulated by other communities who are dedicated to addressing existing dental needs.


Marisa Moret is a pre-dental student at the University of Wyoming. Samuel Lynass is a Colorado State University graduate and Project Smile board member pro tem. Dr. Greg Evans is a pediatric dentist in Fort Collins. Please send questions to greg@gobiggrins.com.